abstract

BACKGROUND:

Thoracic aortic aneurysms (TAA) are degenerative and are often associated with risk factors for atherosclerosis.  TAA often manifest in known genetic connective tissue disorders such as Marfan’s, Loeys-Dietz, or Ehlers-Danlos syndrome. Also have been associated to familial history independent of genetic syndromes.

AIM:
To present a case of a patient presenting with ascending aortic aneurysm complicated with descending aortic aneurysm extending into the abdomen.

METHODS:
A PubMed search was performed searching for single or multiple cases looking for patients who presented with, managed, and/or treated for ascending and descending aortic aneurysms. Terms used in searches include: Ascending Aortic Aneurysm, Descending Aortic Aneurysm, Thoracic Aortic Aneurysms, Abdominal Aortic Aneurysms, and Dissection. Search results provided over 500 case reports, studies, and review articles – of which 6 cases and studies referred to patients having patients having presented with ascending aneurysms complicated by descending aneurysms, dissection or rupture.

RESULTS:
58 year old African American male with past medical history of hypertension, hyperlipidemia, DJD, right hip replacement, and history of noncompliance with medications, with known ascending aortic aneurysm (refused surgery) presented to an outside hospital with dizziness and elevated blood pressures. Patient is a chronic smoker and heavy drinker, only able to walk 1 block before stopping due to fatigue and leg pain. CT peformed found he had 11cm ascending aortic aneurysm, complicated with dissection, and thoracic descending aortic aneurysm extending to the abdomen. Patient was transferred for further medical and surgical management.

Patient was afebrile, heart rates in 60s, systolic BP 120-150, diastolic BP 70-90. Pt was medically managed with carvedilol, amlodipine, lisinopril, clonidine, and furosemide. On physical exam: patient was alert and oriented; lungs were clear to ausculation; normal S1 and muffled S2 with a systolic ejection murmur and early diastolic murmur at the left sternal border; abdomen was distended with palpable pulsatile aneurysm; extremities pulses were diminished bilaterally with no edema; face was remarkable for hypertelorism with eyes being widely separated. Baseline EKG showed sinus rhythm with incomplete right bundle block branch and inferior ST-T abnormality. Creatinine was elevated at 1.43, hemoglobin 12.7, no leukocytosis, and no electrolyte abnormalities. Transthoracic echo with LVEF of 62%, with moderate aortic insufficiency. Transesophageal echo showed normal LVEF, mild mitral regurgitation, moderate aortic insufficiency, with dilated ascending aorta with intramural hematoroma and dissection at descending. CTA neck with occluded left internal carotid artery; CTA coronaries were normal.

Patient underwent successful ascending aortic and aortic arch replacement. Post-operative patient was successfuly extubated and transferred to the telemetry unit. His course was complicated by acute respiratory failure secondary to hospital acquired pneumonia require initially continue bipap and antibiotics; patient required O2 nasal cannula at discharged to rehab. Patient is to undergo rehab and cardiac rehab with plan to repair the descending aortic aneurysm in the future.

Conclusion:




Discussion: