Presentation
This patient came to the hospital emergency room with complaints of pain in the thorax and abdomen that began around five months ago, progressing to severe abdominal pain in the last week. She had no respiratory distress or hematemesis and was hemodynamically stable. On examination, there was a palpable mass in the abdomen without signs of peritoneal irritation and lower extremities with pulses.
Patient Data
Contrast-enhanced computed tomography (CECT) with MPR shows Stanford type B dissection (DeBakey III) with the dissecting flap extending from the arch of the aorta distal to the left subclavian orifice, running downward through the descending thoracic and abdominal aorta, down to the emergence of the iliac arteries. True and false lumens are present at the mentioned levels. The false lumen is larger than the true lumen; both are patent. The celiac trunk, superior mesenteric artery, and right renal artery originate from the true lumen, while the left renal artery arises from the false lumen.
There is a very large aneurysmal sac dilatation in the infrarenal segment of the abdominal aorta, extending to the emergence of the iliac arteries. The aneurysm is 10 cm long longitudinally and measures 9.4 x 7.5 cm in the largest axial diameters. Such aneurysm exerts compressive effects on the left ureter, promoting upstream ureterohydronephrosis. There is a discrepancy in the enhancement of both kidneys, with a hypo-perfused left kidney.
Impression:
Stanford Type B (DeBakey III) thoracoabdominal aortic dissection.
Huge infrarenal abdominal aortic aneurysm predictive of impending rupture.
Given the presence of a giant symptomatic abdominal aortic aneurysm with the potential for imminent rupture, the patient initially underwent endovascular aneurysm repair (EVAR). Subsequently, she experienced the second procedure, which consisted of placing an endoprosthesis in the thoracic aortic with a left-right femoral-femoral bypass to treat the dissection. The medical team requested a control CT.
The control CT demonstrated a well-positioned endoprosthesis in the thoracic aorta and the absence of complications at the endovascular aneurysm repair (EVAR) site in the abdominal aorta. A pleural effusion on the left and left renal compressive ureteropyelocaliectasia persists.
Impression: Usual “Status” after EVAR and endoprosthesis placement in the aorta.
The patient progressed favorably after the procedures, and the medical team discharged her from the hospital in good clinical condition.
Case Discussion
Aortic dissection is an abnormal passage of blood into the media through an intimal tear 1-3. An abdominal aortic aneurysm occurs when a focal dilation of more than 50% of the aorta's diameter 4. Concurrent findings of aortic dissection and aneurysm formation may occur, and the aneurysm may precede or result from the dissection process 1-3. A painful giant abdominal aortic aneurysm may indicate impending rupture, justifying urgent intervention repair 4, as happened with this present patient.
This case illustrates the potential complications from aortic dissection associated with aortic aneurysm formation and highlights the clinical and CT findings that may suggest impending rupture.
Case courtesy
Murilo Pessoa, MD - PGY-2, radiology resident
Daniel Moreira - PGY-4, cardiology resident
Alexandre Magno, MD - cardiovascular surgeon
Jessica Emille de Moura Rocha, MD - physician assistant
Milena Almeida, MD - radiologist
Antonio Rodrigues de Aguiar Neto, MD - radiologist
Hospital da Restauração, and Pronto Socorro Cardiológico de Pernambuco (Procape) – Recife, PE – Brazil
Unable to process the form. Check for errors and try again.