Successful management of a delayed presentation of traumatic descending thoracic aorta pseudoaneurysm: a literature review based on a case report.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second leading cause of death due to traumas in young patients. The primary presentation might be chest or interscapular pain, difficulty in breathing, and, in severe cases, hypotension. Considering the rapid deterioration of these patients' clinical conditions, prompt diagnosis and treatment initiation are crucial. In these injuries, the most involved parts of the aorta are the isthmus (distal to the left subclavian artery) and the descending part in the thorax. Therefore, the main diagnostic strategies include transthoracic echocardiography, CT angiography, and endovascular diagnostic approaches. Case presentation The patient was a 19-year-old male presenting with the symptoms of chest pain, dyspnea, and extremities excruciating pain after a car turnover. The initial evaluation showed no abnormal cardiovascular finding except bilateral hemothorax, addressed with chest tubes. Twelve hours later, when the patient was under observation for orthopedic surgeries, his chest pain and dyspnea started, and TTE and CTA showed a grade three descending aneurysm of the aorta. The patient was treated immediately with an endovascular procedure of stent implantation. A delayed debranching surgery was also performed, which resulted in desirable outcomes and uneventful follow-up. CONCLUSION: Although open thoracic surgery is the main and almost the only option for treating aneurysms of the aorta in hemodynamically unstable patients, the endovascular procedure has shown superior outcomes in selected patients with appropriate anatomy. Debranching surgery, which can be done simultaneously or with delay after the initial procedure, has proven protective against thromboembolic cerebral events. CLINICAL KEY POINT: Patients with an aneurysm of the aorta should be transported to a medical center with a multidisciplinary team for an urgent evaluation and treatment. The initial resuscitation and diagnosis are challenging, considering the fatal nature of these injuries, and the selection of the treatment is based on the patient's clinical condition and evaluated anatomy in cardiovascular imaging.

Case Report: Coil embolization of ascending aortic pseudoaneurysm in patient with Behcet's disease.

Background: Behcet's disease (BD) is a systematic vasculitis that affects vessels with various sizes, presenting as venous thrombosis and arterial pseudoaneurysms. The most severe manifestation in BD is ascending aortic pseudoaneurysm, which is associated with high risks of rupture and mortality. Case presentation: We present a case of ascending aortic pseudoaneurysm in a 50-year-old patient with BD. After preoperative evaluation, coil embolization was successfully performed to treat the pseudoaneurysm, resulting in a satisfactory outcome at the 1-year follow-up. Conclusion: Coil embolization serves as an effective treatment option for ascending aortic pseudoaneurysm in BD when open surgical repair and stent graft placement are unsuitable.

Devastating fungal endocarditis involving ascending aorta in a patient with a history of aortic valve replacement: a case report.

BACKGROUND: Fungal endocarditis is a rare but serious condition associated with high mortality rates. Various predisposing factors contribute to its occurrence, such as underlying cardiac abnormalities, cardiac surgeries, prosthetic cardiac devices, and central venous catheters. Diagnosing fungal endocarditis, particularly Aspergillus, poses challenges, often complicated by negative blood cultures. CASE PRESENTATION: This report details a case of extensive ascending aorta involvement in Aspergillus endocarditis (AE) in a 24-year-old man with a history of bioprosthesis aortic valve replacement (AVR). Three months post-AVR, he presented with pericardial effusion and aortic rupture, leading to a redo biological valved conduit aortic root replacement (Bentall surgery). Despite the intervention, the tubular graft exhibited extensive Aspergillus involvement, resulting in graft disruption and significant peri-aortic infection. A second redo procedure involving aortic homograft root replacement was performed. Unfortunately, the patient succumbed two days after the surgery. CONCLUSION: A combined approach of medical and surgical therapies is recommended to manage fungal endocarditis. Despite efforts, the mortality rate associated with Aspergillus endocarditis remains unacceptably high, with no significant difference observed between combination therapy and antifungal treatment alone. Further research is essential to explore novel therapeutic strategies and improve outcomes for patients with this challenging condition.

Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: case series and literature review.

The number of vascular centers performing endovascular repair of ascending aortic disease is constantly increasing. Accordingly to the guidelines, open surgical repair remains the gold standard for these pathologies. However, approximately one quarter of patients are deemed unfit for open surgery. In this study, we describe three cases of ascending thoracic endovascular aortic repair (TEVAR) performed at our center. All the patients were deemed unfit for open surgery by the aortic team. Two patients had an ascending aortic pseudoaneurysm, and the third had a focal type A aortic dissection. In two cases, we used two abdominal aortic cuffs deployed from zone 0B to zone 0C, with no need for supra-aortic trunk debranching. In one case, we performed a "reverse" extrathoracic debranching, and we deployed a thoracic endograft from zone 0B to zone 2. Complications included one minor stroke and one inguinal hematoma. In one patient with an infected pseudoaneurysm, we performed ascending TEVAR as a bridge strategy for open repair. This patient developed a type Ia endoleak; however, clinical stabilization and infection control were obtained, and he was able to undergo heart surgery successfully. He underwent a second reintervention to treat superior mesenteric embolic occlusion. At 2 years of follow-up, all three patients were alive. Our preliminary experience demonstrates the technical feasibility and clinical appropriateness of ascending TEVAR using standard, commercially available endografts. However, no consensus has been reached regarding some critical aspects, such as the development of a standardized technique or the efficacy of the currently available devices. The improvements in graft design and the adoption of the "aortic team" approach could help in the near future to standardize the procedure, establish appropriate indications, and ensure good clinical outcomes.

Life-Threatening Hemoptysis From Aorto-Bronchial Fistula in a Patient With Remote History of Aortic Coarctation Repair.

"Hemoptysis" refers to the expectoration of blood from the respiratory tract. However, "life-threatening hemoptysis" includes any volume that leads to features such as airway obstruction, hypoxia, or hemodynamic instability. We present a case of life-threatening hemoptysis in a 65-year-old male with a history of benign prostatic hyperplasia and uncontrolled hypertension. Radiological investigations revealed a pseudo-aneurysm at the site of a prior thoracic aortic coarctation repair more than 50 years prior in childhood. He required vascular surgical intervention, during which there was evidence of an aorta-bronchial fistula as the likely cause of bleeding. Following the repair and optimal blood pressure control, the patient had no further episodes of hemoptysis and was discharged from the hospital. His case not only adds to the growing body of medical literature reporting hemoptysis as a complication of coarctation repair but also highlights the aorto-bronchial fistula as a possible and potentially catastrophic mechanism for bleeding in these patients.

Percutaneous repair of a sinotubular junction aortic pseudoaneurysm with an atrial septal defect occluder: a case report.

Background: Aortic pseudoaneurysms are complications that arise following cardiac surgery, thoracic trauma, infections, or inflammatory conditions. The mainstay treatment for aortic pseudoaneurysm is surgical management. Given significant morbidity and mortality related to thoracotomy, high-risk patients are not considered for cardiac surgery. Novel percutaneous repair using a variety of devices are being explored, especially in those with prohibitive risk for cardiac surgery. Case summary: This case describes the use of an Amplatzer atrial septal defect (ASD) occluder device to manage an aortic pseudoaneurysm in a 69-year-old male who had previously undergone coronary artery bypass graft surgery and pericardial drainage for purulent pericarditis. Following successful implant, there were no complications seen after 2 years of follow-up. Discussion: Percutaneous closure of a mycotic pseudoaneurysm with an Amplatzer ASD occluder device can be a safe and efficacious treatment option, especially in patients with prohibitive surgical risk.

False aneurysms of the thoracic aorta: anastomosis investigation using the inflation-extension test.

INTRODUCTION: False aneurysms in the thoracic aorta are dangerous complications that can occur after cardiac surgery. They often result in high mortality rates. These aneurysms are caused by damage to all layers of the aortic wall. This study aimed to pinpoint the area of the experimental specimen (native vessel, anastomosis, or prosthetic graft) with the greatest deformation, to determine whether a false aneurysm is likely to develop in the anastomotic portion. METHODS: We conducted the inflation-extension test by performing eight cycles ranging from 0 to 20. The pressure sampling frequency was 100 Hz, and each cycle lasted approximately 34 seconds, resulting in a loading frequency of 0.03 Hz. During the experiment, each camera captured 3,000 frames. Based on the data collected, we evaluated and compared the loading stages of cycle 1 and cycle 8. RESULTS AND DISCUSSION: During loading, the native vessel experienced a dominant deformation of approximately 7% in the circumferential direction. The prosthetic graft, which had a longitudinal construction, deformed by approximately 8% in the axial direction. The prosthetic graft, on the other hand, only experienced a deformation of up to 1.5% in the circumferential direction, which was about 5 times smaller than the deformation of the native vessel. The anastomosis area was very stiff and showed minimal deformation. Additionally, there was little difference in the mechanical response between the first C1 and the eighth C8 cycle. CONCLUSION: Based on the available evidence, it can be inferred that aortic false aneurysms are more likely to form just behind the suture lines in the native aorta, which is more elastic compared to stiff sections of anastomosis and prosthetic graft. Numerous pulsations of the native vessel will likely cause the impairment of the aorta at the margin of the anastomosis. This will lead to disruption of the aortic wall and false aneurysm formation in the native vessel near the area of anastomosis.

Comprehensive multi-modality treatment of thoracic aorta pseudoaneurysms: a single-center experience.

INTRODUCTION: Thoracic aorta false aneurysms (TAFA) are unexplored complications after cardiac surgery associated with significant morbidity and mortality. Therefore, the purpose of this study was to examine the clinical profiles, surgical techniques, and operative outcomes, of patients treated for TAFA at a single institution. METHODS: From 1996 to 2022, 112 patients were treated for aortic pseudoaneurysm (mean age 55 ± 14 years, 78 patients were male). In the majority of the patients (90%) TAFA developed after previous cardiovascular surgery, the most common diagnosis and surgical procedure preceding the TAFA development was an aortic dissection (52%) and Bentall procedure (47%). In the rest of the cohort, the leading cause was trauma. RESULTS: Sixty-one percent of patients were indicated for reintervention (surgical reoperation, endoluminal graft implantation, septal occluder implantation, coil embolization, or a combination of procedures). Overall, 52 patients had undergone cardiac reoperation. TAFA was resected and the aorta was repaired in 55% or replaced in 45%. Operative mortality was 5.7%. In postoperative follow-up, a hypoechogenic lesion encircling aortic prosthesis was present in 94%, therefore it was determined as a negative prognostic factor. The mean follow-up was 13.2 ± 19.4 years. CONCLUSION: Although there is no specific approach how to prevent TAFA development, maintaining normal blood pressure and regular follow-up should be applied. More frequent follow-ups should be performed in patients with a hypoechogenic lesion encircling and aortic prosthesis. Early detection during long-term postoperative follow-up, an individually tailored approach of a multidisciplinary team is necessary for favorable treatment outcomes.

Large Ascending Aortic Pseudoaneurysm with Focal Dissection after Coronary Artery Bypass Surgery.

Background There are many known complications that occur after surgical revascularization for patients with significant left main coronary artery disease. Case Description This case report highlights the preoperative workup, surgical approach, and postoperative management of a patient who presents with an aortic pseudoaneurysm and dissection 2 years after the index CABG. Conclusion The development of an aortic pseudoaneurysm in combination with an ascending aortic dissection after prior coronary artery bypass grafting (CABG) is a rare compilation of complications that has scarcely been reported in the literature.

A case report of transcatheter closure of post-Bentall ascending aortic pseudoaneurysm due to coronary button dehiscence.

Background: Ascending aortic pseudoaneurysm due to coronary button dehiscence is a rare, yet life-threatening complication of reconstructive cardiac surgery. Because of its rare entity, large data are lacking, and therefore, treatment guidelines are missing. Case summary: We describe a case of a 53-year-old male with a past medical history of ascending aortic aneurysm and severe aortic regurgitation who underwent Bentall procedure with 26 mm conduit and mechanical aortic valve 1 year before. Follow-up chest computed tomography (CT) revealed coronary button dehiscence with a giant aortic root pseudoaneurysm and mural thrombus inside. Given the risk of rupture, the heart team decided to go for a percutaneous approach. Based on a pre-interventional 3D reconstructed CT scan and guided by transoesophageal echocardiography and intravascular ultrasound, the pseudoaneurysm was successfully occluded with a 6 × 4 mm Amplatzer Duct Occluder II and simultaneous left main coronary artery (LMCA) stenting with a 4.0 × 15 mm drug-eluting stent. Post-procedural chest CT and echocardiography revealed minimal contrast leakage posterior to the aortic root and para LMCA region, confirmed thrombosis formation post occluder and stent deployment, and patent flow of LMCA. Discussion: We describe the successful 3D reconstructed CT scan and peri-procedural transoesophageal echocardiography-guided percutaneous treatment of a giant aortic root pseudoaneurysm with an occluder and a drug-eluting stent with excellent results.

Zone 2/3 lesion and emergency repair as potential mortality predictors of TEVAR for thoracic aortic pseudoaneurysm.

OBJECTIVE: Thoracic aortic pseudoaneurysm (TAP) is an uncommon but life-threatening condition. The present study aimed to investigate the early and midterm clinical outcome of TAP patients following TEVAR and identify potential mortality predictors. METHODS: We retrospectively reviewed a series of 37 eligible patients with TAP admitted to our hospital from July 2010 to July 2020. We explored their baseline, perioperative and follow-up data. Fisher exact test and Kaplan-Meier method were applied for comparing difference between groups. RESULTS: There were 29 men and 12 women, with the mean age as 59.5 ± 13.0 years (range 30-82). The mean follow-up period was 30.7 ± 28.3 months (range 1-89). For early outcome (≤ 30 days), mortality happened in 3 (8.1%) zone 3 TAP patients versus 0 in zone 4 (p = 0.028); postoperative acute arterial embolism of lower extremity and type II endoleak respectively occurred in 1(2.7%) case. For midterm outcome, survival at 3 months, 1 year and 5 years was 88.8%, 75.9% and 68.3%, which showed significant difference between zone 2/3 versus zone 4 group (56.3% vs. 72.9%, p = 0.013) and emergent versus elective TEVAR group (0.0% versus 80.1%, p = 0.049). Previous stent grafting or esophageal foreign body with Aortoesophageal fistula (AEF), and systemic vasculitis, as etiologies, resulted in encouraging immediate outcome but worse midterm prognosis. CONCLUSION: TAP lesions at zone 2/3 and emergent TEVAR predict worse midterm outcomes compared to zone 4 lesions and elective TEVAR. The outcomes are also mainly restricted by the etiology of the TAP.

Hemolytic Anemia Occurring 14 Years after Ascending Aortic Replacement for Acute Type A Aortic Dissection Due to Aortic Pseudoaneurysm Derived from Anastomotic Leakage: A Case Report.

A 64-year-old male patient who presented with symptoms indicative of hemolytic anemia was referred to our hospital. After obtaining the patient's history, it was found that hemolysis occurred 14 years after he underwent ascending aortic replacement for acute type A aortic dissection. Enhanced computed tomography revealed an aortic pseudoaneurysm at the proximal anastomosis, which was thought to be the cause of hemolysis. Furthermore, aortic valve regurgitation and dilatation of the sinus of Valsalva were also found on a transthoracic echocardiogram. Therefore, the Bentall procedure was performed. During the surgery, aortic pseudoaneurysm formation and vascular graft stenosis were observed. The postoperative course was uneventful, and hemolysis diminished soon after the surgery.

Case report: Endovascular stent-graft repair of aortic penetrating trauma, literature review, and case report.

Penetrating aortic injuries are infrequent. Its incidence is unknown because most patients die of hemorrhage even before they receive adequate treatment. Aortic wounds generally require conventional thoracotomy/laparotomy repair and are related to high mortality rates. Recently with the advent of endovascular techniques, most authors prefer endovascular management when feasible due to better (still poor) outcomes. The short- and mid-term results of immediate endovascular repair of traumatic aortic injuries are promising, especially when compared with open surgical treatment, indicating that endovascular therapy is preferable in patients with multi-trauma and traumatic ruptures of the thoracic aorta. Here we present the diagnosis and treatment of a 30 years-old male patient with multiple traumatic stab wounds, including anterior aortic laceration with a grade II aortic lesion successfully managed with an endovascular stent graft.

Atypical presentation and percutaneous repair of ascending aortic pseudoaneurysm: a case report.

Background: Ascending aortic pseudoaneurysms (AAPs) are an unusual complication of cardiac or aortic surgery and are associated with a high risk of complications and mortality. Guidelines recommend surgical repair. There is few data concerning percutaneous occlusion of AAP. We present a case of syncope due to vascular and heart chamber compression by a large post-surgical AAP that was filled through a focal leak. Ascending aortic pseudoaneurysm was successfully occluded percutaneously. Case summary: A 66-year-old man with a mechanical aortic prosthesis and a Dacron tube in the ascending aorta presented with syncope due to compression of the right atrium and superior vena cava by a large peritube collection. A computed tomography angiography (CTA) showed a large AAP that was filled through a small focal dehiscence of the tube proximal suture. Patient was dismissed for surgery due to high surgical risk. Then, AAP was successfully occluded percutaneously via a 6-French radial access and local anaesthesia. Discussion: In patients with syncope and previous cardiac surgery, aortic complications should be ruled out. Although transthoracic echocardiography may be useful, CTA is the recommended diagnostic test for ruling out post-surgical AAP and allows the characterization of the number, localization, and size of the leaks. In selected patients with high surgical risk and favourable anatomic characteristics, a percutaneous closure could be indicated.

Double jeopardy: Successful management of a traumatic ascending aortic pseudoaneurysm with concurrent subdural hematoma.

We present the case of a 59-year-old male who sustained an ascending aortic injury and a subdural hematoma after a head on collision. After undergoing emergent craniotomy for evacuation of the subdural hematoma, he was maintained with strict blood pressure control. Once able to be safely anticoagulated, he underwent replacement of the ascending aorta. This exceedingly rare case was managed by a multidisciplinary team approach that led to an optimal outcome given his disastrous multi-traumatic injuries.

Aortic Pseudoaneurysm as an Unusual Cause of Vocal Palsy.

The recurrent laryngeal nerve travels a variable course on either side due to the differences in the structures related during development. The nerve is at risk of injury due to a number of pathologies in any of these structures. We came across a very rare pathology causing vocal palsy in a 62-year-old male with hoarseness of voice. Laryngoscopy examination showed left vocal cord palsy without any obvious laryngeal mass. Contrast-enhanced computed tomography study of the neck and chest revealed aortic arch pseudoaneurysm with left vocal cord palsy.

Traumatic aorta injuries in a rural area: late manifestations and review of therapeutic aspects.

Traumatic thoracic aortic injuries (TTAI) are associated with high rates of morbidity and mortality. They are classified according to the extent of damage and computed tomography angiography has the highest sensitivity and specificity for identifying the degree of injury and potential associated lesions. Treatment strategies for TTAI are based on the type and extent of injury and associated lesions. The patient's degree of stability can also help to define the choice of treatment, which can be conventional or endovascular surgery (EVAR) or even conservative management in selected cases. Among patients with adequate vascular anatomy, endovascular surgery is associated with better survival and fewer risks. The objective of this article is to describe a series of four cases followed up at a tertiary service in a Brazilian state that has few centers that provide high complexity care. Endovascular therapy was employed as the preferred method. All four patients had favorable outcomes, with no complications up to discharge, and are currently in outpatient follow-up.

In situ reconstruction of an infected infrarenal aortic pseudoaneurysm and arteriovenous fistula with self-made pericardium graft.

Infectious aortic disease is a challenging life-threatening disease in cardiovascular surgery. A 70-year-old man patient presented with an infected infrarenal aortic pseudoaneurysm and right iliac artery- left iliac vein fistula (arteriovenous fistula). He underwent total infected tissues excision, debridement, in situ reconstructions of the aorta using a self-made pericardium graft with omental coverage and arteriovenous fistula patch repair to prevent leakage. One-year follow-up revealed the absence of clinically relevant infection with patency of the graft and the absence of biochemical inflammatory markers.