Ann Thorac Surg 1999;68:1060-1061
© 1999 The Society of Thoracic Surgeons
Case Reports
Unusual presentation of aortic pseudoaneurysm: middle lobe pneumonia
Edward G. Izzo, MDa,
Patricia A. Conant, MSa
a Department of Cardiovascular and Thoracic Surgery, St. Joseph’s Heart Institute, Tampa, Florida, USA
Address reprint requests to Dr Izzo, 2814 W Virginia Ave, Tampa, FL 33607
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Abstract
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Pseudoaneurysms of the aorta are rare. We report an unusual presentation of an ascending thoracic pseudoaneurysm found with atypical presenting symptoms.
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Introduction
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Pseudoaneurysms are rare. We submit a clinical case of what presented as right middle lobe pneumonia, but in actuality was a large ascending aortic pseudoaneurysm. The diagnostic testing led to the appropriate management.
A 58-year-old man presented to the emergency department with a 2-week history of shortness of breath, nonproductive cough, fever, and intermittent hemoptysis. His medical history was significant, as it included a 45-pack per year tobacco abuse, chronic obstructive pulmonary disease, and alcohol abuse. He denied heart disease, hypertension, recent traumatic events, and took no medications. On admission his blood pressure was 156/107. The chest roentgenogram was consistent with a right middle lobe pneumonia with an incidental finding of scattered gunshot pellets (Fig 1). Significant laboratory values included a WBC of 13,800, hemoglobin of 12.0 mcg/dL, and hematocrit of 37 gm. Intravenous antibiotics were instituted and cardiac and pulmonary workup ensued. Electrocardiogram and echocardiogram were normal. With his smoking history and symptoms of hemoptysis, a computerized tomography was ordered. Surprisingly, a 9 cm x 6 cm pseudoaneurysm of the ascending aorta was identified above the level of the right atrial appendage. The aneurysm compressed the right middle lobe bronchus resulting in a post obstructive pneumonia (Fig 2). Further diagnostic evaluation included an aortogram that confirmed the unexpected findings. Subsequent cardiac catheterization revealed concomitant triple vessel coronary artery disease (Fig 3).
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Fig 2. Computerized tomography illustrates extreme compression of right middle lobe with obstructive pneumonia.
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The patient underwent repair of the pseudoaneurysm using an interposition graft (30 mm Hemashield; Meadox Medical, Oakland, NJ) and a triple vessel coronary artery bypass. The aneurysm was located just above the level of the right atrial appendage. There was obvious compression of the right atrium and the right middle lobe of the lung was adherent to both the pericardium and to the right lung. There was no identifiable entry site of the dissection or evidence of a foreign body. There were no adhesions to suggest previous intrapericardial hemorrhage. An old thrombus was contained between the adventitial and medial layer. His postoperative course was uneventful and he was discharged on the 6th postoperative day.
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Comment
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Survival of aortic rupture and subsequent chronic aneurysmal formation at the site of rupture or dissection is uncommon and associated with delayed fatal rupture [1–3].
Pseudoaneurysms of the thoracic aorta are associated with traumatic deceleration injuries at the level of the ligamentum arteriosum or with previous aortic or cardiac surgery [1, 2]. By definition a pseudoaneurysm occurs after disruption of all arterial layers with hematoma formation contained by surrounding tissue [3]. Presenting symptoms for chronic pseudoaneurysm of the aorta include chest pain, pressure, cough, dyspnea, hemoptysis, syncope, and hoarseness [1–4]. In this case, chest roentgenogram revealed that the mediastinum was not widened and the pneumonic process obscured the pseudoaneurysm. Because of the high mortality of delayed rupture which has been reported up to 27 years post event, once diagnosed, surgical intervention is usually indicated [2].
This case was unusual in two aspects: the initial presentation and etiology of the mechanism of injury. Typical presentation of fever, cough, hemoptysis, and chest roentgenogram led to the presumptive diagnosis of pneumonia. The nonspecific presenting symptoms could represent a myriad of etiologies. The chest roentgenogram showed a pneumonic process and obscured detection of the saccular pseudoaneurysm of the ascending aorta. There was no evidence of widened mediastinum, typical of 80% of the traumatic pseudoaneurysms that form at the isthmus. Had the patient not been at risk for a lung mass, the incidental finding of the pseudoaneurysm on computerized tomography would not have been discovered. In terms of the cause, the patient, a poor historian, did not recall any traumatic deceleration type injuries or previous cardiac surgery. The evident buckshot residual from a gunshot wound seen on chest roentgenogram may have been contributory but this was not proved. Postoperative radiographs showed no change in the distribution or number of pellet shadows. Infectious and syphilitic etiologies were ruled out. Although the patient denied hypertension, he presented with an elevated blood pressure and the location of the aneurysm was at a common site of ascending aortic dissections found in hypertensive patients.
This unusual case presentation of an ascending thoracic pseudoaneurysm reiterates the need for timely surgical intervention once the diagnosis is made. Appropriate diagnostic studies aided in prompt and accurate treatment. Computerized tomography and aortogram are still the gold standard for delineation of the aortic pathology. Incidental findings emphasize that presenting symptomatology cannot exclusively be attributed to suspected pathology.
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References
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Albuquerque F.C., Krasna M.J., McLaughlin J.S. Chronic, traumatic pseudoaneurysm of the ascending aorta. Ann Thorac Surg 1992;54:980-982.[Abstract/Free Full Text]
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Razzouk A., Gimdru S., Wang N., et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Surgery 1993;59:818-823.
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Schwartz M.L., Fisher R., Sako Y., et al. Post-traumatic aneurysms of the thoracic aorta. Surgery 1975;78:589-593.[Medline]
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Bennett D.E., Cherry J.K. The natural history of traumatic aneurysm of the aorta. Surgery 1967;61:516-523.[Medline]
Accepted for publication January 11, 1999.
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Abstract
Introduction
