Discussion
Patients with thoracic-abdominal aortic aneurysm usually have no
symptoms until the lesion is severe enough to cause compression of the
surrounding organs or dissection or rupture1.
Therefore, the diagnosis of thoracic-abdominal aortic aneurysm is often
accidentally discovered during imaging examinations due to other
unrelated medical diseases. This patient has no symptoms, and a huge
mass in the upper mediastinum was discovered during routine chest
radiographs. In addition, once the patient has symptoms, it often
indicates that the aneurysm is about to rupture. The most common
symptoms are pain in the chest, abdomen, and back. This pain is due to
the compression of adjacent organs by an aortic aneurysm, or it may be
due to dissection or rupture. Clinically, these symptoms should be
highly vigilant.
The diagnosis of thoracic-abdominal aortic aneurysm mainly relies on
X-ray imaging2. At present, CTA and 3-dimensional
reconstruction of the aorta have become the gold standard for
preoperative imaging. CTA plays a vital role in formulating surgical
strategies, especially when endovascular treatment is planned.
Performing 3-dimensional reconstruction while observing the axial
section will help to understand the anatomy of the aneurysm in detail.
This patient’s CTA was intuitive and provided detailed information for
disease diagnosis and surgical design.
The entire thoracic-abdominal aneurysm involves start at the root of the
aorta to the end at the bifurcation of the aorta-iliac artery. Surgery
methods include staged total aortic replacement, elephant trunk staged
total aortic replacement, or one-stage total aortic
replacement3.One-stage total aortic replacement is the
most complicated operation in aortic surgery, including the replacement
and repair of the aortic root, ascending part, arch, descending thoracic
aorta and abdominal aorta, involving the protection of all important
organs of the human body, such as heart, brain, spinal cord, lungs,
kidneys and liver. In addition, the operation time is long, the trauma
is huge, and the postoperative complications and mortality are very
high4. The patient is an older female and has obvious
aortic calcification. In order to reduce the risk of surgery, we finally
chose two-staged total aortic replacement with a stent elephant trunk,
and the clinical results were satisfactory.
In conclusion, patients with total thoracic-abdominal aortic aneurysm
may not have typical clinical symptoms and require a careful and
comprehensive physical examination and related auxiliary examinations by
clinicians. Staged repair of total thoracic-abdominal aortic aneurysms
is still a safe and effective treatment.
Conflict of interest: All authors declare that there is no
conflict of interest.
Ethical review: This study has been approved by the ethics
committee of the Chongqing Kanghua Zhonglian Cardiovascular Hospital and
DeltaHealth Hostital, and has been recognized as exempt from ethical
review.
Informed consent statemen t: Informed consent and ethical
approval were waived for this report, which contains no patient
identifiable data.
References
- Massimo CG, Presenti LF, Favi PP, Crisci C, GuadrĂ³net EAC.
Simultaneous total aortic replacement from valve to
bifurcation:experience with 21 cases. Ann Thorac Surg. 1993;
56(5):1110-1116.
- LeMaire SA, Carter SA, Coselli JS. The elephant trunk technique for
staged repair of complex aneurysms of the entire thoracic aorta. Ann
Thorac Surg. 2006; 81(5):1561-1569.
- Hu XP, Chang Q, Zhu JM, Yu CT, Liu ZG, Sun LZ. One-stage total or
subtotal aortic replacement. Ann Thorac Surg. 2006; 82(2):542-546.
- Safi HJ, Miller 3rd CC, Estrera AL, et al. Staged repair of extensive
aortic aneurysms: morbidity and mortality in the elephant trunk
technique. Circulation. 2001; 104(24):2938-2942.
Figure Legends:
Figure 1. Chest radiograph showed a huge mass in the upper mediastinum
(A); CTA showed a total aortic aneurysm, and the lesion involved the
aortic root, ascending aorta, aortic arch, and the entire
thoraco-abdominal aorta. The aneurysm is tortuous and deformed, mural
thrombus can be seen in the aortic arch and abdominal aorta, multiple
penetrating ulcers can be seen also in the thoracic and abdominal aorta,
and the widest part of the aneurysm is 72mm in diameter (B).
Figure 2. A re-examination CT of the patient after the first-stage
operation showed that the lesions of aortic root, ascending aorta,
aortic arch, and descending aorta were eliminated and the rest aneurysm
of thoracic-abdominal aorta can be seen clearly.
Figure 3. The patient successfully underwent the second-stage surgery
(thoracic-abdominal aortic replacement) and a re-examination CT showed
that the artificial vessel was smooth in shape, the entire
thoracic-abdominal aortic aneurysm was completely removed, and the
revascularization of important organs was satisfactory.