Large Ascending Thoracic Aortic Aneurysm with Protruding Pseudoaneurysm

A 53-year-old man was transferred from another hospital and admitted to our unit with a diagnosis of intercostal protruding aneurysm of the ascending thoracic aorta. The patient had a history of smoking and alcohol consumption.

On physical examination, an expanding and pulsating mass in the 2nd right parasternal intercostal space was easily seen (Fig. 1). A thoracoabdominal computed tomographic (CT) scan showed a chronic ascending aortic and arch aneurysm, with a maximum diameter of 9 cm in the transverse view (Fig. 2). The upper sagittal view of the CT scan revealed progression, throughout the 2nd right intercostal space, of a pseudoaneurysm, which was also patent (Fig. 3).

Fig. 1 Physical examination reveals a pulsating mass protruding through the 2nd right intercostal space.

Fig. 2 Thoracic computed tomographic scan, transverse view, shows the ascending aortic and arch aneurysm and pseudoaneurysm.

Fig. 3 Thoracic computed tomographic scan, upper sagittal view, reveals the patent pseudoaneurysm spreading throughout the 2nd right intercostal space.

On 27 July 1998, the patient underwent surgery. A median sternotomy approach was extended to a left anterior thoracotomy. On entering the chest, we found a ruptured thoracic ascending aortic aneurysm that was chronic, degenerative, and atherosclerotic. The aneurysm was complicated by a large pseudoaneurysm that was eroding and protruding into the 2nd intercostal space. With the patient under cardiopulmonary bypass, deep hypothermia, and total circulatory arrest, we were able to achieve total replacement of the ascending aorta and aortic arch with 2 straight Dacron vascular grafts, sutured end-to-end. An elliptic segment of the native aortic arch containing the 3 supra-aortic trunks was inserted directly into the vascular prosthetic graft. The patient survived the operation; however, he died of hemorrhagic shock during the postoperative period.