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Case 316

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Male patient, 71 years old, referred due to complaint of upper abdominal pain with radiation to the back in three episodes in the last three months. There are not aggravating or relieving factors, as well as episodes of subtle worsening of the pain. Hypertensive, former smoker (ceased 20 years ago). Previous CVA report, without significant sequelae and without history of thoracic trauma. Submitted to radiological propedeutics, including chest radiography and, subsequently, thoracic and abdominal CT angiography.

Considering the clinical history and the presented images, which one is the most likely diagnosis?

a) Dissecting aneurysm of the thoracic aorta

25%

b) Thoracic aortic pseudoaneurysm

25%

c) Saccular aneurysm of the thoracic aorta

25%

d) Fusiform aneurysm of the thoracic aorta

25%
   

Image Analysis

 

Image 1 - Analysis: Chest radiograph, posteroanterior view, orthostatic position. Superior mediastinum widening consistent with dilatation of the aortic arch, which induces displacement/diametrical reduction of the adjacent trachea. Technical limitations: exclusion of the basal portion of the thorax; right side of the patient is not identified.

 

 

Image 2 - Analysis: Chest radiograph, lateral view, orthostatic position. Evidence of diametrical increase of the horizontal portion of the aortic arch (red arrow). Small nodular formations projected at the pulmonary hila area (green arrows), without evident correspondence with the posteroanterior view associated. Pleuropericardial adipose cushion (blue arrow). Ligamentar calcifications at the inferior thoracic spine (yellow arrows).

 

 

Image 3 - Analysis: Thoracic and abdominal aorta CT angiography, sequential coronal reconstructions. Fusiform aneurysmatic dilatation of the horizontal portion of the aortic arch and the proximal descending segment (blue line), from the emergence of the left subclavian artery, in the origins of the brachiocephalic trunk, the left common carotid artery and the left subclavian artery (red arrow). Non contrast-enhanced eccentric intramural area in the aneurysm corresponding to chronic thrombus (yellow arrows). Small cysts in both kidneys (green arrows) - non-directed study.

 

 

Image 4 - Analysis: Thoracic aorta computed tomography (CT) angiography, axial view, at the aortic arch level, before (a and b) and after iodinated intravenous contrast injection, arterial phase (c and d). Fusiform aneurysmatic dilatation of the horizontal portion of the aortic arch (red line) with non contrast-enhanced eccentric intramural portion corresponding to chronic thrombus (yellow arrows). Atheromatous parietal and diffuse calcifications (green arrows).

Highlights

  • - The fusiform aneurysm of the thoracic aorta differ from others because it involves all layers of the arterial wall and all the arterial circumference;

  • - Most of the fusiform aneurysms are secondary to degenerative diseases;

  • - It is usually asymptomatic. When symptomatic, anterior thoracic pain, back pain and upper abdomen pain may appear. There is no correlation between symptomatology and arterial rupture risk;

  • - The surgical approach is recommended when symptomatic or when the arterial diameter is greater than 5,5 cm or when the expansion rate is high;

  • - The open surgery, the endovascular repair and the hybrid techniques are the current options of intervention.

References

- Ince H, Nienaber C. Etiology, pathogenesis and management of thoracic aortic aneurysm. Nature Clinical Practice Cardiovascular Medicine. 2007;4(8):418-427.

- Isselbacher E. Thoracic and Abdominal Aortic Aneurysms. Circulation. 2005;111(6):816-828.

- Black JH, Greene CL, Woo JY. Epidemiology, risk factors, pathogenesis, and natural history of thoracic aortic aneurysm. UpToDate. 2017. Access on March 11, 2017.

- Woo JY, Greene CL. Clinical manifestations and diagnosis of thoracic aortic aneurysm. UpToDate. 2017. Access on March 11, 2017.

- Woo JY, Greene CL. Management of thoracic aortic aneurysm in adults. UpToDate. 2017. Access on March 11, 2017.

- Forsythe RO, et al. 18F-Sodium Fluoride Uptake in Abdominal Aortic Aneurysms: The SoFIA3 Study. J Am Coll Cardiol. 2018 Feb 6;71(5):513-523.

Author

Thiago Ruiz Rodrigues Prestes, 5th year medical student at Universidade Federal de Minas Gerais (UFMG)

E-mail: ruiz.thiago[at]hotmail.com

Supervisors

Túlio Pinho Navarro, Adjunct Professor at the Department of Surgery of UFMG, Post-graduation Coordinator at Applied Sciences to Surgery and Ophthalmology, Chief of the Division of Vascular and Endovascular Surgery at the Hospital das Clínicas of UFMG and at the Hospital Risoleta Tolentino Neves.

E-mail: tulio.navarro[at]gmail.com

 

Túlio Cezar S. Bernardino, Substitute Professor at the Department of Anatomy and Image at Medical School of UFMG

E-mail: itulio[at]gmail.com

Reviewers

Mateus Nardelli, Bruno Campos, Vinícius Avelar, Guilherme Rocha, Eduardo Paolinelli, Professor José Nelson Mendes Vieira, Professor Viviane Santuari Parisotto Marino.

Translated by

Gabriella Yuka Shiomatsu, 3rd year medical student at Universidade Federal de Minas Gerais.

E-mail: gabi.yuka[at]hotmail.com

Test question

(Unifesp - 2015) 22 years old patient with Marfan syndrome (MS), asymptomatic, with family history of MS, in semiannual evaluation, currently presents ascending thoracic aorta aneurysm of 5,5 cm. Choose the most appropriate option.

a) Continue the follow-up every six months

25%

b) Increase the dose of the beta blocker

25%

c) Surgery must be indicated

25%

d) Surgery must be indicated only if the aortic diameter is > 6,0 cm

25%

e) Surgery does not change the natural history of the Marfan syndrome

25%
   

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