Descending thoraco-abdominal aortic aneurysm rupture with left massive Hemothorax—diagnosis and emergency management

Sri Anjali Devi1, Santhosam1, Arunagiri Viruthagiri2, Nedounsejiane Mandjiny2, Karthik Raman3, Mithun Chakkaravarthi2

1Department of Critical Care, Kauvery Hospital, Cantonment, Trichy

2Department of Vascular Surgery, Kauvery Hospital, Tennur, Trichy

3Department of Cardiology, Kauvery Hospital, Heart City, Trichy

Background

A Hemothorax in the context of a ruptured thoracoabdominal aneurysm can present with significant clinical challenges. When the aneurysm ruptures, it often leads to massive bleeding into the thoracic cavity, resulting in Hemothorax. This can cause a rapid deterioration in the patient condition due to the large volume of blood loss and increased intrathoracic pressure. Risk of mortality 80–90%.

Case Report

A 66 year aged female with a known case of Type 2 DM, HTN, recently diagnosed as type B abdominal aortic aneurysm, presented in the Emergency department with abdominal pain, back pain , worsening dyspnea and hemodynamic instability.

Examination

On examination, Patient was conscious, oriented, pale, tachypneic absent breath sounds and dullness to percussion on the left chest. Chest wall asymmetry and tracheal deviation to right side was noted, RR: 35/min, spo2:93%on RA, tachycardic and Hypotensive BP: 70/50mmhg, PR: 120/min. Epigastric pulsatile mass felt with tenderness and guarding.

POCUS: Centrally displaced heart with EF – 60% and left massive collection in pleural space.

Recent CECT Abdomen: Saccular aneurysm proximal abdominal aorta-1.5×1.3cm with no leak.

Investigations

Hb: 6.7 Gm %

Chest X-ray: Hypodensity noted, mediastinum shifted to the right with massive hemothorax. Suspected hemothorax secondary to ruptured Aortic aneurysm. Left intercostal drainage was done within 30 min, 900ml of hemorrhagic fluid was drained.pt was diagnosed to have grade 2 hemorrhagic shock,

Patient was started on aggressive fluid resuscitation at 30ml/kg. According to MTP, blood products (1:1:1) were transfused and with stable hemodynamics, patient was shifted for emergency OT for aneurysm repair within 1 hr.

OT Findings

Aortic aneurysm extends from the descending thoracic aorta up to the pre-celiac segment, ruptures into the left pleural cavity and chronic clots present over the left lung.

Emergency open Trans Abdominal Aortic Aneurysm rupture repair with interposition graft B-BRAUN with successful results—intraoperatively 2 units of PRBC and 2 units of FFP transfusion done. Patient shifted to the ICU post-operatively.

Hb improved to 9.2 and gradually weaned off from ventilator. Patient improved symptomatically.

Conclusion

Aortic aneurysm rupture with hemothorax is a fatal condition. It requires immediate recognition and aggressive resuscitation to prevent mortality. This unusual presentation should always be considered in the emergency department. We present this case to emphasize that ruptured Aortic Aneurysm should be considered in the evaluation of spontaneous hemothorax even if its left sided particularly in the elderly ,emergent therapy is necessary to prevent mortality.

Reference

  • Pizon A, Bissell BJ, Gilmore N. Rupture of an ascending and descending thoracic aortic aneurysm causing tension hemothorax: a case report. J Emerg Med 2012; 43 (4): 625–6.
  • Spontaneous Right Hemothorax in the Elderly , Samira Aouadi , corresponding author Asma Sebai, Houda Gharsalli, Hazem Zribi, Henda Neji, Sonia Maâlej, and Leila Douik El Gharbi
  • Rupture of an Ascending and Descending Thoracic Aortic Aneurysm Causing Tension Hemothorax.

Dr. Sri Anjali Devi
MEM -Resident

Dr Santhosam

Dr. C. M. Santhosam
Critical Care Specialist

Dr.Arunagiri Viruthagiri Vascular Surgeon

Dr. Arunagiri Viruthagiri
Consultant Vascular & Endovascular Surgeon

Dr Nedounsejiane Mandjiny

Dr. Nedounsejiane Mandjiny
Vascular surgeon

Dr. Karthik Raman
Consultant cardiac surgeon

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