Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm. In one case, a 45-year-old man complained of chronic chest pain, dysphagia, and hoarseness of voice; posteroanterior view chest radiograph revealed lobular enlargement of the superior mediastinum and elevated right hemidiaphragm. Contrast-enhanced computed tomography (CT) of the thorax revealed a giant partially thrombosed aneurysm originating from the ascending aorta and extending into the aortic arch, causing a widening of the aorta-pulmonary window and a compression of the thoracic esophagus. Right hemidiaphragm elevation was explained by the gross mass effect of the aneurysm on the right hilum, causing right phrenic nerve palsy. The patient was to be operated on for surgical correction of the aneurysm, but died before surgery due to spontaneous rupture.
dysphagia; hoarseness; thoracic aortic aneurysm; palsy; phrenic nerve
Hoarseness due to left recurrent laryngeal nerve paralysis (LRLN) caused by identifiable cardiovascular disease is described as Ortner’s syndrome or Cardiovocal syndrome. This was first described by Ortner in 1897 to describe left recurrent laryngeal nerve palsy secondary to Mitral Stenosis. The common conditions which gave rise to Ortners’ syndrome include mitral stenosis, mitral valve prolapse, aortic aneurysm, septal defect, following cardiothoracic surgery, high altitude pulmonary hypertension, ductal aneurysm, aortic dissection etc. Herewith we are presenting an unusual presentation of Aortic arch aneurysm.
Aortic arch aneurym; laryngeal nerve paralysis
Saccular aortic arch aneurysms in unusual sites may be misdiagnosed as a neoplasm. We present the case of a rare saccular aortic arch aneurysm between trachea and esophagus that resembled a mediastinal neoplasm in the preoperative findings.
PRESENTATION OF CASE
A 63-year-old male with an abnormal mediastinal shadow on chest X-ray was referred to the hospital. An axial plain computed tomogram of the chest revealed mediastinal soft tissue next to the right side of the aortic arch resembling a neoplasm originating from the gap between the trachea and the esophagus. The coronal view constructed by enhanced 64-row multi detector computed tomography revealed the soft tissue was an aneurysm arising from the inner side of the aortic arch. An aortic arch replacement was performed via a median sternotomy.
A thoracic aortic aneurysm sometimes behaves like a mediastinal neoplasm. The multiple cross-sectional image from multidetector computed tomography was useful for the correct diagnosis of such an aneurysm.
The possibility of an aneurysm should be considered whenever a mass in contact with the aortic wall is identified.
Saccular aortic aneurysm; Mediastinal neoplasm; Computed tomography
Retained oesophageal foreign bodies must be urgently removed to prevent potentially serious complications. Recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus.
We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign body.
Oesophagoscopy is essential to fully assess patients with persistent symptoms after foreign body ingestion, irrespective of the level of dysphagia. Recurrent laryngeal nerve palsy may indicate impending perforation and should prompt urgent evaluation and treatment.
Although recurrent laryngeal nerve injury has been described following central venous access via the jugular route, it has not previously been reported following access via the subclavian route.
A 63-year-old man presented with acute dysphonia immediately after insertion of a Hickman line via the subclavian route. Flexible laryngoscopy revealed a left vocal fold palsy. A computed tomography scan from the skull base to the thoracic inlet showed no obvious abnormality other than an abducted left vocal cord.
The timing of the events and the computed tomography scan results strongly support the conclusion that the left recurrent laryngeal nerve was injured during insertion of the Hickman line, resulting in a left adductor vocal cord palsy.
This case illustrates an unusual example of iatrogenic injury to the recurrent laryngeal nerve. It is important to recognize the possibility that such injuries may occur in order to prevent them.
A 56 year-old woman presented with a ruptured bilobed wide neck aneurysm of the P2 segment of the PCA, atherosclerotic fusiform basilar artery aneurysm, subarachnoid bleeding with negative CT scan and chronic renal failure. She was managed by a cooperative approach involving neurosurgeons, neuroradiologist, neurointensivist, emergency room physicians, nurses and technicians.
She underwent operation by proximal clipping for the aneurysm of the PCA. Postoperative neurological deficits include homonymous hemianopsia and ipsilateral third nerve palsy. The operation was performed through asubtemporal approach. At surgery, the aneurysm was located in the distal of the P2 segment of PCA, bilobed up and down, no definitive neck with small distal branches, and was treated by proximal clipping of the PCA aneurysm. The fusiform basilar artery aneurysm was severely atherosclerotic and left untouched.
This is a rare case which required a high index of suspicion to detect subarachnoid bleeding from ruptured posterior fossa aneurysm, accurate prediction of the site of bleeding and the location of aneurysm location by conventional angiogram, MRI and MRA, and careful planned surgical strategy with the right approach for the P2 segment of the PCA aneurysm, complicated post operative care with airway management, triple H therapy, nutrition, additional measures and multiple hemodialysis.
brain, aneurysms, SAH, renal failure
In the surgical treatment of abdominal aortic aneurysm, the single proximal cross-clamp can be placed at 3 alternative aortic levels: infrarenal, hiatal, and thoracic. We performed this retrospective study to evaluate the advantages and disadvantages of the 3 main aortic clamping locations. Eighty patients presented at our institution with abdominal aortic aneurysms from March 1993 through May 1998. Fifty of these patients had intact aneurysms and underwent elective surgery, and 30 had ruptured aneurysms that necessitated emergency surgery. Proximal aortic clamping was applied at the infrarenal level in 24 patients (22 from the intact aneurysm group, 2 from the ruptured group), at the hiatal level in 34 patients (22 intact, 12 ruptured), and at the thoracic level (descending aorta) via a limited left lateral thoracotomy in 22 patients (6 intact, 16 ruptured). Early mortality rates (within 30 days) were 4% (2 of 50 patients) among patients with intact aneurysms and 40% (12 of 30 patients) among those with ruptured aneurysms. In the 2 patients from the intact aneurysm group, proximal aortic clamps were applied at the hiatal level. In the ruptured aneurysm group, proximal aortic clamps were placed at the thoracic level in 10 patients, the infrarenal level in 1, and the hiatal level in 1. According to our study, the clinical status of the patient and the degree of operative urgency--as determined by the extent of the aneurysm--generally dictate the proximal clamp location. Patients who present with aneurysmal rupture or hypovolemic shock benefit from thoracic clamping, because it restores the blood pressure and allows time to replace the volume deficit. Infrarenal placement is advantageous in patients with intact aneurysms if there is sufficient space for the clamp between the renal arteries and the aortic aneurysm. In patients with juxtarenal aneurysms, hiatal clamping enables safe and easy anastomosis to the healthy aorta. Clamping at this level also helps prevent late anastomotic aneurysm formation, which is frequently encountered after inadvertent anastomosis of the graft to a diseased portion of the aorta. Further studies are needed in order to confirm these results.
Cardiovocal syndrome or Ortner's syndrome is hoarseness due to left recurrent laryngeal nerve palsy caused by mechanical affection of the nerve from enlarged cardiovascular structures. Chronic thromboembolic pulmonary hypertension is extremely rarely found to cause this syndrome. We describe a case of a 56-year-old patient with sudden onset of hoarseness. The patient had known long standing severe pulmonary hypertension. Fiberoptic laryngoscopy showed left vocal cord palsy. Computed tomography of the neck and chest revealed extensive enlargement of the pulmonary arteries and excluded a malignant tumor. The diagnosis of cardiovocal syndrome was retained. It is important for the radiologist to be aware of this possible etiology causing left recurrent laryngeal nerve palsy and to understand its mechanism.
Endovascular repair of inflammatory aortic aneurysms has been reported as an alternative to open surgical treatment. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We report a case of endovascular repair of an inflammatory aortic aneurysm in a patient with Behçet's disease using a carotid-carotid bypass graft to provide an adequate landing zone. A 45-yr-old man with a voice change was referred to our hospital with the diagnosis of saccular aneurysm of the distal aortic arch resulting from vasculitis. Computed tomography showed a thoracic aortic aneurysm with thrombosis. Right to left carotid-carotid bypass grafting was performed. After 8 days, the patient underwent an endovascular stent graft placement distal to the origin of the innominate artery. The patient was discharged with medication and without postoperative complications after 5 days. Hybrid endovascular treatment may be suitable a complementary modality for repairing inflammatory aortic aneurysms.
Endovascular Repair; Aortic Aneurysm; Inflammatory; Carotid-Carotid Bypass; Behçet Syndrome
Aortic arch aneurysm is a rare condition but carries a high risk of rupture. We report one case of aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery aneurysm, which is extremely rare. Left internal carotid artery aneurysm resection and revascularization, carotid and carotid graft bypass combined with endovascular stent graft and embolization with coils were successfully performed. There were no any complaints and complications at 8 months follow-up. The follow-up CTA demonstrated thrombus formation in the aneurysm lumen, no endoleak and the aortic arch and bypass graft were all patent. We feel that hybrid procedure may be a valuable therapeutic alternative when treating this type of lesion. However, long-term clinical efficacy and safety have yet to be confirmed.
Aneurysm; Aortic arch; Stent graft; Hybrid procedure
Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient.
A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14x7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts.
The patient was discharged on the 9th postoperative day.
This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.
Tracheal and esophageal compression is a well-recognized complication of aneurysms of the aortic arch. Most of the patients present with dysphagia and/or respiratory insufficiency. In the adult population a right-sided aortic arch is often asymptomatic unless aneurysmal disease develops. This usually occurs at the level of the take-off of an aberrant left subclavian artery and is known as a Kommerell's aneurysm. In spite of its rarity, this condition is clinically relevant because of the mortality associated with rupture, the morbidity caused by compression of mediastinal structures, and the complexity of surgery. In many cases, surgical resection of the aneurysm relieves the symptoms. We present a case in which tracheal compression and bilateral vocal cord palsy caused by an aneurysm arising from Kommerrell's diverticulum. The patient developed respiratory embrassement after extubation and was subsequently treated with continue positive airway pressure (CPAP) with a favorable result.
Aneurysm; Trachea; Oesophagus; Tracheomalacia; Flexometallic tube
Ortner's syndrome (left recurrent laryngeal nerve palsy caused by cardiovascular pathology) is described in literature as occurring secondary to a variety of conditions. Spontaneous aneurysm of ductus arteriosus is a rare cause of this condition. We present a case where an adult patient with an aneurysm of the ductus arteriosus presented for the first time at the age of 62 years with hoarseness of voice secondary to left recurrent laryngeal nerve palsy.
Aneurysm of ductus arteriosus; hoarseness of voice; left recurrent laryngeal nerve palsy in adults
Aortic arch aneurysm, pseudocoarctation, and coronary artery stenosis are extremely rare in Behçet's syndrome. We present the case of a 25-year-old man with Behçet's syndrome who underwent coronary artery bypass grafting for severe stenosis in the proximal left anterior descending coronary artery and concomitant surgical correction of a saccular aneurysm that was causing pseudocoarctation of the aortic arch. The surgery was successful.
Aortic aneurysm, thoracic/complications/diagnosis/surgery; Behcet syndrome/complications/diagnosis/surgery; coronary artery bypass; coronary disease/diagnosis/etiology/surgery; coronary stenosis/etiology/surgery; vascular surgical procedures/methods
A rare case of bilateral third cranial nerve palsy due to a ruptured anterior communicating artery aneurysm is presented. A 68-yr-old woman was semicomatose with bilaterally fixed dilated pupil, abducted eyes, and ptosis. A computed tomography demonstrated extensive hemorrhage spreading around the both Sylvian and interhemisheric fissure without focal mass effect. Intracranial pressure via extraventricular drainage before surgery was 15-50 mmHg. Three months later, brain MRI showed infarction of left posterior cerebral artery territory and lacuna infarction of the pons. Eleven months after aneurysm repair, nerve palsy improved slowly and recovered partially. The patient communicated well with simple words. The author reviewed and discussed the possible mechanism of this rare neuro-ophthalmological manifestation in view of a false localizing sign.
Oculomotor Nerve; Paralysis; Palsy; Anterior Communicating Artery; Intracranial Aneurysm
Endovascular treatment of complex thoracic pathologic conditions involving the aortic arch can often be appropriate and safe; however, minimally invasive procedures are not always feasible, especially in emergent cases. We report the case of a 78-year-old woman who emergently presented in hemorrhagic shock with a ruptured chronic dissecting aneurysm that involved the aortic arch. Eight years earlier, she had undergone aortic valve replacement and plication of the ascending aorta, which was complicated a day later by Stanford type B dissection, malperfusion, and ischemia that required an axillobifemoral bypass. At the current admission, we successfully treated her surgically through a left thoracotomy, using moderate hypothermic extracorporeal circulation and advanced organ-protection methods. We discuss the surgical indications and our operative strategy in relation to open surgical repair versus endovascular treatment in patients with complex conditions.
Aneurysm, dissecting/radiography/surgery; aortic aneurysm, thoracic/radiography/surgery; aortic diseases/surgery; aortic rupture/surgery; treatment outcome; vascular surgical procedures
Saccular type of thoracic aortic aneurysm is a rarely seen phenomenon. Here, we present a case of saccular-type aortic aneurysm admitted to coronary care unit with a diagnosis of acute coronary syndrome. A 63-year-old woman presented to our clinic with chest pain lasting for 2-3 hours. Because her chest pain persisted despite intensive medical treatment, she underwent coronary angiography. Coronary arteries appeared normal but a saccular type aneurysm of ascending aorta was detected on aortography. The patient underwent urgent surgery. The aneurysmal segment was resected and tube graft inserted. The patient was discharged without any postoperative complication.
Acute Coroner Syndrome; Saccular Aortic Aneurysm; Dissection
Pulmonary hypertension in systemic lupus erythematosus (SLE) is rare in the absence of parenchymal lung disease. We report such a case, which was complicated by the subsequent development of a left recurrent laryngeal nerve palsy, and in which there was a strong family history of SLE.
Retropharyngeal hematoma is a rare form of pharyngeal pathology and can present as acute airway obstruction. Among the many causes of retropharyngeal hematoma, thoracic aortic rupture is extremely rare.
Methods and results
A 78-year-old female with airway obstruction by a retropharyngeal hematoma secondary to thoracic aortic aneurysm rupture was successfully treated by total aortic arch replacement and open stent-graft insertion.
Rupture of the thoracic aorta should be considered as a rare but important cause of retropharyngeal hematoma and airway obstruction.
Retropharyngeal hematoma; Airway obstruction; Thoracic aorta; Aortic aneurysm; Rupture; Shock; Aortic arch; Open-stent graft; Mediastinal hematoma
Rupture of the free wall of the left ventricle (LV) is a catastrophic complication occurring in 4% of patients after myocardial infarction (MI) and in 23% of those who die of MI. Rarely the rupture is contained by an adherent pericardium creating a pseudo-aneurysm. This clinical finding calls for emergency surgery. If no ruptures are detectable and myocardium wall integrity is confirmed, we are in the presence of a true aneurysm, which can be treated by means of elective surgery. Differentiation between these two pathologies remains difficult. We report the case of a patient with a true aneurysm, initially diagnosed as pseudo-aneurysm at our institution; we have reviewed the literature on this difficult diagnosis and outlined characteristic findings of each clinical entity.
Background: Endovascular aneurysm repair has gained
widespread acceptance, and there has been a significant increase in the number of
aneurysms treated with stent grafts. However, the endovascular technique alone is often
not appropriate for anatomically complex aneurysms involving the neck branches. We used
the TAG stent for thoracic aortic aneurysms (TAA), and report our initial results.
Patients and Results: We deployed 80 TAG stents in 65
patients electively treated with TAA between June 2006 and June 2008. Thoracic
endovascular aneurysm repair (TEVAR) was performed in 45 cases of descending aortic
aneurysm with no morbidity or mortality. A combination of open surgery and TEVAR was
performed in 11 out of 20 cases with aneurysms of the aortic arch. The prior total arch
replacement and elephant trunk procedure was performed in 3 cases with dilated ascending
aorta, total debranching from ascending aorta with sternotomy in 5, and carotid-carotid
artery crossover bypass in 3 cases. Meanwhile, TEVAR with coverage of the left subclavian
artery was performed in the remaining 9 distal arch cases. In 3 cases with extremely short
necks, a 0.018” guide wire was inserted percutaneously in a retrograde manner through the
common carotid artery (CCA) into the ascending aorta to place the stent graft in close
proximity to the CCA (wire protection). In 1 of these 3 cases, the TAG stent was deployed
through the CCA, and the 0.018” guide wire was used to deliver a balloon-expandable stent
in order to restore the patency of the CCA. In arch and distal arch aneurysm cases,
perioperative mortality and the incidence of stroke were both 5.0%; dissection of the
ascending aorta was seen in one case (5.0%).
Conclusion: As treatment for descending aortic aneurysms,
TEVAR can replace conventional open repair. However, TEVAR for arch aneurysms has some
problems, and further improvement is necessary. (English Translation of Jpn J Vasc Surg
2010; 19: 547-555.)
Keywordsthoracic aortic aneurysm; endovascular surgery; stent graft
Compression of the trachea, bronchi, and pulmonary arteries are complications in patients with large thoracic aortic aneurysms. In this case, we report unexpected cardiopulmonary collapse manifested by general anesthesia before surgery in an asymptomatic patient with a large thoracic aortic aneurysm.
We present the case of a 32-year-old man with a 10-cm aneurysm in the ascending aorta. A total aortic arch replacement was planned. After intravenous anesthesia, his aneurysm occluded the left main bronchus and right pulmonary artery simultaneously, and induced severe hypoxia. Percutaneous cardiopulmonary support was conducted and the patient recovered from cardiopulmonary collapse successfully. After the patient regained consciousness from anesthesia, the findings of organ compressions disappeared. At the second surgery, percutaneous cardiopulmonary support was initiated with local anesthesia before general anesthesia and intubation. The operation was performed successfully without any adverse events.
We experienced a case of hemodynamic collapse induced by general anesthesia in a patient of an unruptured thoracic aortic aneurysm. It is important to recognize that fatal organ compression might be caused by general anesthesia even in asymptomatic patients with thoracic aortic aneurysm.
Thoracic aortic aneurysm; Anesthesia; Percutaneous cardiopulmonary support
The aim of the present study was to determine whether immediate revision surgery has benefits for patients with iatrogenic bilateral recurrent laryngeal nerve (RLN) palsy. From January 1, 2004 to January 30, 2011, 29 consecutive patients underwent immediate revision after total thyroidectomy. The cohort comprised 29 patients, 2 males and 27 females, aged 23 to 76 years (median 52 years). Identification of the type and extent of injury of each branch was reported in the protocol, and reconstruction was performed whenever possible. A complete transection of the nerve or one of its branches was found in 14 and 5 nerves, respectively. In three patients, the nerve was completely or partially transected on both sides. Seven anatomically intact nerves were injured by loaded ligature, in one case there was a sign of thermal damage and four nerves showed signs of excessive manipulation (thinning of the nerve trunk). Primary end-to-end anastomosis was performed in seven completely transected RLN and four transected anterior branches of RLN. None of the reconstructed nerve trunks or its branches regained function, although good muscle tone was observed. 23 of 38 intact nerves (61%) regained function, and normal vocalcord mobility on both sides was restored in only four patients. In all cases with regained vocal-cord mobility, functional recovery occurred within 3 months after primary surgery. In conclusion, immediate revision after thyroidectomy may help to indicate the type of RLN damage, which is a predictor of functional recovery and one of major factors influencing future therapeutic management.
Bilateral recurrent laryngeal nerve palsy; Immediate revision; Functional recovery; Thyroid surgery
A prospective study was carried out in patients undergoing thyroid and parathyroid surgery using a laryngeal mask airway (LMA) and electrical nerve stimulation to identify the recurrent laryngeal nerves. A total of 150 consecutive patients undergoing thyroid and parathyroid surgery by a single surgeon were assessed for suitability of anaesthesia via the LMA. Peroperatively, a fibre-optic laryngoscope was passed through the LMA to enable the anaesthetist to visualise the vocal cords while adduction of the cords was elicited by applying a nerve stimulator in the operative field. In all, 144 patients were selected for anaesthesia via the LMA. Fibre-optic laryngoscopy and nerve stimulation were performed in 64 patients (42.7%). The trachea was deviated in 51 (34.0%) and narrowed in 33 (22.0%). The recurrent laryngeal nerves were identified in all patients. There were no cases of vocal cord dysfunction resulting from surgery. The LMA can be safely used for thyroid and parathyroid surgery even in the presence of a deviated or narrowed trachea. It can assist in identification and preservation of the recurrent laryngeal nerve and is, therefore, of benefit to both patient and surgeon.
The authors report a rare case of a 75 year old man who presented 35 years after radiotherapy for carcinoma of the larynx, with catastrophic bleeding through the mouth. Both the time and mode of presentation were unusual. The patient required emergency sacrifice of the left vertebral artery to stop the bleeding. The literature has been reviewed.
osteoradionecrosis; haemorrhage and radiotherapy; vertebral artery embolisation