Thoracic Aortic Aneurysm Presenting Research Articles

Hemoptysis as a Rare Presentation of Thoracic Aorta Aneurysm

Hemoptysis is the rarest presentation of thoracic aortic aneurysm (TAA).This critical condition is one of the life-threatening medical emergencies. Even with prompt approaches, TAA can have highly terrible outcomes. Although TAA is an almost asymptomatic condition that is accidentally discovered, imaging with contrast is the most useful modality to diagnosis it.

P723 A dissecting thoracic aortic aneurysm presenting with mild symptoms in a young woman

Abstract Introduction Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. Case presentation We present the case of a 29 years old young woman, brought to the emergency department with mild chest and back pain, shortness of breath on exertion with an onset of 12 days prior to admission. The patient has a history of 3 pregnancies delivered by natural birth and C-section (last one 2 years ago), but no personal cardiovascular disease history. She relates a family history of sudden cardiac death at a young age (mother, grandmother, great-grandmother) and a sister with diagnosed aortic aneurysm associated with a genetic mutation. Physical examination revealed a marfanoid habitus, diastolic heart murmur, low diastolic blood pressure (BP of 90/25 mmHg). Transthoracic echocardiography performed in the ED, discovered an anuloaortic aneurysm with a maximum diameter of 8.7 cm at the aortic root and a dissecting intimal flap of the ascending aorta up to the aortic arch. We also detected a dilated left ventricle with a low ejection fraction (30%) and a severe aortic regurgitation. The findings were confirmed by contrast-enhanced CT Angiography, showing the aneurysm of 8.4/8.7 cm and the intimal dissection flap with patency of both true- and false lumens. At this point we diagnosed an anuloaortic aneurysm with Stanford type A acute aortic dissection and a Marfan syndrome (according to the Ghent Nosology criteria). She immediately underwent surgery, the Bentall procedure was performed, consisting of a composite graft replacement of the entire ascending aorta and aortic valve, followed by direct implantation of the coronary arteries. Histopathological examination of the excised aortic wall reinforced the diagnoses of a connective tissue disorder. The early postoperative evolution was marked by the development of a left-sided hemiparesis and seizures, caused by an acute ischemic stroke. The patient was discharged after the complete resolution of the neurological symptoms under appropriate medication. Recommendations were made for periodic follow-up, genetic testing and the screening of her children after the age of 10 years old. Conclusion Discussions evolve around the interesting fact that she managed to survive 3 pregnancies, natural births and a C-section, without developing an aortic dissection or even a possible fatal rupture up until this presentation. It is imperative to mention that the lack of a follow-up from a general practitioner, who could have notice the signs of a possible connective tissue disorder, have possibly led to the development of such aortic sizes. The current guidelines sustain the importance of surgical approach in all types of ascending aortic dissection, the only treatment proven to increase the short- and long term mortality. Abstract P723 Figure. Imaging studies

Point-of-care ultrasound diagnosis of thoracic aortic aneurysm in a patient presenting with hemoptysis

IntroductionHemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions.Case ReportA 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day.DiscussionThe vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Hemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions. A 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day. The vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Figure 1. POC-US of suprasternal notch view showed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma (arrow). Figure 2. CTA of the aorta revealed proximal ruptured thoracic aortic aneurysm with adjacent hematoma.•Sun D, Mehta S. Hemoptysis caused by erosion of thoracic aortic aneurysm. CMAJ. 2010; 182:186.•Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg 1985; 89:50.•Nair G, Jindal S, Chandra A, Swami S, Garg P. Haemoptysis - a rare presentation of aortic aneurysm. Lung India. 2008;25:20.

Dysphagia Aortica: Diagnostic Dilemma and Therapeutic Paradigm

Objective: Intrinsic esophageal pathologies constitute prime cause for dysphagia clinically. However, thoracic esophageal domain is prone to extrinsic compression by various vascular afflictions including aneurysms with attendant therapeutic challenges. Herein, we present a case series of dysphagia aortica with emphasis on its appropriate management option based on grade of dysphagia. Methods: Patients who presented to the vascular division of our tertiary care referral institute between January 2014 and October 2015 with dysphagia due to extrinsic esophageal compression by aneurysmal thoracic aorta form the basis for this report. Prior to referral, all patients were evaluated elsewhere to rule out intrinsic causes and computed tomography angiogram performed delineating aortic aneurysm in four patients and penetrating aortic ulcer in one. Patient cohort included one female and four male patients whose age ranged from 40 to 68 years, with a median of 62 years. Left posterolateral thoracotomy provided access to an aneurysm which was repaired using interposition polyester graft in four patients. Due to severe comorbidities which precluded open surgery, one patient who presented with mild dysphagia was managed by endovascular stent graft repair. Results: Degree of dysphagia was assessed between grades 0 and 4 as in literature. All patients, including four open conventional and one endovascular, recovered well and left hospital totally symptom free. Conclusion: Dysphagia due to vascular diseases in the thoracic domain is an uncommon clinical entity. Patients with thoracic aortic aneurysm presenting with severe dysphagia deserve open surgical repair to provide optimal symptomatic relief in addition to saving life. The state-of-the-art endovascular stent grafting may be considered in very elderly patient having severe comorbidities presenting with mild dysphagia.

Chronic Thoracic Aortic Aneurysm Presenting 29 Years following Trauma.

Blunt, nonpenetrating injuries of the thoracic aorta are uncommon and associated with a high mortality rate within the first hour. Aortic injury is missed in 1-2% of patients that survive to hospital, and a chronic thoracic aortic aneurysm may subsequently form. We present a case in which a chronic thoracic aortic aneurysm was diagnosed 29 years following a significant motor vehicle accident. We discuss the epidemiology, presentation, and management of this uncommon consequence of blunt, nonpenetrating aortic injury. Our case illustrates an important clinical lesson; a past medical history of trauma should not be overlooked at any patient assessment.

Thoracic Aortic Aneurysm Presenting as Vocal Cord Paralysis

We present a case of 80-year-old man with two-year history of hoarseness of voice secondary to left vocal cord paralysis. CT scanning revealed a saccular thoracic aneurysm compressing the left recurrent laryngeal nerve. A review of literature on Ortner's or cardiovocal syndrome is presented

Loss-of-function mutations in TGFB2 cause a syndromic presentation of thoracic aortic aneurysm

Loeys-Dietz syndrome (LDS) associates with a tissue signature for high transforming growth factor (TGF)-β signaling but is often caused by heterozygous mutations in genes encoding positive effectors of TGF-β signaling, including either subunit of the TGF-β receptor or SMAD3, thereby engendering controversy regarding the mechanism of disease. Here, we report heterozygous mutations or deletions in the gene encoding the TGF-β2 ligand for a phenotype within the LDS spectrum and show upregulation of TGF-β signaling in aortic tissue from affected individuals. Furthermore, haploinsufficient Tgfb2(+/-) mice have aortic root aneurysm and biochemical evidence of increased canonical and noncanonical TGF-β signaling. Mice that harbor both a mutant Marfan syndrome (MFS) allele (Fbn1(C1039G/+)) and Tgfb2 haploinsufficiency show increased TGF-β signaling and phenotypic worsening in association with normalization of TGF-β2 expression and high expression of TGF-β1. Taken together, these data support the hypothesis that compensatory autocrine and/or paracrine events contribute to the pathogenesis of TGF-β-mediated vasculopathies.

An unusual presentation of thoracic aortic aneurysm rupturing into the esophagus: an autopsy case report

Ruptured aortic aneurysms often present with sudden death, and have varied signs and symptoms depending on the site of rupture and hemorrhage. We report a case of an aortic aneurysm with an aorto-esophageal fistula, which showed slow gastrointestinal bleeding for days before death. A 79-year-old male was brought to a hospital emergency unit, with a history of melena for about 3 days, and recent hematemesis. He collapsed immediately after endoscopy and died. A forensic autopsy which was performed due to possible medical malpractice demonstrated a large saccular aneurysm of the descending thoracic aorta with a fistula into the esophagus. A significant finding was a lid or valve shaped thrombus covering the aortic orifice of the fistula, which may have partly contributed to slow bleeding, and which may have been dislodged by endoscopy. This case suggests that very careful management of aorto-esophageal fistula is needed in patients with clinical signs of possible thoracic aortic aneurysm with slow hemorrhage.

Acute dissecting thoracic aortic aneurysm presenting with stroke, consumptive coagulopathy, and gastrointestinal hemorrhage

We report the case of a 70-year-old man who had an acute dissection of a previously undiagnosed thoracic aortic aneurysm. The diagnosis was challenging because of the neurologic and hematologic complications that overwhelmed the clinical presentation. Three simultaneous complications of thoracic aortic aneurysm with dissection (ischemic stroke, consumption coagulopathy, and superior mesenteric infarction with gastrointestinal hemorrhage) made the case unique and the diagnosis difficult.

Thoracic Aortic Aneurysm Presenting as Pulmonary Vein Stenosis

We present the case of a 66-year-old woman presenting with pulmonary vein stenosis with a large descending thoracic aortic aneurysm. Pulmonary vein stenosis is a rare condition and can be caused by extrinsic compression, as well as by inflammatory diseases, congenital anomalies and related surgical repair, tuberculosis, and pulmonary veno-occlusive disease. With obstruction to pulmonary vein flow, the velocity increases and becomes continuous. The finding of turbulent antegrade flow in the left atrium through the use of transthoracic color flow Doppler and pulsed-Doppler warrants further investigation to evaluate known causes of pulmonary vein stenosis. We believe this is the first reported case of a patient with an aortic aneurysm causing pulmonary vein stenosis.

Thoracic aortic aneurysm presenting as paraparesis

Thoracic aortic aneurysm presenting as paraparesis

Descending Thoracic Aortic Aneurysm Presenting in the Right Thorax; Diagnosis and Surgical Management

An unusual case is presented of a patient with a rightsided descending thoracic aortic aneurysm which was misdiagnosed as a bronchogenic carcinoma until oblique views of the chest, tomograms, and aortogram disclosed a saccular aneurysm. Using an aorta-to-aorta shunt without the administration of heparin, the aneurysm was resected and an end-to-end anastomosis performed without a graft. The initial satisfactory course was marred by reserpine-induced hypotension (70 mm Hg) followed by paresis of the left lower extremity and hypaesthesia distal to the T8 dermatome. This consequence of ischemia of the spinal cord was consistent with sacrifice of a high arteria radicularis magna and inadequate collateral circulation. An unusual case is presented of a patient with a rightsided descending thoracic aortic aneurysm which was misdiagnosed as a bronchogenic carcinoma until oblique views of the chest, tomograms, and aortogram disclosed a saccular aneurysm. Using an aorta-to-aorta shunt without the administration of heparin, the aneurysm was resected and an end-to-end anastomosis performed without a graft. The initial satisfactory course was marred by reserpine-induced hypotension (70 mm Hg) followed by paresis of the left lower extremity and hypaesthesia distal to the T8 dermatome. This consequence of ischemia of the spinal cord was consistent with sacrifice of a high arteria radicularis magna and inadequate collateral circulation.