Abdominal Pseudoaneurysm Arising from a True ...

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as a Pulmonary Mass. Received May 21 , 1985; accepted after revision September 11, 1985. .... The hematoma also extended through the right hemidiaphragm.
155

Abdominal Aneurysm: Myung

S. Shin,1

Atherosclerotic

Pseudoaneurysm Arising from a True Presentation as a Pulmonary Mass Kang-Jey

Ho,2 John

W. Kirklin,3

John

M. Forman,3

of the abdominal aorta often it ruptures into the pleural, peritoneal, or retroperitoneal space or compresses adjacent structures [1 -4]. The most common symptom is pain, but an asymptomatic, nontender, pulsatile mass is often palpable above the umbilicus. We describe a case of a ruptured atherosclerotic aneurysm of the abdominal aorta with minimal symptomatology that simulated a lower lung mass on conventional chest radiography. The correct diagnosis was made by CT and was confirmed at surgery.

produces

aneurysm

no symptoms

unless

Case Report A 61 -year-old

man was admitted

with a 3-month

history

of cough,

hemoptysis, and weight loss. He was hypertensive and had a history of seizure disorder probably associated with alcohol abuse and withdrawal. He also had smoked two packs of cigarettes per day for more than 30 years and had only recently reduced to one-half pack per day. His cough

was productive

of white

sputum

The patient refused surgical intervention and was discharged; 1 month later he developed massive hemoptysis. When brought to the emergency room, he was in shock followed by apnea and cardiac arrest requiring cardiopulmonary resuscitation. Chest radiography revealed irregular opacification of the right lower lung base with pleural effusion. CT showed marked enlargement of the original false aneurysm,

2

3

AJR

Department Department

146:155-156,

Address

reprint

requests

to M.

irregular

border

and right posterior surgery. At surgery,

of the mass of diaphragmatic

pleural effusion.

the giant retroperitoneal

1986 0361-803X/86/1461-0155

false aneurysm

was confirmed.

Discussion Most patients than

60; more

who develop than

aortic aneurysms

half have

long survival

aneurysm

are men older

hypertension

and

with

minimal

symptoms

[5]. The suspicion

after

the rupture

of the

of lung cancer was unavoidable

in a patient with a newly developed chest mass associated with cough, hemoptysis, weight loss, and a long history of heavy cigarette smoking. After a futile clinical search for lung cancer, CT proved extremely useful, as has been the experi-

ence ofothers in identifying aortic aneurysms [6, 7]. CT clearly delineated the extent of the false aneurysm and its relation to the aorta (figs. 1C and 1 D). The CT findings of a smoothly outlined, irregularly shaped mass with a density identical to that of blood, lying in direct continuity with a dilated segment of aorta, are quite diagnostic of a false aneurysm secondary to rupture of a true aneurysm. It has been shown that when the diameter of an aneurysm is greater than 6 cm, the possibility of rupture in a 1 0-year

S. Shin.

0 American Roentgen

associated

many are cigarette smokers [1 , 4]. Our patient fits such a profile. However, there are several unique aspects of this case, such as the unusual location of the aneurysm and the

Hospital, and Wiversity

of Pathology, University of Alabama School of Medicine and Veterans Administration Hospital, Birmingham, of Cardiovascular Surgery, University of Alabama School of Medicine and Veterans Administration Hospital, January

eventration,

At this time the patient agreed to

After a huge amount of blood clot was evacuated, a large opening measuring 4 x 6 cm became evident on the right side ofthe abdominal aorta just superior to the origin of the celiac artery. The hematoma also extended through the right hemidiaphragm to the chest cavity, eroding into the lung parenchyma. Although the aortic aneurysm was successfully repaired by patch graft, the patient developed wound dehiscence and aspiration and died 10 days after surgery. No autopsy was performed.

Received May 21 , 1985; accepted after revision September 1 1 , 1985. 1 Department of Radiology, University of Alabama School of Medicine, Veterans Administration AL 35233.

L. Berland

and occasionally

fresh blood and was associated with low back pain and a 17-kg weight loss. The pertinent findings on admission included a blood pressure of 140/1 00 mm Hg, pulse of 96/mm, greatly diminished dorsalis pedis and posterior tibial pulses bilaterally, epigastric tenderness without palpable mass, a packed cell volume of 32%, and hemoglobin of 1 1 g/dl. A chest radiograph showed a fairly smooth, well demarcated mass at the right lung base (fig. 1A) that had not been present 6 months earlier. The initial clinical impression was bronchogenic carcinoma. Bronchoscopy revealed a small amount of blood in the anterior basal segment of the right lower lobe but no visible endobronchial lesion. The cytologic studies of the bronchial washing and brushing specimens and the sputums were all negative for malignancy. A CT scan then showed that the mass at the right lung base was the upper part of a 9 x 13.5 cm mass located in the retropentoneal space between the diaphragm and the renal hila (figs. 1B-i D). The mass had a smooth outline, irregular shape, and homogeneous density with an attenuation value of 40-45 H, similar to that of the blood. The lumen of the abdominal aorta was irregularly dilated with a less dense area between the lumen and calcified wall suggestive of mural thrombus (fig. 1 D). These CT findings were compatible with a giant pseudoaneurysm arising from a ruptured atherosclerotic aneurysm of the abdominal aorta and associated with a diaphragmatic eventration.

Birmingham,

and Lincoln

Ray Society

of Alabama AL 35233. Birmingham,

Hospitals, 619 5.

AL 35233.

19th St.,

156

SHIN

ET

AL.

AJR:146,

Fig. 1 -A,

January

1986

film on admission. mass lesion at right lung base. Contrast-enhanced CT scans at levels above (B) and below (C)diaphragm and at renal hila (0). Note lobulated demarcated mass adjacent to aorta with diaphragmatic eventration. Posteroanterior

Well demarcated

period is 45%-50%, diameter

is less

whereas than

6 cm

it is only 15%-20% [3, 8]. The

aneurysm before rupture in this case was theless, it did rupture into the retroperitoneal likely that the unusually high position ofthe in a massive but contained retroperitoneal of intraperitoneal rupture and rapid demise. of the aneurysm

the diaphragm

also allowed

and present

the false

actual

when the size

of the

unknown. Neverspace. It is most aneurysm resulted hematoma instead The high position

aneurysm

to eventrate

as an intrathoracic

mass.

555

REFERENCES 1.

Gore

Hirst AE Jr. Arteriosclerotic aneurysms of the abdominal Cardiovasc Dis 1973;16: 1 13-1 50 Bergan JJ, Yao JST. Modern management of abdominal aortic aneurysms. Surg Clin North Am 1974;54: 175-193 aorta.

2. 3.

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tion of life. Mn Surg 1966;164:678-699 Melton U Ill, Bickerstaff LK, Hollier LH, et al. Changing incidence of abdominal aortic aneurysms: a population-based study. Am J Epidemiol 1984;1 20:379-386 5. Makin GS. Somefactors influencing hospital mortality in ruptured abdominal aortic aneurysm. J Cardiovasc Surg (Tormno) 1983;24:646-648 6. Iliceto 5, Ettorre G, Francioso G, Antonelli G, Biasco 0, Rizzon P. Diagnosis of aneurysm of the thoracic aorta. Comparison between two noninvasive techniques: two-dimensional echocardiography and computed tomography. Eur Heart J 1984;5:5454.

DE,

Smith

AF,

of abdominal

DeAusso aortic

EJ,

Elliott

JP,

aneurysmectomy

Shemn

FW.

to prolonga-

7. Miller GA Jr, Heaston DK, Moore AV Jr, Korobkin M, Braun SD, Dunnick NA. CT differentiation of thoracic aortic aneurysms from pulmonary masses adjacent to the mediastinum. J Comput Assist Tomogr 1984;8:437-442 8. Dailing RC. Ruptured arteriosclerotic abdominal aortic aneurysms: a pathologic and dinical study. AmJSurg 1970;199:397401