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Journal of General and Emergency Medicine

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Case Report

Giant Pseudoaneurysm of Ascending Aorta

Andre Rodrigues Duraes, Igor Santos Schonhofen, Christiane Padua Arantes Freitas, Yasmin de Souza Lima Bitar

Correspondence Address :

Andre Rodrigues Duraes
Specialist in Cardiology by the Brazilian Society of Cardiology
Assistant Professor of Federal University of Bahia/UFBA
Brazil
Tel: 55 71 99188-8399
Email: andreduraes@gmail.com

Received on: June 19, 2017, Accepted on: July 03, 2017, Published on: July 10, 2017

Citation: Andre Rodrigues Duraes, Igor Santos Schonhofen, Christiane Padua Arantes Freitas, Yasmin de Souza Lima Bitar (2017). Giant Pseudoaneurysm of Ascending Aorta

Copyright: 2017 Andre Rodrigues Duraes, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract
Aortic pseudoaneurysms are rare, life-threatening complication that usually occurs after cardiac or aortic surgery. In most cases, pseudoaneurysms of the ascending aorta are asymptomatic. We report the case of a 54-year-old Brazilian man, asymptomatic, who presented with a giant pseudoaneurysm of the ascending aorta, without previous history of cardiac surgery. The aneurysm size was 8.5*7.4*10.3 cm. The patient died on the sixth postoperative day due to infectious complications. In this case report, our objective is to discuss of aortic pseudoaneurysm, especially in an atypical case due to exuberance in the clinical manifestation.
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Keywords: Aorta, Pseudoaneurysm, Management

Introduction
Aortic pseudoaneurysms result from disruption of the intima and media of a vessel. They are contained by the adventitia and surrounding structures of the mediastinum [1]. The incidence of ascending aortic pseudoaneurysm is rare (<1%) and mortality is high [2-4]. In most cases, ascending aortic pseudoaneurysms are asymptomatic.

Case Report
In October 2015, a 54-year-old Brazilian man, hypertensive 10 years ago and smoker 20 years ago, arrived at the hospital with a 2-year history of mass with progressive increase initially located in a region of furcular sternal and extending later to the left cervical region (Figure 1, panel A and B). He denied any other symptoms, chest trauma,
surgery or genetic disorders.
A chest computed tomography (scout view) with contrast agent showed a mediastinal enlargement with accentuation of the contours forming a shadow (Figure 1, arrows in panel C), and a giant pseudoaneurysm of the ascending aorta in axial (Figure 2, Panel A to C) and sagittal (Figure 2, panel D) reconstructing with deviation of trachea and erosion of retrosternal bony structures, a massive pseudoaneurysm of the ascending aorta, measuring in its largest axes 8.5*7.4*10.3 cm and showing a proximal right and wide neck, measuring 3.7 cm and distal neck measuring 1.6 cm. The surgery was performed with great technical difficulty. Before sternotomy, cardiopulmonary bypass (CPB) was instituted by means of right femoral artery perfusion and right femoral venous drainage. Hypothermic circulatory arrest was established. Durin sternotomy, noted destruction of the sternal manubrium and the presence of thrombus in the aortic arch. Made surgical repair with patch (Dacron),
which was placed and fixed in the area of aortic rupture and removed the trombis. CPB time was 135 minutes and circulatory arrest was 57 minutes. Unfortunately, the patient died 6 days after surgery due to septic shock secondary to nosocomial pneumonia.

Discussion
Aortic pseudoaneurysms result from the rupture of the intima and media of a vessel. They are contained by the adventitia and surrounding structures of the mediastinum [1]. The incidence of ascending aortic pseudoaneurysm is rare (<1%), and usually results from complications of cardiac surgery in which the ascending aorta is cannulated or incised. Other possible causes are infection, genetic disorders or trauma, but a large percentage is due to mechanical rupture of sutures in the aorta [1,5].
In most cases, as in this case, the pseudoaneurysms of the ascending aorta are asymptomatic. A simple chest x-ray may detect enlargement of the mediastinum and the diagnosis can be confirmed with computed tomography and echocardiogram [6].
The risk of rupture of pseudoaneurysms should be taken into account, especially of large masses, to indicate emergency treatment [5]. Despite reports of percutaneous exclusion of false aneurysms, surgery is still required for most cases [7,8].
From the surgical point of view, the treatment of pseudoaneurysms of the ascending aorta remains a challenge. The mortality presented by several authors ranges from 29 to 46%, being in most cases, as a result of fatal hemorrhage, due to rupture of the pseudoaneurysm during surgical maneuvers for its treatment [3,4]. 
In this case, the surgery was successful, but the patient died of septic shock secondary to nosocomial pneumonia.

Acknowledgments
We would like to Ana Nery Hospital Staff.

Disclosure Statement
The authors have no conflicts of interest to disclose.
References
1. Garisto JD, Medina A, Williams DB, Roger G. Carrillo. Surgical Management of a Giant Ascending Aortic Pseudoaneurysm. Tex Heart Inst J. 2010;37(6):710-713.
2. Sabri MN, Henry D, Wechsler AS, Di Sciascio G, Vetrovec GW. Late complications involving the ascending aorta after cardiac surgery. Am Heart J. 1991;121(6):1779-1783.
3. Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest. 1988;93:138-143.
4. Razzouk A, Gundry S, Wang N, et al. Pseudoaneurysms of the aorta after cardiac surgery or chest trauma. Am Surg. 1993;59(12):818-823.
5. Almeida e cols. Correcao Cirurgica de um Pseudoaneurisma da Aorta Ascendente, apos Troca Valvar Aortica. Arq Bras Cardiol. 2001;76(4):323-325.
6. Jung TE, Lee DH. Surgery for pseudoaneurysm of the ascending aorta under moderate hypothermia. J Cardiothorac Surg. 2011;6:125.
7. Malvindi PG, van Putte BP, Heijmen RH, Schepens MA, Morshuis WJ. Reoperations for aortic false aneurysms after cardiac surgery. Ann Thorac Surg. 2010;90:1437-1443.
8. Merchan A, Tejada J, Pineda T, Lopez-Minguez JR, Robles M, Fresneda P. Pulsating thoracic mass as a main symptom of gigantic pseudoaneurysm of the ascending aorta. Rev Esp Cardiol. 2002;55(4):442-445.
Tables & Figures
Figure 1. A: Showing tortuous tumor in the anterior thoracic and cervical left; B: Showing tortuous tumor in the anterior thoracic and cervical left; C: Computed tomography-scout view showing mediastinal enlargement with accentuation of the contours forming a shadow (arrows)

Figure 2. A,B,C: Chest computed tomography with axial reconstructing showing a large pseudoanerysm in ascending aorta; D: Chest computed tomography with sagittal reconstructing showing a large pseudoanerysm in
ascending aorta in craniocaudal extent with deviation of trachea and erosion of retrosternal bony structures.
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