Thoracic aortic aneurysm rupture

Case contributed by Dr Dayu Gai


This 46 year old man presented to the emergency department with sudden onset right upper abdominal pain. This was associated with oxygen desaturation to 86% on room air. A CT chest/abdomen/pelvis was performed.

Patient Data

Age: 45
Gender: Male
  • There is a large aneurysm involving the descending thoracic and suprarenal abdominal aorta which on the antero-posterior view has a maximal diameter of 9cm involving the distal thoracic aorta. There is rupture of the aneurysm into the right pleural space which tracks into the posterior mediastinum as well as to the right retroperitoneum.

Case Discussion

Traumatic aortic injury is commonly seen in high-speed motor vehicle collisions1.
Chest radiographs are commonly used for screening in motor vehicle accidents. Radiographic signs of aortic injury include:

  • Mediastinal widening (greater than 8cm or 25% of the thoracic width)
  • Transverse aortic arch abnormality
  • Loss of aorto-pulmonary window

CT is considered the diagnostic test of choice for traumatic aortic injury. It has a sensitivity which is greather than 98%. Signs of aortic injury on CT include the presence of1:

  • intimal flap
  • traumatic pseudoaneurysm
  • contained rupture
  • intraluminal mural thrombus
  • abnormal aortic contour
  • sudden change in aortic caliber

Since the 1990's, there has been a shift away from open surgical repair of aortic injury. Instead, thoracic endovascular aortic repair (TEVAR) has gradually replaced open repair as the mainstay of operative aortic injury management2. It is associated with significantly lower operative times, procedural blood loss and intraoperative blood transfusion compared to open repair.

In this particular case, note the calcified walls of the aorta. Also note the bilateral hemothorax; in particular, the right sided hemithorax is full of heterogeneous fluid which is a combination of old blood and new blood from the ruptured aneurysm.

Case contributed by A/Prof. Pramit Phal.

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