- Email: [email protected]
Influence of hydrocarbon fuel structural constitution and flame temperature on soot formation in laminar diffusion flames
American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness☆,☆☆,★ Pseudocoarctation of the aorta is a rare congenital anomaly of the aortic arch, and it has been described as an elongation of the aortic arch with kinking at the level of the ligamentum arteriosum. It is usually asymptomatic or presents with hypertension; therefore, it is often diagnosed late despite the recognition of hypertension in young patients. It is also occasionally misdiagnosed as a mediastinal mass or a true coarctation of the aorta, for which surgical correction is often needed. We present an unusual case of pseudocoarctation of the aorta associated with multiple saccular aneurysms and a hypoplastic left subclavian artery in a 19-year-old man who was admitted in the emergency department for chest discomfort with a pulsatile left supraclavicular mass and left arm coldness. The patient was free from any major cardiovascular events for a follow-up period of 12 months with conservative treatment. A 19-year-old man was admitted in the emergency department for chest discomfort. He reported that the chest discomfort worsened during hard exercise or emotional stress and was often accompanied by a pulsatile left supraclavicular mass and left arm coldness. He had a medical history of hypertension without medication diagnosed at 2 years ago. On initial examination, auscultation of the heart revealed a 3/6 harsh pansystolic murmur at the left upper sternal border with a 2.0 × 2.0-cm pulsating left supraclavicular mass. Review of vital signs revealed pressures of 150/91 (right brachial), 112/74 (left brachial), 154/96 (right ankle), and 145/87 mm Hg (left ankle); and his pulse was 71 beats/min. He had weaker left radial pulsation, and the left arm was cold compared with the opposite arm. Radial-femoral delay of the right extremities was palpated within the normal range but was palpated relatively weak on the left side. Twelve-lead electrocardiogram on admission showed sinus rhythm. Posteroanterior chest x-ray (CXR) revealed left superior mediastinal widening with a positive cervicothoracic sign (Fig. 1), presumed to be a posterior superior mediastinal mass without cardiomegaly. The subsequent 3-dimensional thoracic computed tomographic angiography (CTA) revealed pseudocoarctation of the aorta (PCoA) with multiple saccular aneurysms (Fig. 2A-D). Seven saccular aortic aneurysms were observed, with a maximal aortic diameter of 34 mm. The left subclavian artery was even more hypoplastic than the right (maximal diameter 4 mm vs 8 mm), but collateral circulation was not detected (Fig. 2E). The pulsatile left supraclavicular mass was likely caused by the
☆ Grant or other financial support: None. ☆☆ Previous presentation: None. ★ Conflicts of interest: None declared.
elongated and kinked aorta with saccular aneurysms (Fig. 2F), and the left arm coldness likely resulted from hypoplastic left subclavian artery (Fig. 2E). To relieve peripheral vascular resistance, we prescribed ramipril 5 mg daily, which was gradually increased to 10 mg, and added bisoprolol 2.5 mg daily for heart rate control. Transthoracic echocardiography was performed in the outpatient clinic and showed normal cardiac function (ejection fraction, 62%) without evidence of other associated congenital cardiac anomalies. The patient was followed up with a CT scan every 6 months for follow-up of multiple saccular aneurysms, as described in the relevant guidelines [1]. The patient's symptoms were relieved, and he was free from any major cardiovascular events for a total follow-up period of 12 months. Pseudocoarctation of the aorta is a rare anomaly of the thoracic aorta that occurs when the third to seventh embryonic dorsal segments fail to fuse properly to form the aortic arch. An elongation of the aortic arch and the first portion of the descending aorta occurs; as it is fixed by the ligamentum arteriosum, an abnormal kink develops [2]. Although cardiac catheterization and interventional angiography provide a definitive diagnosis for this condition, CXR with thoracic CTA is very helpful, and the following findings are considered diagnostic of this congenital anomaly according to previous case reports: (1) demonstration of the abnormal mass in the superior mediastinum; (2) an unusually high aortic arch in the mediastinum; (3) visualization of the isthmic portion of the descending thoracic aorta not adjacent to the spine but rather ventral to it and surrounded by aerated lung; and (4) a more caudal origin of the left subclavian artery [3,4]. Unlike true coarctation of the aorta, PCoA has no critical isthmic lesion and has been described in the literature as a “benign” entity that warrants no interventional therapy, but surgical treatment is considered in cases of aneurysm formation, which seems to increase the risk of rupture [5,6]. Our case was unusual in terms of patient symptoms and associated findings. To the best of our knowledge, there have been no previous reports of PCoA associated with multiple saccular aneurysms and hypoplastic left subclavian artery. Despite the abnormal tortuosity and morphologic aspects, similar to those of aortic coarctation, a significant gradient rarely develops through the kinking, and it is usually asymptomatic, even if hypertension, chest pain, or dysphagia may occasionally be present [2]. Moreover, although a few case reports [5,7,8] demonstrated PCoA complicated by an aortic aneurysm, PCoA with 3 or more aneurysms has rarely been reported [6,9]. Our case showed an exceptional association of PCoA with a hypoplastic left subclavian artery. Embryologically, the left subclavian artery is derived entirely from the left seventh intersegmental artery, whereas the portions of the right are derived from the right fourth arch and the
http://dx.doi.org/10.1016/j.ajem.2016.10.025 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Kim I-S, et al, Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.10.025
2
I-S. Kim et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Seong Jong Yun, MD Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea ⁎Corresponding author at: Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea. Tel.: +82 43 290 5691; fax: +82 43 290 5692. E-mail: [email protected] Sun Hwa Lee, MD, PhD Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Seoul, Nowon-gu 139-707, Republic of Korea
Dong Hyeon Kim, MD Hyeon Hwan Cho, MD Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea
Fig. 1. Posteroanterior CXR demonstrates left superior mediastinal widening (arrows). This silhouette extends to the upper border above the level of the clavicle (cervicothoracic sign positive).
Minji Kim, MD Yonsei University College of Medicine, Yonsei University Health System, 250 Seungsanno, Seodaemun-gu, Seoul 120-752, Republic of Korea
http://dx.doi.org/10.1016/j.ajem.2016.10.025 References right dorsal aorta [10]. We believe that the hypoplastic subclavian artery impacted the pseudocoarctation. The hypoplastic left subclavian artery was responsible for the difference in pulsations and blood pressures between the upper limbs. In summary, PCoA with multiple saccular aneurysms and a hypoplastic left subclavian artery is a rare clinical condition, but emergency physicians should remember this clinical entity and related clinical presentation, especially in young patients with hypertension, because PCoA may mimic other diseases and may present as aortic rupture in cases of late diagnosis.
In-Soo Kim, MD Yonsei University College of Medicine, Yonsei University Health System, 250 Seungsanno, Seodaemun-gu, Seoul 120-752, Republic of Korea Division of Cardiology, Department of Internal Medicine, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea
[1] Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873–926. [2] Singh S, Hakim FA, Sharma A, Roy RR, Panse PM, Chandrasekaran K, et al. Hypoplasia, pseudocoarctation and coarctation of the aorta—a systematic review. Heart Lung Circ 2015;24:110–8. [3] Gaupp RJ, Fagan CJ, Davis M, Epstein NE. Pseudocoarctation of the aorta. J Comput Assist Tomogr 1981;5:571–3. [4] Taneja K, Kawlra S, Sharma S, Rajani M. Pseudocoarctation of the aorta: complementary findings on plain film radiography, CT, DSA, and MRA. Cardiovasc Intervent Radiol 1998;21:439–41. [5] Grigsby JL, Galbraith T, Shurmur S, Deligonul U. Pseudocoarctation of the aorta complicated by saccular aneurysm: treatment by aortic arch replacement. Am Heart J 1996;131:200–2. [6] Makani S, Julia M, Metton O, Pozzi M, Di Filippo S, Henaine R, et al. Surgical repair of a pseudocoarctation with cervical aortic arch complicated by multiple aneurysms of the aorta: a case report. J Vasc Med Surg 2016;4:246. [7] Kessler RM, Miller KB, Pett S, Wernly JA. Pseudocoarctation of the aorta presenting as a mediastinal mass with dysphagia. Ann Thorac Surg 1993;55:1003–5. [8] Shindo S, Katsu M, Kojima A, Kobayashi M, Tada Y. Thoracic aortic aneurysm associated with pseudocoarctation of the aorta. Gen Thorac Cardiovasc Surg 2002;50:520–2. [9] Choi BW, Choe KO, Kim YJ. Magnetic resonance angiography of pseudocoarctation. Heart 2004;90:1213. [10] Kau T, Sinzig M, Gasser J, Lesnik G, Rabitsch E, Celedin S. Aortic development and anomalies. Semin Intervent Radiol 2007;24:141–52.
Please cite this article as: Kim I-S, et al, Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.10.025
I-S. Kim et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
3
Fig. 2. A, Three-dimensional thoracic CTA reveals a high-riding aortic arch located just below the left thyroid gland (asterisk). B, The descending aorta is kinked and elongated, and the narrowest lumen (arrows) measured approximately 13 mm immediately distal to the origin of the left subclavian artery, at the level of the ligamentum arteriosum. C and D, Volumerendering images show 5 saccular aneurysms in the ascending aorta (C) and 2 saccular aneurysms in the descending aorta near the more caudal originated left subclavian artery (arrow) (D). E, The diameter of the left subclavian artery (arrows) is even smaller than that of the right (arrowheads), but collateral circulation is not detected. F, The location of the pulsatile left supraclavicular mass is consistent with saccular aneurysms (arrows) at the left supraclavicular level.
Please cite this article as: Kim I-S, et al, Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.10.025
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness☆,☆☆,★ Pseudocoarctation of the aorta is a rare congenital anomaly of the aortic arch, and it has been described as an elongation of the aortic arch with kinking at the level of the ligamentum arteriosum. It is usually asymptomatic or presents with hypertension; therefore, it is often diagnosed late despite the recognition of hypertension in young patients. It is also occasionally misdiagnosed as a mediastinal mass or a true coarctation of the aorta, for which surgical correction is often needed. We present an unusual case of pseudocoarctation of the aorta associated with multiple saccular aneurysms and a hypoplastic left subclavian artery in a 19-year-old man who was admitted in the emergency department for chest discomfort with a pulsatile left supraclavicular mass and left arm coldness. The patient was free from any major cardiovascular events for a follow-up period of 12 months with conservative treatment. A 19-year-old man was admitted in the emergency department for chest discomfort. He reported that the chest discomfort worsened during hard exercise or emotional stress and was often accompanied by a pulsatile left supraclavicular mass and left arm coldness. He had a medical history of hypertension without medication diagnosed at 2 years ago. On initial examination, auscultation of the heart revealed a 3/6 harsh pansystolic murmur at the left upper sternal border with a 2.0 × 2.0-cm pulsating left supraclavicular mass. Review of vital signs revealed pressures of 150/91 (right brachial), 112/74 (left brachial), 154/96 (right ankle), and 145/87 mm Hg (left ankle); and his pulse was 71 beats/min. He had weaker left radial pulsation, and the left arm was cold compared with the opposite arm. Radial-femoral delay of the right extremities was palpated within the normal range but was palpated relatively weak on the left side. Twelve-lead electrocardiogram on admission showed sinus rhythm. Posteroanterior chest x-ray (CXR) revealed left superior mediastinal widening with a positive cervicothoracic sign (Fig. 1), presumed to be a posterior superior mediastinal mass without cardiomegaly. The subsequent 3-dimensional thoracic computed tomographic angiography (CTA) revealed pseudocoarctation of the aorta (PCoA) with multiple saccular aneurysms (Fig. 2A-D). Seven saccular aortic aneurysms were observed, with a maximal aortic diameter of 34 mm. The left subclavian artery was even more hypoplastic than the right (maximal diameter 4 mm vs 8 mm), but collateral circulation was not detected (Fig. 2E). The pulsatile left supraclavicular mass was likely caused by the
☆ Grant or other financial support: None. ☆☆ Previous presentation: None. ★ Conflicts of interest: None declared.
elongated and kinked aorta with saccular aneurysms (Fig. 2F), and the left arm coldness likely resulted from hypoplastic left subclavian artery (Fig. 2E). To relieve peripheral vascular resistance, we prescribed ramipril 5 mg daily, which was gradually increased to 10 mg, and added bisoprolol 2.5 mg daily for heart rate control. Transthoracic echocardiography was performed in the outpatient clinic and showed normal cardiac function (ejection fraction, 62%) without evidence of other associated congenital cardiac anomalies. The patient was followed up with a CT scan every 6 months for follow-up of multiple saccular aneurysms, as described in the relevant guidelines [1]. The patient's symptoms were relieved, and he was free from any major cardiovascular events for a total follow-up period of 12 months. Pseudocoarctation of the aorta is a rare anomaly of the thoracic aorta that occurs when the third to seventh embryonic dorsal segments fail to fuse properly to form the aortic arch. An elongation of the aortic arch and the first portion of the descending aorta occurs; as it is fixed by the ligamentum arteriosum, an abnormal kink develops [2]. Although cardiac catheterization and interventional angiography provide a definitive diagnosis for this condition, CXR with thoracic CTA is very helpful, and the following findings are considered diagnostic of this congenital anomaly according to previous case reports: (1) demonstration of the abnormal mass in the superior mediastinum; (2) an unusually high aortic arch in the mediastinum; (3) visualization of the isthmic portion of the descending thoracic aorta not adjacent to the spine but rather ventral to it and surrounded by aerated lung; and (4) a more caudal origin of the left subclavian artery [3,4]. Unlike true coarctation of the aorta, PCoA has no critical isthmic lesion and has been described in the literature as a “benign” entity that warrants no interventional therapy, but surgical treatment is considered in cases of aneurysm formation, which seems to increase the risk of rupture [5,6]. Our case was unusual in terms of patient symptoms and associated findings. To the best of our knowledge, there have been no previous reports of PCoA associated with multiple saccular aneurysms and hypoplastic left subclavian artery. Despite the abnormal tortuosity and morphologic aspects, similar to those of aortic coarctation, a significant gradient rarely develops through the kinking, and it is usually asymptomatic, even if hypertension, chest pain, or dysphagia may occasionally be present [2]. Moreover, although a few case reports [5,7,8] demonstrated PCoA complicated by an aortic aneurysm, PCoA with 3 or more aneurysms has rarely been reported [6,9]. Our case showed an exceptional association of PCoA with a hypoplastic left subclavian artery. Embryologically, the left subclavian artery is derived entirely from the left seventh intersegmental artery, whereas the portions of the right are derived from the right fourth arch and the
http://dx.doi.org/10.1016/j.ajem.2016.10.025 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Kim I-S, et al, Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.10.025
2
I-S. Kim et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Seong Jong Yun, MD Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea ⁎Corresponding author at: Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea. Tel.: +82 43 290 5691; fax: +82 43 290 5692. E-mail: [email protected] Sun Hwa Lee, MD, PhD Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Seoul, Nowon-gu 139-707, Republic of Korea
Dong Hyeon Kim, MD Hyeon Hwan Cho, MD Department of Radiology, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea
Fig. 1. Posteroanterior CXR demonstrates left superior mediastinal widening (arrows). This silhouette extends to the upper border above the level of the clavicle (cervicothoracic sign positive).
Minji Kim, MD Yonsei University College of Medicine, Yonsei University Health System, 250 Seungsanno, Seodaemun-gu, Seoul 120-752, Republic of Korea
http://dx.doi.org/10.1016/j.ajem.2016.10.025 References right dorsal aorta [10]. We believe that the hypoplastic subclavian artery impacted the pseudocoarctation. The hypoplastic left subclavian artery was responsible for the difference in pulsations and blood pressures between the upper limbs. In summary, PCoA with multiple saccular aneurysms and a hypoplastic left subclavian artery is a rare clinical condition, but emergency physicians should remember this clinical entity and related clinical presentation, especially in young patients with hypertension, because PCoA may mimic other diseases and may present as aortic rupture in cases of late diagnosis.
In-Soo Kim, MD Yonsei University College of Medicine, Yonsei University Health System, 250 Seungsanno, Seodaemun-gu, Seoul 120-752, Republic of Korea Division of Cardiology, Department of Internal Medicine, Aerospace Medical Center, Republic of Korea Air Force, PO Box 335-21, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea
[1] Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873–926. [2] Singh S, Hakim FA, Sharma A, Roy RR, Panse PM, Chandrasekaran K, et al. Hypoplasia, pseudocoarctation and coarctation of the aorta—a systematic review. Heart Lung Circ 2015;24:110–8. [3] Gaupp RJ, Fagan CJ, Davis M, Epstein NE. Pseudocoarctation of the aorta. J Comput Assist Tomogr 1981;5:571–3. [4] Taneja K, Kawlra S, Sharma S, Rajani M. Pseudocoarctation of the aorta: complementary findings on plain film radiography, CT, DSA, and MRA. Cardiovasc Intervent Radiol 1998;21:439–41. [5] Grigsby JL, Galbraith T, Shurmur S, Deligonul U. Pseudocoarctation of the aorta complicated by saccular aneurysm: treatment by aortic arch replacement. Am Heart J 1996;131:200–2. [6] Makani S, Julia M, Metton O, Pozzi M, Di Filippo S, Henaine R, et al. Surgical repair of a pseudocoarctation with cervical aortic arch complicated by multiple aneurysms of the aorta: a case report. J Vasc Med Surg 2016;4:246. [7] Kessler RM, Miller KB, Pett S, Wernly JA. Pseudocoarctation of the aorta presenting as a mediastinal mass with dysphagia. Ann Thorac Surg 1993;55:1003–5. [8] Shindo S, Katsu M, Kojima A, Kobayashi M, Tada Y. Thoracic aortic aneurysm associated with pseudocoarctation of the aorta. Gen Thorac Cardiovasc Surg 2002;50:520–2. [9] Choi BW, Choe KO, Kim YJ. Magnetic resonance angiography of pseudocoarctation. Heart 2004;90:1213. [10] Kau T, Sinzig M, Gasser J, Lesnik G, Rabitsch E, Celedin S. Aortic development and anomalies. Semin Intervent Radiol 2007;24:141–52.
Please cite this article as: Kim I-S, et al, Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.10.025
I-S. Kim et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
3
Fig. 2. A, Three-dimensional thoracic CTA reveals a high-riding aortic arch located just below the left thyroid gland (asterisk). B, The descending aorta is kinked and elongated, and the narrowest lumen (arrows) measured approximately 13 mm immediately distal to the origin of the left subclavian artery, at the level of the ligamentum arteriosum. C and D, Volumerendering images show 5 saccular aneurysms in the ascending aorta (C) and 2 saccular aneurysms in the descending aorta near the more caudal originated left subclavian artery (arrow) (D). E, The diameter of the left subclavian artery (arrows) is even smaller than that of the right (arrowheads), but collateral circulation is not detected. F, The location of the pulsatile left supraclavicular mass is consistent with saccular aneurysms (arrows) at the left supraclavicular level.
Please cite this article as: Kim I-S, et al, Pseudocoarctation of the aorta presented as chest discomfort with a pulsatile left supraclavicular mass and left arm coldness, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.10.025