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(Circulation. 2005;111:e303.)
© 2005 American Heart Association, Inc.

Images in Cardiovascular Medicine

Leaking Saccular Aortic Arch Aneurysm

Shekar L.C. Reddy, FRCS; Stephen Livesey, FRCS; Ivan Brown, FRCR

From the Wessex Cardiothoracic Centre, Southampton General Hospital, Southampton, UK.

Correspondence to Mr L.C.S. Reddy, FRCS, 40 Langham Close, North Baddesely, Southampton, Hampshire, UK SO52 9NT. E-mail reddylcs{at}aol.com

A 71-year-old man complained of central chest pain radiating to his back and neck and both arms. Investigations for ischemic heart disease were negative. Chest x-ray showed a soft tissue density in the aortopulmonary area. CT scan revealed a saccular aneurysm arising from the inferolateral aspect of the mid-transverse arch of the aorta, measuring a maximum diameter of 7 cm (Figure 1). The presence of fluid in the left pleural space signified a leaking aortic aneurysm. Aggressive management of blood pressure was undertaken, and the patient was promptly transferred to surgery.

View larger version (160K): [in this window] [in a new window]   Figure 1. Three-dimensional surface-shaded reconstruction of a contrast-enhanced CT scan of the chest.

Left lateral thoracotomy through the fourth intercostal space was performed. Blood (1.5 L) was aspirated from the pleural space. An impressive saccular aneurysm arising from the undersurface of the aortic arch, displacing the surrounding structures, was noted. The left phrenic nerve was paralyzed, raising the left hemidiaphragm. The left recurrent laryngeal nerve was displaced dorsally by mass effect of the aneurysm. The apex of the aneurysm showed areas of wall weakness, which facilitated the leakage of blood (Figure 2, arrow). Cardiopulmonary bypass was established by cannulating the left atrial appendage for drainage and descending thoracic aorta for arterial return. With circulatory arrest, the aneurysm was carefully dissected and excised. Inspection of the aneurysm from inside showed areas of porosity and defects in the vessel wall thickness, which permitted blood seepage. After excision, the defect in the aortic wall measuring 3.5 cm x 3.5 cm was repaired with bovine pericardium. The patient made a complete recovery without evidence of recurrent nerve injury. It is rare to see such incipient and impending rupture of an aortic arch saccular aneurysm. These images reinforce the need for aggressive preoperative management of arterial pressure and prompt surgical intervention.

View larger version (148K): [in this window] [in a new window]   Figure 2. Leaking saccular aortic arch aneurysm. The arrow identifies the area of leakage and impending rupture.

	Acknowledgments

 
The authors thank the CT department of St. Richards Hospital, Chichester, UK, for allowing the use of Figure 1.

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Issue Highlights
Circulation 2005 111: 2551. [Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Reddy, S. L.C. Articles by Brown, I. Search for Related Content PubMed PubMed Citation Articles by Reddy, S. L.C. Articles by Brown, I. Related Collections CT and MRI CV surgery: aortic and vascular disease Related Article