From my archives, January 23, 2010,
A Fossil of the Kennedy Administration
The patient was sent to my clinic with the diagnosis of a saccular thoracic aortic aneurysm of 5x10mm. He is a 78 year old man who was working at restoring a vintage John Deere tractor when he developed chest pain. He underwent a cardiopulmonary workup which included a CT which showed a 5x10mm saccular aneurysm of the inner curve of his aortic arch opposite the origin of the left subclavian artery. This same CT showed no pulmonary embolism. His past medical history is significant for hypertension and he has never had surgery. His only hospitalization was in 1962 when he had a head-on collision which caused rib and collar bone fractures -he was the driver and he bent the steering column.
His examination was normal. He had had a complete cardiac workup including a stress test which was also normal. He persisted on having this intermittent midsternal chest pain.
CTA images: above and below. The CT shows a small area of contrast fill consistent with a focal 5x10mm saccular aneurysm of the inner curve of the aortic arch.
My impression is this is a residual saccular aneurysm of the thoracic aorta in the ligamentum arteriosum, related to the head on collision from time of the Kennedy administration. The injuries and the steering column damage suggest significant transfer of energy. It may have been the cause of his pain. We discussed surveillance with medical therapy (to include anti-inflammatories for any tractor lifting injuries) versus TEVAR. Ultimately we chose TEVAR.
This entry was posted on my old Medscape Blog, The Pipes Are Calling, with great comments and a poll. The poll results show a majority favoring medical therapy and watching. The only problem was that this patient was still having chest pain without a good explanation -pulmonary embolism and coronary artery disease were ruled out. The patient also lived two hours away from a hospital and would be lifting old tractors and their parts because that is what old farmers in Iowa do for fun –they also never truly retire. I think it also shows a general skepticism of surgical solutions –this feeling is based on historical bias with open surgery rather than contemporary results using percutaneous techniques.
The saccular aneurysm is an inherently unstable one as the angles on the surface of the aorta caused by a sac create areas of focused high wall stress. Rupture is usually fatal and the mortality rates for emergency surgery exceed 50%.
The other consideration was the relative risks of intervention have decreased with endovascular technique. Where mortality and morbidity of open repair on the proximal thoracic aorta ranged from 5 to 10%, with endovascular techniques, these fall to under 2-5%. I have been placing these thoracic endografts percutaneously and have had good results with low complication rates.
I performed percutaneous TEVAR of this saccular aortic aneurysm. The patient recovered well and went home after two days. Two years later, his CTA (below) shows complete resolution of the saccular aortic aneurysm. His chest pain never recurred.