Ann Thorac Surg 2001;72:1763
© 2001 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Aortic rupture presenting with hemoptysis
Thoralf M. Sundt, III, MD*a,
Fernando R. Gutierrez, MDb
a Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
b Department of Diagnostic Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
* Address reprint requests to Dr Sundt, Department of Surgery, Washington University School of Medicine, Suite 3106, Queeny Tower, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110, USA
e-mail: sundtt{at}msnotes.wustl.edu
A 60-year-old man with a history of previous abdominal aortic aneurysm repair presented to an outside hospital with acute onset of left-sided chest pain for 5 hours. On admission he was hypotensive with intact peripheral pulses and no cardiac murmurs. Shortly after arrival he had hemoptysis prompting intubation for airway control and pulmonary toilet. Computed tomography of the chest (Figs 1 and 2) was interpreted as demonstrating an acute aortic dissection. The patient was transferred to our institution for surgical treatment. On arrival the patient was hypotensive requiring pressor support. Our radiologist reviewed the computed tomographic scan, confirming aortic dissection and noting thickening of the walls of the pulmonary arteries.
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Fig 1. Contrast-enhanced computed tomographic scan at the level of the ascending aorta demonstrating an intimal flap (arrowhead) in the aorta. A large filling defect (asterisk) is seen in the distal main pulmonary artery extending into the proximal right branch. Additional soft tissue thickening is seen around the left pulmonary artery (curved arrow).
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Fig 2. Computed tomographic image at the level of the aortic root demonstrating extension of the intimal flap inferiorly (arrowhead). Soft-tissue attenuation is seen in the subcarinal area compressing the left atrial cavity from above (asterisk), as well as around the pulmonary vessels and airways (arrow).
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At operation there was no mobile intimal flap apparent by transesophageal echocardiography, and there was no aortic regurgitation. On gross inspection after opening the pericardium, however, the ascending aorta had the typical appearance of acute dissection or intramural hematoma. There was clotted blood in the pericardium, the evacuation of which improved the patient’s hemodynamics. In preparation for cardiopulmonary bypass, the superior and inferior vena cavas were cannulated separately to permit retrograde cerebral perfusion. Bypass was initiated. During dissection around the superior vena cava to place a snare, a hematoma overlying the right pulmonary artery was entered, with immediate free flow of systemic arterial blood. There was an obvious site of aortic rupture posteriorly into the mediastinum just cephalad to the transverse sinus. The hematoma had clearly dissected from this site proximally into the roof of the left atrium and distally along the pulmonary arteries into the hila of the lungs, which explains the thickening of their walls. The hemorrhage was controlled by placement of an aortic cross-clamp just proximal to the innominate artery above the site of rupture. Systemic cooling was continued. The ascending aorta, including the clamp site, was replaced with a synthetic graft while the patient was under profound hypothermia with circulatory arrest. There was a very small intimal flap more dorsal and distal than usual, with an extensive intramural hematoma, DeBakey type II in extent, with disruption of the aortic adventitia posteriorly into the mediastinum. The patient recovered well and was discharged home.
No site of direct communication between the hematoma and the lumen of the airway was identified. Presumably the hemoptysis was secondary to dissection of arterial blood under aortic pressure around the distal thin-walled airways.
