Article, Cardiology

Penetrating atherosclerotic aortic ulcer rupture causing a right hemothorax; a rare presentation of acute aortic syndrome

American Journal of Emergency Medicine 31 (2013) 755.e5-755.e7

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Case Report

Penetrating atherosclerotic aortic ulcer rupture causing a right hemothorax; a rare presentation of acute aortic syndrome


Acute aortic syndrome is a spectrum of diseases that have similar presentation and clinical background and include aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer. Presented here is an 82-year-old woman with a medical history of diabetes, hypertension, nephrectomy, and chronic renal failure who complained of sudden abdominal pain radiating to epigastrium and back. At presentation, the patient was hemody- namically stable with a hemoglobin level of 10.2 and white blood cell count of 12. Chest x-ray showed a right pleural effusion and lung opacity with interstitial pulmonary edema. Computed tomog- raphy demonstrated an aortic penetrating atherosclerotic ulcer that ruptured into the right pleural space resulting in right hemothorax. A percutaneous endostent was placed with subsequent discharge of the patient 10 days after admission.

Typically, acute aortic syndrome of the descending aorta involves the left chest and pleura. In this case, the presentation of acute aortic syndrome is atypical with a right hemothorax from the ruptured aorta. This presentation of a penetrating aortic ulcer causing right hemothorax has not been described in the searched literature, although there have been sporadic reports of right hemothorax from dissection or aortic aneurysm rupture. This report highlights the diverse spectrum of presentation of acute aortic syndrome. The radio- logic images and findings are presented with a summary of pene- trating aortic ulcers as part of the acute aortic syndrome.

Acute aortic syndrome is a spectrum of diseases with a similar clinical presentation and includes aortic dissection, intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU) [1]. Mortality from AAS is high. As much as 50% of patients die prior or during the hospital stay from thoracic aortic dissection or aneurysm, and with rupture, mortality is extremely high. However, with surgery, 92% can survive the first year [2-4]. Complications such as aortic insufficiency, rupture to the surrounding structures causing a hematoma or hemopericardium or hemothorax or ischemia to the organs involved are life threatening. The therapeutic approach to this can be both surgical and nonsurgical and depends on the location of the disease and the clinical implications; however, the key to survival is early and correct diagnosis [5].

An 82-year-old woman with a medical history of diabetes, hypertension, nephrectomy, and chronic renal failure complained of sudden sharp stabbing abdominal pain radiating to the epigastric region and back. At presentation, the patient was alert, the blood pressure was 160/93 and the heart rate was 97, and the temperature was 36.5. Physical examination was unremarkable. Initial blood

work revealed potassium of 5.8, a serum urea nitrogen of 70, a creatinine of 2.62, and hemoglobin level of 10.2 and white blood cell count of 12. An electrocardiogram was interpreted as normal sinus rhythm; minimal voltage criteria for left ventricular hypertrophy that may be a normal variant. Septal infarct, age undetermined. A chest x-ray showed a right pleural effusion and basal lung opacity with interstitial pulmonary edema (Fig. 1). A noncontrast computed tomographic (CT) scan showed a pseudoaneurysm of the aorta and hemothorax (Fig. 2); therefore, for better characterization, a computed tomographic angiography of the aorta was per- formed (Fig. 3A and B) showing a penetrating aortic ulcer with contained aortic rupture at the level of the thoracoabdominal transition. A percutaneous endostent was placed with subsequent discharge of the patient 10 days after admission. Follow-up CT showed a receding hematoma and resolution of the pleural effusion. Acute aortic syndrome includes 3 major presentations: aortic dissection, IMH, and PAU. Aortic dissection with symptoms of less than 2 weeks is considered acute [6]. Both aortic dissection and IMH can be classified according to the anatomical location by the Stanford criteria, type A involving the Ascending aorta and type B

Fig. 1. Frontal radiograph of the chest demonstrates a Right-sided pleural effusion and intestinal pulmonary edema. The upper mediastinum is not widened; however, the aorta is atherosclerotic and tortuous.

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indicating involvement distal to the left subclavian artery origin [7,8]. The implication of this classification is that type A is usually considered for surgical therapy, whereas type B is typically treated medically. Although aortic dissection and IMH have been extensively studied, PAU has had less focus. Aortic dissection and IMH are diffused disease, while PAU is a more focal disease and is usually in the descending aorta. The ulcer penetrates into the media and can cause an intramural hematoma that may be extensive [1]. Penetrat- ing atherosclerotic ulcer is usually incidentally discovered in cross- sectional imaging done for a different purpose and present with symptoms in only 17.2%. It affects mostly men in their eighth decade of life and is commonly associated with hypertension. Rupture is rare and is seen in 4.1% of cases [9]. When presenting to the emergency department, the diagnosis of AAS can be challenging. Aortic dissection is missed in up to 38.2% of the time. An incorrect diagnosis is associated with lack of pulse deficit on physical exami- nation and a chest radiograph that does not show widened

mediastinum [5] as in this case. A diagnosis of AAS can be reached by different imaging modalities; however, today, the ideal choice is

Fig. 2. Non contrast axial CT image at the level of the chest base shows left pleural

effusion with a moderate hemothorax on the right. Note the high density in the right pleural space indicated hemothorax (arrow).

Fig. 3. A, Contrast-enhanced axial CTA image at the level of the thoracoabdominal transition. A large ruptured penetrating atherosclerotic ulcer can be seen extending from the right side of the aorta with an associated containing hematoma (white arrow). Blood is tracking along the right paraspinal tissue into the right chest and pleura (black arrow). B, A 3-dimensional rendition of the CTA showing the thoracic aorta and right-sided penetrating ulcer (arrow). Note the irregular surface of the aorta due to atherosclerotic plaque.

an electrocardiogram-gated CTA that, in addition to the diagnosis, can characterize the aorta and evaluate additional disease in the surrounding structures [10]. In the patient presented here, the diagnosis is especially challenging because of the clinical presenta- tion and the chest film. The film shows an effusion on the right that can be mistaken for effusion secondary to pulmonary edema. In fact, unilateral pleural effusion secondary to heart failure is usually on the right [11]. Nontraumatic rupture of the descending aorta most commonly involves the surrounding soft tissue or left chest as the descending aorta is on the left. In addition, ruptured penetrating ulcers can present with hemothorax on the left [12]. Although there have been descriptions of dissection or ruptured aneurysms causing right-sided effusion [13-15], PAU causing a right hemothorax was not described in a literature search. This case brings to light the uncommon disease of PAU. Although right-sided effusion is not typically caused by of AAS, this diagnosis can be consider in the appropriate clinical setting.

Yoel Siegel MD Department of Radiology Thoracic and Abdominal imaging University of Miami Miller School of Medicine

Jackson Memorial Hospital Miami, FL 33136, USA

E-mail address: [email protected]


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