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Case 115: Aortic Pseudoaneurysm from Penetrating Superior Vena Cava Stent¹

¹ From the Departments of Radiology (D.M.W., R.K.A., M.A.M.) and Surgery (C.H.S., H.S.T.), University of North Carolina School of Medicine, Campus Box 7510, Chapel Hill, NC 27599-7510. Received May 27, 2004; revision requested August 9; revision received August 30; accepted October 4; final version accepted October 20.

Correspondence: Address correspondence to D.M.W. (e-mail: david_warshauer{at}med.unc.edu).

	HISTORY

TOP HISTORY IMAGING FINDINGS DISCUSSION References

 
A 35-year-old man presented with acute substernal chest pain. He described the pain as dull and constant, with occasional episodes of knifelike pain that radiated to his back and neck. These episodes were exacerbated by dialysis that was performed through a right upper extremity brachiocephalic fistula. His medical history included uncontrolled hypertension, end-stage renal disease, and cocaine abuse. He had been hospitalized multiple times in the past year and a half for chest pain, but no evidence of pulmonary embolism or cardiac ischemia was found. Serial transthoracic echocardiograms demonstrated nonconstrictive pericardial effusion. The present episode differed somewhat from prior episodes in that it was associated with hemodialysis.

Two months prior to the current episode, this patient experienced poor venous outflow during dialysis. Shunt venography depicted a tight stenosis at the junction of the right brachiocephalic vein and the superior vena cava (SVC). This area was successfully opened with a 15 x 50-mm Gianturco stent (Cook, Bloomington, Ind) and dilated to 12 mm. Subsequently, the patient was hospitalized two additional times for chest pain. At the time of the current episode, he had a blood pressure of 164/101 mm Hg, a pulse of 112 beats per minute, a respiratory rate of 18 breaths per minute, and 100% oxygen saturation on room air. Physical examination revealed a thin man in no distress; the only notable finding was engorged upper extremity veins due to the dialysis shunt. Conventional chest radiographs and computed tomographic (CT) images of the chest were obtained.

	IMAGING FINDINGS

TOP HISTORY IMAGING FINDINGS DISCUSSION References

 
Upright anteroposterior radiograph of the chest (Fig 1) revealed cardiomegaly but no evidence of pulmonary edema. A Gianturco stent that crossed the junction between the right brachiocephalic vein and the SVC was noted. Transverse and coronal CT images of the chest (Figs 2, 3) showed a contrast material–filled outpouching from the right side of the ascending aorta that was consistent with an aortic pseudoaneurysm. Two struts of the Gianturco stent were noted to have penetrated the SVC wall and sat in relatively close proximity to the aortic pseudoaneurysm. An aortogram (Fig 4) was obtained per the request of the admitting physician team and enabled the diagnosis of an aortic pseudoaneurysm to be confirmed.

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Upright anteroposterior radiograph of the chest shows cardiomegaly but no evidence of pulmonary edema. A Gianturco stent (arrow) is seen at the juncture of the brachiocephalic vein and SVC.

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Transverse CT images of the upper part of the chest. (a) Image obtained with soft-tissue window settings shows an aortic pseudoaneurysm (arrow). (b) Image obtained with bone window settings better demonstrates a strut (arrowhead) of the Gianturco stent that has penetrated the SVC wall and sits in close proximity to the aortic pseudoaneurysm (arrow).

View larger version (32K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Transverse CT images of the upper part of the chest. (a) Image obtained with soft-tissue window settings shows an aortic pseudoaneurysm (arrow). (b) Image obtained with bone window settings better demonstrates a strut (arrowhead) of the Gianturco stent that has penetrated the SVC wall and sits in close proximity to the aortic pseudoaneurysm (arrow).

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: Coronal CT images of the chest. (a) Image shows an aortic pseudoaneurysm (arrow). (b) Image obtained slightly posterior to a shows two struts of the Gianturco stent (arrow) in close proximity to the aortic pseudoaneurysm. The struts have penetrated the venous wall.

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: Coronal CT images of the chest. (a) Image shows an aortic pseudoaneurysm (arrow). (b) Image obtained slightly posterior to a shows two struts of the Gianturco stent (arrow) in close proximity to the aortic pseudoaneurysm. The struts have penetrated the venous wall.

View larger version (174K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Aortogram obtained per the request of the admitting physician team enabled the diagnosis of an aortic pseudoaneurysm (arrow) to be confirmed.

	DISCUSSION

TOP HISTORY IMAGING FINDINGS DISCUSSION References

Serosanguinous pericardial fluid and dense adhesions between the SVC and ascending aorta were identified. The pseudoaneurysm was opened and found to be 10 mm in diameter (Fig 5). The adjacent aorta was healthy, and the defect was repaired with a Dacron patch. Examination of the SVC revealed two struts of the Gianturco stent that had perforated medially (Fig 5) and a third strut just under the adventitia. These struts were debrided, and the SVC defect was repaired primarily. A large pericardial fat pad was mobilized and interposed between the SVC and aorta to support the repair. Postoperatively, the patient had an uneventful recovery and was discharged on the 5th postoperative day.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 5: Intraoperative photograph shows the perforated struts (arrows) of the Gianturco stent adjacent to the aorta (A). The pseudoaneurysm had been repaired when this photograph was obtained. Its location is marked by the suture material (arrowhead).

The mechanism of thoracic pseudoaneurysm in this patient differed from the previously mentioned causes. We suspect that repetitive local trauma, which was caused by the pulsating aorta beating against the perforated struts of the adjacent Gianturco stent, caused this pseudoaneurysm. To our knowledge, thoracic pseudoaneurysm secondary to repetitive local trauma has not been previously reported at this site; however, local trauma has been reported to induce pseudoaneurysm formation. Pseudoaneurysm formation in the popliteal artery has been seen in patients with femoral osteochondromas. The injury mechanism has been postulated to be repetitive trauma to the artery as it is stretched over the exostosis during flexion and extension of the knee (5,6). Penetration of the adjacent aorta by a prong of an inferior vena cava filter has also been noted. This has been reported to cause pseudoaneurysm (7), aortocaval fistula (8), and mural thrombus (9) formation, as well as fatal retroperitoneal bleeding (10). Penetration of the aorta without pseudoaneurysm formation or other complications has also been reported (11,12). These arterial complications of vena caval filters are quite rare and have been noted primarily in case reports. Vena caval wall penetration, however, is more common and was seen in 9% of patients in a study in which a variety of filter types were used (13). We suspect that the aortic arch may be more susceptible to damage by adjacent penetrated struts because of the relative vigor of the more proximal aortic pulsation and the primary force vector being directed toward, rather than parallel to, the penetrated strut. A mycotic origin was felt to be unlikely in this case because of the absence of fever and leukocytosis. In addition, the area had a benign appearance at surgery, and the patient recovered after he received only the usual prophylactic antibiotics for cardiac bypass surgery.

Central venous stenosis is seen in patients who undergo hemodialysis, and it is thought to result from the chronic high-flow state seen in the draining veins and the resultant turbulence. In this setting, the use of stents has proved more successful than the use of balloon angioplasty alone and is currently recommended (14). Stents have also been used in the setting of SVC syndrome associated with both malignant and postirradiation fibrosis (15). The mechanism of aortic pseudoaneurysm associated with stent use in the SVC in this patient indicates that care should be exercised when stents are placed so that the tines do not directly face the pulsating aorta and instead follow the normal curve of the right brachiocephalic vein.

The diagnosis of aortic pseudoaneurysm has undergone a substantial shift in recent years. Catheter angiography was considered the reference standard (3), but it has been supplanted by helical CT (16). The results of a study that involved 142 patients suspected of having traumatic aortic pseudoaneurysm showed sensitivity and negative predictive values of 100% for helical CT; these values were equivalent to those obtained with aortography (17). At the time of this writing, the results of studies performed with new multi–detector row CT scanners had not been reported; however, we suspect that the results obtained with these scanners will be substantially better than those obtained with single–detector row CT scanners, given the ease with which thin-section images are acquired and the quality of these images. Isotropic resolution also allows for high-quality coronal and oblique reconstructions, as demonstrated in this case.

	FOOTNOTES

 
Authors stated no financial relationship to disclose.

Part one of this case appeared 4 months previously and may contain larger images.

 

	References

TOP HISTORY IMAGING FINDINGS DISCUSSION References

 

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13. Ferris EJ, McCowan TC, Carver DK, McFarland DR. Percutaneous inferior vena caval filters: follow-up of seven designs in 320 patients. Radiology 1993;188:851–856.[Abstract/Free Full Text]
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