Medical Image of the Week: Tortuosity of Thoracic Aorta Mimicking a Lung Mass

Figure 1. PA (A) and lateral (B) chest X-ray showing a 5x4 cm round mass with sharp margins in retrocardiac area.

Figure 2. A-C: Initial CT image showing thoracic aorta acutely angulated above the diaphragm and crossing to the right side of the chest. Then the aorta acutely angulates again and descends into the abdomen on the right. D: Follow-up CT image after 2 years showing saccular dilatation of transverse area of thoracic aorta.

An 83-year-old female presented with epigastric discomfort and nausea for 1 month. Her past medical history included hypertension and osteoarthritis. Her vital signs at were unremarkable. Her electrocardiogram revealed only atrial premature beats. Laboratory examination, including complete blood count, liver function test, blood urea nitrogen, creatinine, and electrolytes were normal.

Esophagogastroduodenoscopy revealed minimal changes of reflux esophagitis, erosive gastritis, and extrinsic compression of lower esophagus. Her chest x-ray (Figure 1) showed a 5x4 cm sized round retrocardiac mass with sharp margin. Chest CT was ordered to evaluate the lung mass and it revealed that acutely angulated lower thoracic aorta which crossed from left to right above the left diaphragm (Figure 2). After treatment with a proton pump inhibitor and a gastrointestinal pro-motility agent, her symptoms gradually decreased. Follow-up CT after 2 years shows saccular dilatation of the transverse area of thoracic aorta (Figure 2D), however, she has no specific symptoms.

Abnormal vascular structures like a severe tortuous thoracic aorta occasionally can be confused with a lung mass or neoplasm. The most common cause of aortic disease mimicking lung mass on CXR is an aortic aneurysm (1). Some cases have reported an intervention or even an operation being performed. The symptoms of tortuosity of thoracic aorta are varied from asymptomatic to dysphagia, gastroesophageal reflux, nausea and vomiting (2). Therefore, clinical symptom is not helpful to diagnose the underlying cause. As in this case, chest computed tomography (CT) can be beneficial for the differential diagnosis between vascular lesion and lung mass. Chest CT also gives additional information for communication of the aneurysm with the aorta, relationship of vascular structure to mediastinal organs. In children, Loeys-Dietz syndrome or arterial tortuosity syndrome should be considered (3). If aortic aneurysm or tortuosity of aorta is diagnosed as a cause in older age, close observation should be performed because of the possibility of progression to aortic aneurysm, dissection or compression of adjacent organs.

Jong Seol Park, MD and Yong Sung Kim, MD, PhD

Department of Internal Medicine

Wonkwang University Sanbon Hospital

Gunpo, Korea

References

1. Wixson D, Baltaxe HA, Sos TA. Pitfalls in the plain film evaluation of the thoracic aorta: the mimicry of aneurysms and adjacent masses and the value of aortography. Part I. Transverse aortic arch. Cardiovasc Radiol. 1979 Apr 27;2(2):69-76. [CrossRef] [PubMed]
2. Badila E, Bartos D, Balahura C, Daraban AM. A rare cause of Dysphagia - Dysphagia aortica - complicated with intravascular disseminated coagulopathy. Maedica (Buchar). 2014 Mar;9(1):83-7. [PubMed]
3. Na KJ, Park KH. Multiple aortic operations in loeys-dietz syndrome: report of 2 cases. Korean J Thorac Cardiovasc Surg. 2014 Dec;47(6):536-40. [CrossRef] [PubMed] 

Cite as: Park JS, Kim YS. Medical image of the week: tortuosity of thoracic aorta mimicking a lung mass. Southwest J Pulm Crit Care. 2017;15(2):80-1. doi: https://doi.org/10.13175/swjpcc086-17 PDF 

Medical Image of the Week: Massive Abdominal Aortic Aneurysm

Figure 1. Non-contrast CT A) axial, B) sagittal, and C) coronal views demonstrate a massive abdominal aortic aneurysm measuring 12.5 cm wide at maximal diameter.

Figure 2. Representative images from a CT-angiogram shows A) upper and B) lower abdominal axial sections showing renal artery involvement (red arrow) and substantial intramural thrombus (light blue brace). C) Coronal view demonstrates fusiform dilation of the iliacs (green arrow) and D) sagittal view demonstrates involvement of the thoracoabdominal aorta (pink arrow) and all major arterial branches of the abdominal aorta (celiac trunk, superior and inferior mesenteric arteries; dark blue arrows).

An 88 year-old presented to the emergency department with left flank and lower back pain as well as lower abdominal fullness. The fullness had started 2 days prior, but the left flank pain acutely started in the early morning before presenting. He had a history of unmedicated hypertension, hyperlipidemia, and mild vertigo. His review of systems was positive for chills and difficulty urinating but no hematuria. He was a non-smoker, and had undergone orthopedic surgeries but had otherwise avoided emergent hospitalizations.

On exam, vitals were unremarkable; there was no flank nor costovertebral angle tenderness; however, a midline pulsatile mass was present. An initial non-contrast CT abdomen/pelvis revealed a massive abdominal aortic aneurysm (AAA, Figure 1). Follow-up CT angiogram of the AAA can be seen in Figure 2. Upon further questioning, he had undergone a research study some 30 years earlier involving ultrasound to screen for AAA and was told he did not have one at the time.

AAA’s occur in 4-9% of the population (1-3) because of the diminished elastin in the infrarenal aorta. Inciting or etiologic factors include inflammatory, genetic and biochemical mediators, with positive risk factors including white race, atherosclerosis, smoking, male gender, hypertension, personal history of other arterial aneurysms, family history of AAA’s, and advancing age. Screening all men aged 65-79 has been shown to reduce mortality (2) despite the non-trivial mortality associated with elective AAA repair (3). Only 1% of 65 year-old men with a negative ultrasound will go on to develop an AAA (2).

The feared and fatal complication of AAA is rupture, and occurs in 10,500 ± 1,500 patients yearly in the U.S.A., with larger AAA’s posing higher annual risk of rupture (1-3). Emergent surgical repair mortality in the 30-50% that survive a rupture long enough to go to the operating room is roughly 50%.

The extensive nature of this patient’s aneurysm would have made for a nearly-impossible surgery, with operative mortality estimates between 15% using the British Aneurysm Repair Score (3) to 50% based on clinical opinion. This dissuaded the patient, his family, and vascular surgery team from pursuing elective repair. The patient desired discharge with pain medications and stricter blood pressure control with outpatient follow-up.

Michael Larson, M.D., Ph.D.

Tucson Hospitals Medical Education Program

Tucson, AZ, USA

References

1. Lederle FA. Ultrasonographic screening for abdominal aortic aneurysms. Ann Intern Med. 2003 Sep 16;139(6):516-22. [CrossRef] [PubMed]
2. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD002945. [CrossRef] [PubMed]
3. Grant SW, Hickey GL, Grayson AD, Mitchell DC, McCollum CN. National risk prediction model for elective abdominal aortic aneurysm repair. Br J Surg. 2013 Apr;100(5):645-53. [CrossRef] [PubMed]

Cite as: Larson M. Medical image of the week: massive abdominal aortic aneurysm. Southwest J Pulm Crit Care. 2016:13(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc052-16 PDF

Medical Image of the Week: Atherosclerotic Aneurysm of Great Vessels

Figure 1.Unsual appearance of the aortic root with irregular contours and a 41 x 37mm dilatation at the level of the sinuses of Valsalva.

Figure 2. Saccular outpouchings of the intrathoracic great vessels.

Figure 3. Video of the MRI images of the intrathoracic vascular abnormalities.

A 60 year-old man with a 33 pack-year history of tobacco abuse, presented with difficulty speaking and voice change for several weeks. His review of systems was positive for fatigue, night sweats and weight loss. Physical exam of the oropharynx with flexible laryngoscopy demonstrated immobile bilateral true and false vocal cords fixed in the para-median position without laryngeal lesions. Concern for intra-thoracic process with recurrent laryngeal nerve involvement, a computed tomography (CT) of the chest and thoracic vessels demonstrated unusual appearing arteries with multiple penetrating atherosclerotic ulcers versus saccular aneurysms scattered throughout the aorta and its major branches (Figures 1 and 2). A magnetic resonance imaging (MRI) with contrast, demonstrated multiple foci of saccular outpouchings involving the arch vessels distal to their origins with the largest dilatation measuring 26 x 25 mm in the case of proximal innominate (Figure 3). Although imaging lacked resolution, it was specialist opinion that patient likely had compression of recurrent laryngeal nerve leading to vocal cord dysfunction without significant airway compromise.

Atherosclerotic aneurysms of the great vessels are rare with evidence limited to case series (1,2). Patient presentation varies dependent on the structures involved including embolic phenomenon from atherosclerosis. Surgical intervention with endovascular approach remains treatment of choice with good success rate.

Given our patient’s poor nutritional status, multiple co-morbidities and diagnosis of large colonic mass, risks of surgery outweighed benefits of intervention and thus outpatient follow up was recommended.

Faraz Jaffer, MD and Don Leo Pepito, MD

Department of Internal Medicine

Banner-University Medical Center – South

Tucson, AZ

References

1. Cury M, Greenberg RK, Morales JP, Mohabbat W, Hernandez AV. Supra-aortic vessels aneurysms: diagnosis and prompt intervention. J Vasc Surg. 2009;49(1):4-10. [CrossRef] [PubMed]
2. Kasashima F, Urayama H, Ohtake H, Watanabe Y.Intrathoracic aneurysm of the innominate and right subclavian arteries: report of a case. Surg Today. 2001;31(1):51-4. [CrossRef] [PubMed] 

Cite as: Jaffer F, Pepito DL. Medical image of the week: athersclerotic aneurysm of great vessels. Southwest J Pulm Crit Care. 2015;11(5):231-2. doi: http://dx.doi.org/10.13175/swjpcc104-15 PDF