Aortic Pseudoaneurysm Caused by Migration of a Swallowed Sewing Needle
Interventional Radiology and Endoscopic Management
A white 64-year-old woman who made dresses for her livelihood was admitted to the emergency department for evaluation of acute chest pain and respiratory distress. Physical examination was unremarkable except for low arterial blood pressure (90 mm Hg systolic, 65 mm Hg diastolic), whereas ECG showed left atrial enlargement, possible previous septal myocardial infarction, negative T waves in the inferior leads, and no evidence of acute ischemia (Figure 1). Myocardial enzyme levels, including Troponin I, were within normal values after serial determination.
Chest x-ray was performed and showed a thin radiopaque foreign body at the 5° body of the thoracic vertebra level, near the trachea (Figure 2). When questioned specifically, the patient mentioned the possible accidental ingestion of a sewing needle approximately 1 month before her chest pain began. A contrast-enhanced multidetector computed tomography (MDCT) scan of the thorax was then performed, which confirmed the presence of the foreign body, located in the mediastinum between the esophageal wall and the aortic arch, and a pseudo-aneurysm of the medial aortic arch wall above the needle (Figures 3 through 5⇓⇓). The bottom of the needle was close to the esophageal wall, with no signs of mediastinitis. It was hypothesized that migration of the sewing needle from the esophagus into the mediastinum could have produced a lesion in the aortic wall, resulting in a pseudoaneurysmal dilatation of the vessel.1–3
According to the American Society of Anesthesiologists classification, the patient was considered as a “class 3 preoperative risk” for conventional thoracic open surgery. A less-invasive procedure was thought to be the implantation of a thoracic aortic endoprosthesis, with subsequent removal of the needle through mediastinoscopy.4 Doppler ultrasound was performed and showed normal blood flow of vertebral, carotid, and Willis arteries, and an aortic arch angiogram demonstrated the pseudoaneurysm arising just behind (<1 cm from) the left subclavian artery (Figure 6).
The patient underwent endovascular repair under general anesthesia. The thoracic aortic stent graft was inserted under fluoroscopic guidance just distal to the left common carotid artery, covering the left subclavian artery origin. The final aortogram revealed the complete exclusion of the aortic arch pseudoaneurysm without endoleak and a delayed revascularization of the left subclavian artery by the omolateral vertebral artery (Figure 7).
Contrast-enhanced MDCT scan of the thorax confirmed, 3 days after the thoracic endoprosthesis implantation, the exclusion of the pseudoaneurysm and showed that the bottom of the sewing needle had been moved into the esophageal lumen (Figure 8). An upper gastrointestinal endoscopy was performed, under thoracic fluoroscopy, with identification of the bottom of the sewing needle, which was easily removed with no complications (Figures 9 through 11⇓⇓).