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An Accident Waiting to Happen: Thoracic Aortic Aneurysm

  • Ami Schattner
    Correspondence
    Correspondence: Address to Ami Schattner, MD, Hebrew University and Hadassah Medical School, Jerusalem, Israel 91120.
    Affiliations
    Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel; and the Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel
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  • Ina Dubin
    Affiliations
    Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel; and the Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel
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      An 85-year-old man presented with dyspnea and mild left precordial pain. He was a heavy smoker with chronic obstructive pulmonary disease, diabetes, hypertension, and a 20-year history of thoracic aortic aneurysm (TAA) that he refused to have repaired. Over the past few weeks he became increasingly dyspneic, dysphonic, and developed solid-food dysphagia.
      On admission, he was tachypneic (22/min) and hypoxemic (91%), and breath sounds over the left hemithorax were barely audible. Chest X-ray revealed a large TAA (Figure). Hemoglobin was 10.5 g/dL (normal renal, adrenal, thyroid function), erythrocyte sedimentation rate was 60 mm/h, serum sodium level was 124 mmol/L, urine sodium level was 43 mmol/L, and urine osmolality was 693 mOsm/kg.
      Figure thumbnail gr1
      FigureThe patient's chest X-ray 2 years prior (left) showing moderate enlargement of the aortic arch, and on admission (right) showing huge aortic aneurysm filling the left upper hemithorax.
      Chest computed tomography was ominous (Supplemental Figure A and B, available online at http://www.mayoclinicproceedings.org). He died suddenly hours later.
      Most TAAs are asymptomatic and discovered incidentally on imaging in patients older than 55 years.
      • Isselbacher E.M.
      Thoracic and abdominal aortic aneurysms.
      Current guidelines recommend intervention for any symptomatic TAA (regardless of size), aortic diameter of more than 55 mm, or rapid expansion (>5 mm/y) to anticipate acute aortic events (dissection/rupture).
      • Kim J.B.
      • Kim K.
      • Lindsay M.E.
      • et al.
      Risk of rupture or dissection in descending thoracic aortic aneurysm.
      However, most patients with type A dissections have smaller-diameter aneurysms,
      • Pape L.A.
      • Tsai T.T.
      • Isselbacher E.M.
      • et al.
      International Registry of Acute Aortic Dissection (IRAD) Investigators
      Aortic diameter > or = 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD).
      and recent studies suggest a need to consider a lower threshold for repair.
      • Kim J.B.
      • Kim K.
      • Lindsay M.E.
      • et al.
      Risk of rupture or dissection in descending thoracic aortic aneurysm.
      Medial degeneration is the principal pathology, accelerated by hypertension and atherosclerosis risk factors. Our patient's refusal to consider intervention led to a prolonged natural history of relentless expansion (faster the larger the diameter) and myriad symptoms due to compression of the trachea and lung (causing dyspnea), esophagus (dysphagia), and recurrent laryngeal nerve (hoarseness). Despite the aortic arch aneurysm (10% of TAAs), he had neither acute neurological symptoms nor thromboembolism.
      • Isselbacher E.M.
      Thoracic and abdominal aortic aneurysms.
      His syndrome of inappropriate antidiuretic hormone secretion has not been previously reported in TAA to our knowledge.
      Lack of intervention led to the inevitable conclusion.
      • Davies R.R.
      • Goldstein L.J.
      • Coady M.A.
      • et al.
      Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size.
      He died of probable TAA rupture, heralded by mild pain and the “bulge sign” (Supplemental Figure A and B, available online at http://www.mayoclinicproceedings.org) on the computed tomography scan.

      Acknowledgements

      The expertise of Y. Drahy, MD, in the analysis of the imaging studies is gratefully acknowledged.

      Supplemental Online Material

      Supplemental Online Material

      Supplemental material can be found online at http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.

      References

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