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Slight back pain, large abdominal mass

Session Clinical cases moderated - The nightmare of aortic syndromes: be prepared to survive

Speaker Ines Aguiar Ricardo

Event : EuroEcho 2017

  • Topic : diseases of the aorta, peripheral vascular disease, stroke
  • Sub-topic : Acute Aortic Syndromes, Aortic Dissection
  • Session type : Moderated Posters

I Aguiar-Ricardo1 , J Rigueira1 , I Goncalves1 , J Agostinho1 , N Andre1 , R Santos1 , AN Ferreira1 , R Placido1 , J Fausto-Pinto1 , AG Almeida1 , 1Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology - Lisbon - Portugal ,

European Heart Journal Supplements ( 2017 ) 18 ( Supplement 3 ), iii82

Aneurysm is the second most frequent disease of the aorta after atherosclerosis. An abdominal aortic aneurysm (AAA) is defined as a dilation of the subdiaphragmatic aorta to a diameter greater than 3.0 cm. When AAAs rupture, the mortality rate is approximately 81%; therefore, efforts have been made toward early detection, especially when cardiovascular risk factors are present.

Case report description 
We present a case of a 50-year-old male, smoker (48 pack-year smoking history), who presented to the emergency department with a mild back pain of 8 hours duration, associated with nausea and postprandial general discomfort feeling. He denied another symptomatology. He had no documented history of any other cardiovascular risk factor and he had no daily medication. The patient's vital signs were within normal ranges. On physical examination, the patient was in mild discomfort due to back pain. His pulses were intact and symmetrical in the upper and lower extremities. His abdomen was soft and but a pulsatile mass was present. It was performed a transthoracic echocardiography that revealed a thoracic and abdominal descending aortic aneurysm with mural thrombosis, exerting a compressive effect on the cardiac cavities. This exam did not show other significant changes. A CT scan of the thorax, abdomen and pelvis with intravenous iodinated contrast was immediately performed, which revealed an aneurysmal dilatation of the thoracic-abdominal aorta with fusiform morphology with 14.2 cm of greater diameter (figure 1). With longitudinal extension of 21cm, from the descending aorta to the emergence of the renal arteries. There was a mural thrombus with irregular contours but homogeneous density with no evidence of active extravasation of contrast. In the thoracic segment evidence of intra-mural hematoma. The patient underwent surgical resection of AAA type III and reconstruction by the Crawford technique. The procedure was uneventful. A new Angio-CT scan was performed showing aortic prosthesis inside the aneurysm, permeable, with only slight stenosis at the level of the superior anastomosis with the descending thoracic aorta. 

Discussion, conclusion and implication for clinical practice
Although it is a more common pathology in men over 65 years of age, the possibility of aortic aneurim should be part of the differential diagnosis of all patients> 50 years with complaints of back pain, especially when associated with cardiovascular risk factors. In this case, despite the presence of only one, it is important to focus that the smoking not only plays a role in the pathogenesis of AAA, but also increases the rate of expansion and risk of rupture of established aortic aneurysm; in fact it is a much greater risk factor for AAA than dyslipidemia. The transthoracic echocardiogram, in this case, was performed taking into account the possibility of dissection of the aorta in the differential diagnosis. In addition to being an examination that can be quickly performed at the head of the patient, it is an excellent tool without risk and at low cost. However it is the CT and MRI, which are considered "gold-standard" in the pre-operative and post-operative evaluation. In case of suspicion, the patient should be referred for advanced imaging.

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