Perforation of the Thoracic Aorta by a Metallic Object
Willythssa S. Pierre-Louis, MD.
University of Cincinnati, Cincinnati, OH, USA.
Demographics
A 79 year old male with past medical history of coronary artery disease status post coronary artery bypass grafting in 1995 and 2000, presented with 10-day history of severe substernal chest pain which started abruptly after a bite of steak at a restaurant.
History
Four days prior, after multiple primary care visits, he had undergone serial esophageal dilatation which only worsened the pain. In our emergency room, a pulmonary angiogram Cat Scan (CTPA) was obtained. A radiopaque object measuring 2cm penetrated both the esophagus and the aorta and was surrounded by a phlegmon at the mediastinum. A small pseudoaneurysm of the aorta was noted. He was admitted to the critical care unit on strict blood pressure control, broad spectrum antibiotics and antifungals.
Plan
A multidisciplinary team (cardiac, thoracic, and vascular surgery) differed in opinion on the appropriate management. He remained hemodynamically stable and afebrile with no leukocytosis. Therefore, we devised an endovascular approach for retrieval of the object, placement of an aortic stent graft if needed, with long term antibiotics and antifungals.
Discussion
The object was visualized with fluoroscopy, two large sheaths were placed into the aorta via bilateral common femoral arteries. A compliant aortic balloon and an appropriately sized aortic cuff were prepared in case of instability during its manipulation. With a 18-30mm-ENSnare, the object was released from the aortic wall and withdrawn into the sheath. He remained hemodynamically stable. An aortogram confirmed no extravasation. After 10 vigilant minutes, both sheaths were removed. The metallic object was
recovered. His chest pain resolved and his hospital course continued uneventfully. He was discharged after 2 days on 6 weeks of intravenous antibiotics and antifungals. He was seen in the clinic one year later with a normal CT-scan. Pathology confirmed a steak brush bristle.
Ingestion of foreign object is a common medical emergency. Perforation of the esophagus can often be managed with endoscopy. Perforation of both esophagus and aorta is a rare scenario where the most serious complication remains an aortoenteric fistula. This can result in massive fatal hemorrhage. Management traditionally involves wide mediastinal drainage with reconstruction of the aorta and the esophagus. In the absence of bleeding and systemic inflammatory signs, endovascular retrieval and long term antibiotics provide a safe and less morbid alternative.
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