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
  1. 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.
  2. 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.
  3. 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.
  4. 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.