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Transesophageal echocardiographic identification of an abdominal aortic pseudoaneurysm complemented by a transpulmonary echo contrast agent
Transesophageal Echocardiographic Identification of an Abdominal Aortic Pseudoaneurysm Complemented by a Transpulmonary Echo Contrast Agent Andrea V. Brasch,
MD,
Sharo S. Raissi, MD, Errol L. Hackner, MD, Steven S. Khan, Tomoo Nagai, MD, and Robert J. Siegel, MD
MD,
seudoaneurysm of the abdominal aorta is a rare entity, with P an incidence of 5% of all aortic pseudoaneurysms.1 There have been ⬍30 cases2,3 reported since the first description by Makins in 1920.4 In most of these cases, false aneurysms developed after penetrating injuries. Although pseudoaneurysm formation protects from exsanguination and is lifesaving in the acute phase, most patients with chronic traumatic pseudoaneurysms will eventually develop complications, sometimes after many years.5 We report a case of a large, abdominal aortic pseudoaneurysm after penetrating trauma in which a transpulmonary echo contrast agent (Optison, Mallinckrodt, St. Louis, Missouri; human albumin microspheres injectable suspension, octafluoropropane formulation) helped identify the orifice of the pseudoaneurysm during intraoperative transesophageal echocardiographic (TEE) examination. •••
After a gunshot wound to his right flank, a 19-year-old man presented to the emergency room with hemorrhage, hypotension and a hemoglobin of 2.0 g/dl. He underwent emergency abdominal exploration for ligation of bleeding vessels in the retroperitoneal area. During hospitalization, the patient had recurrent abdominal pain, but the physical examination was reportedly normal and the patient From the Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Siegel’s address is: Division of Cardiology, Room 5335, 8700 Beverly Boulevard, Los Angeles, California 90048. E-mail address: [email protected]. This study was supported by the Dunitz Family and the Save-AHeart Foundation, Los Angeles, California. Manuscript received December 31, 1998; revised manuscript received and accepted March 1, 1999.
240
FIGURE 1. A, a large abdominal aortic pseudoaneurysm (16 cm in diameter) with a laminar thrombus (white arrows). An asterisk identifies the abdominal aorta. B, after intravenous injection of the transpulmonary echo contrast agent, the contrast is seen in the abdominal aortic lumen and entering into the pseudoaneurysm. Black arrows show the site of communication. C and D, taken within 5 seconds after the initial appearance of the echo contrast agent, showing increasing opacification of the pseudoaneurysm. E, color flow Doppler also demonstrates abdominal aortic pseudoaneurysm flow. F, pulsed wave Doppler indicates that there is systolic flow into the pseudoaneurysm and diastolic flow back to the aorta.
was discharged after 11 days. Four weeks later the patient presented again to the emergency room for
©1999 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 84 July 15, 1999
increasing abdominal discomfort, fever and a 5-kg weight loss since his surgery. He was febrile (38.3°C) 0002-9149/99/$–see front matter PII S0002-9149(99)00245-3
and a pulsatile abdominal mass associated with a bruit was palpated. Computer tomographic scan of the abdomen documented a large aortic pseudoaneurysm in the suprarenal location. At surgery, the patient was placed on hypothermic cardiopulmonary bypass through the left femoral vein and artery and abdominal exploration was performed from a retroperitoneal approach. Before the procedure, the TEE examination revealed a large pseudoaneurysm in the abdominal aorta (suprarenal), 10 ⫻ 16 cm in size at a level 50 to 70 cm from the bite block (Figure 1A). The entrance site to the pseudoaneurysm was identified at the posterior aspect of the aorta by injection of Optison, a transpulmonary echo contrast agent (Figure 1B to 1D). The communication was clearly delineated by the echo contrast agent. A laminar thrombus also
was found along the wall of the pseudoaneurysm. Color flow Doppler also showed communication between the aorta and pseudoaneurysm (Figure 1E), and pulsed wave Doppler demonstrated systolic flow into the cavity and diastolic flow back into the aorta (Figure 1F). The findings at surgery were entirely concordant with TEE examination: a laceration was found at the posterior aspect of the descending aorta, leading to a large pseudoaneurysm that contained a laminar clot. The pseudoaneurysm was resected and the laceration was patched with an aortic homograft. The pathologic examination of the resected pseudoaneurysm showed no signs of inflammation. The patient was discharged home in good general condition 1 week after surgery. •••
This report is the first for TEE identification of an abdom-
inal aortic pseudoaneurysm. In addition, we found that use of a transpulmonary contrast agent helped in the precise anatomic localization of the pseudoaneurysm as well as demonstration of its site of intravascular communication.
1. Bennett DE, Cherry JK. The natural history of
traumatic aneurysms of the aorta. Surgery 1967;61: 516 –523. 2. Potts RG, Alguire PC. Pseudoaneurysm of the abdominal aorta: a case report and review of the literature. Am J Med Sci 1991;301:265–268. 3. Miller JS, Wall MJ Jr, Mattox KL. Ruptured aortic pseudoaneurysm 28 years after gunshot wound: case report and review of the literature. J Trauma 1998; 44:214 –216. 4. Makins GH. Specimen showing the effects of gunshot injury on the heart and blood vessels: now on exhibit in the museum of the Royal College of Surgeons of England. Br J Surg 1920;8:107. 5. Chase CV, Layman TS, Barker DE, Clemens JB. Traumatic abdominal aortic pseudoaneurysm causing biliary obstruction: a case report and review of the literature. J Vasc Surg 1997;25:936 –940.
CASE REPORTS
241
MD,
Sharo S. Raissi, MD, Errol L. Hackner, MD, Steven S. Khan, Tomoo Nagai, MD, and Robert J. Siegel, MD
MD,
seudoaneurysm of the abdominal aorta is a rare entity, with P an incidence of 5% of all aortic pseudoaneurysms.1 There have been ⬍30 cases2,3 reported since the first description by Makins in 1920.4 In most of these cases, false aneurysms developed after penetrating injuries. Although pseudoaneurysm formation protects from exsanguination and is lifesaving in the acute phase, most patients with chronic traumatic pseudoaneurysms will eventually develop complications, sometimes after many years.5 We report a case of a large, abdominal aortic pseudoaneurysm after penetrating trauma in which a transpulmonary echo contrast agent (Optison, Mallinckrodt, St. Louis, Missouri; human albumin microspheres injectable suspension, octafluoropropane formulation) helped identify the orifice of the pseudoaneurysm during intraoperative transesophageal echocardiographic (TEE) examination. •••
After a gunshot wound to his right flank, a 19-year-old man presented to the emergency room with hemorrhage, hypotension and a hemoglobin of 2.0 g/dl. He underwent emergency abdominal exploration for ligation of bleeding vessels in the retroperitoneal area. During hospitalization, the patient had recurrent abdominal pain, but the physical examination was reportedly normal and the patient From the Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Siegel’s address is: Division of Cardiology, Room 5335, 8700 Beverly Boulevard, Los Angeles, California 90048. E-mail address: [email protected]. This study was supported by the Dunitz Family and the Save-AHeart Foundation, Los Angeles, California. Manuscript received December 31, 1998; revised manuscript received and accepted March 1, 1999.
240
FIGURE 1. A, a large abdominal aortic pseudoaneurysm (16 cm in diameter) with a laminar thrombus (white arrows). An asterisk identifies the abdominal aorta. B, after intravenous injection of the transpulmonary echo contrast agent, the contrast is seen in the abdominal aortic lumen and entering into the pseudoaneurysm. Black arrows show the site of communication. C and D, taken within 5 seconds after the initial appearance of the echo contrast agent, showing increasing opacification of the pseudoaneurysm. E, color flow Doppler also demonstrates abdominal aortic pseudoaneurysm flow. F, pulsed wave Doppler indicates that there is systolic flow into the pseudoaneurysm and diastolic flow back to the aorta.
was discharged after 11 days. Four weeks later the patient presented again to the emergency room for
©1999 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 84 July 15, 1999
increasing abdominal discomfort, fever and a 5-kg weight loss since his surgery. He was febrile (38.3°C) 0002-9149/99/$–see front matter PII S0002-9149(99)00245-3
and a pulsatile abdominal mass associated with a bruit was palpated. Computer tomographic scan of the abdomen documented a large aortic pseudoaneurysm in the suprarenal location. At surgery, the patient was placed on hypothermic cardiopulmonary bypass through the left femoral vein and artery and abdominal exploration was performed from a retroperitoneal approach. Before the procedure, the TEE examination revealed a large pseudoaneurysm in the abdominal aorta (suprarenal), 10 ⫻ 16 cm in size at a level 50 to 70 cm from the bite block (Figure 1A). The entrance site to the pseudoaneurysm was identified at the posterior aspect of the aorta by injection of Optison, a transpulmonary echo contrast agent (Figure 1B to 1D). The communication was clearly delineated by the echo contrast agent. A laminar thrombus also
was found along the wall of the pseudoaneurysm. Color flow Doppler also showed communication between the aorta and pseudoaneurysm (Figure 1E), and pulsed wave Doppler demonstrated systolic flow into the cavity and diastolic flow back into the aorta (Figure 1F). The findings at surgery were entirely concordant with TEE examination: a laceration was found at the posterior aspect of the descending aorta, leading to a large pseudoaneurysm that contained a laminar clot. The pseudoaneurysm was resected and the laceration was patched with an aortic homograft. The pathologic examination of the resected pseudoaneurysm showed no signs of inflammation. The patient was discharged home in good general condition 1 week after surgery. •••
This report is the first for TEE identification of an abdom-
inal aortic pseudoaneurysm. In addition, we found that use of a transpulmonary contrast agent helped in the precise anatomic localization of the pseudoaneurysm as well as demonstration of its site of intravascular communication.
1. Bennett DE, Cherry JK. The natural history of
traumatic aneurysms of the aorta. Surgery 1967;61: 516 –523. 2. Potts RG, Alguire PC. Pseudoaneurysm of the abdominal aorta: a case report and review of the literature. Am J Med Sci 1991;301:265–268. 3. Miller JS, Wall MJ Jr, Mattox KL. Ruptured aortic pseudoaneurysm 28 years after gunshot wound: case report and review of the literature. J Trauma 1998; 44:214 –216. 4. Makins GH. Specimen showing the effects of gunshot injury on the heart and blood vessels: now on exhibit in the museum of the Royal College of Surgeons of England. Br J Surg 1920;8:107. 5. Chase CV, Layman TS, Barker DE, Clemens JB. Traumatic abdominal aortic pseudoaneurysm causing biliary obstruction: a case report and review of the literature. J Vasc Surg 1997;25:936 –940.
CASE REPORTS
241