Society For Clinical Vascular Surgery

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Traumatic Thoracic Aortic Pseudoaneurysm causing Heart Failure symptoms
Tarundeep Singh, BS, Constantinos Lovoulos, MD, Timothy Wu, MD.
Rutgers New Jersey Medical School, Newark, NJ, USA.

We report the case of an 82 year old male who presents thirty years after penetrating gunshot injury to the chest, with complaints of syncope, dizziness, and dyspnea. Initial presentation gave the appearance of heart failure and further imaging led to the diagnosis of a thoracic aortic pseudoaneurysm in proximity to a retained bullet. A chest x-ray showed a large lower mediastinal mass, which led to a contrast-enhanced CT scan of the chest showing a distal descending thoracic aortic pseudoaneurysm, measuring 7.2 cm at its greatest dimension, at the level of the T10 vertebra; the bullet was seen in close proximity. Transesophageal echocardiogram showed an ejection fraction of 60% with no valvular abnormalities, EKG showed no evidence of arrhythmia, and there was no evidence of vertebrobasilar steal syndrome. Given the size of the pseudoaneurysm, stent graft exclusion of the aneurysm sac was performed six days after initial presentation. Through a percutaneous approach, a Medtronic Valiant thoracic endograft was deployed successfully, achieving exclusion of the pseudoaneurysm; there were no complications with endograft placement. The pseudoaneurysm and associated hematoma decreased in size in follow-up CT imaging. The thoracic stent graft exhibited no evidence of endoleak. With resolution of the aneurysm, the patient also noted resolution of the aforementioned syncopal episodes and dizziness. He was discharged and remained asymptomatic on follow-up examination. Given the 30 year interval from injury to diagnosis due to the compressive effect of the aneurysm on the heart, this case demonstrates the longest asymptomatic interval described after penetrating trauma to the thoracic aorta. Diagnosis was greatly dependent on imaging studies, and a degree of clinical suspicion was necessary. Due to the high mortality rate from spontaneous aortic aneurysm rupture, early diagnosis and intervention is essential, and imaging should be considered promptly in all patients with a prior history of trauma.

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