Circulation. 2008;118:e11-e15
doi: 10.1161/CIRCULATIONAHA.107.753269
(Circulation. 2008;118:e11-e15.)
© 2008 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Aortic Pseudoaneurysm Caused by Migration of a Swallowed Sewing Needle
Interventional Radiology and Endoscopic Management
Carlo Ferro, MD;
Umberto G. Rossi, MD;
Giulio Bovio, MD;
M’Hamed Dahmane, MD;
Sara Seitun, MD;
Renato Santucci, MD;
Luigi Martinelli, MD
From the Departments of Diagnostic and Interventional Radiology (C.F., U.G.R., G.B., M.D., S.S.), Gastroenterology (R.S.), and Cardiac Surgery (L.M.), San Martino University Hospital, Genoa, Italy.
Correspondence to Umberto G. Rossi, MD, Department of Diagnostic and Interventional Radiology, San Martino University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy. E-mail urossi76{at}hotmail.com
A white 64-year-old woman who made dresses for her livelihood was admitted to the emergency department for evaluation of acute chest pain and respiratory distress. Physical examination was unremarkable except for low arterial blood pressure (90 mm Hg systolic, 65 mm Hg diastolic), whereas ECG showed left atrial enlargement, possible previous septal myocardial infarction, negative T waves in the inferior leads, and no evidence of acute ischemia (Figure 1). Myocardial enzyme levels, including Troponin I, were within normal values after serial determination.
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Figure 1. ECG shows sinusal rhythm with 98 bpm, left atrial enlargement, possible previous septal myocardial infarction, and negative T waves in inferior leads.
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Chest x-ray was performed and showed a thin radiopaque foreign body at the 5° body of the thoracic vertebra level, near the trachea (Figure 2). When questioned specifically, the patient mentioned the possible accidental ingestion of a sewing needle approximately 1 month before her chest pain began. A contrast-enhanced multidetector computed tomography (MDCT) scan of the thorax was then performed, which confirmed the presence of the foreign body, located in the mediastinum between the esophageal wall and the aortic arch, and a pseudo-aneurysm of the medial aortic arch wall above the needle (Figures 3 through 5
). The bottom of the needle was close to the esophageal wall, with no signs of mediastinitis. It was hypothesized that migration of the sewing needle from the esophagus into the mediastinum could have produced a lesion in the aortic wall, resulting in a pseudoaneurysmal dilatation of the vessel.1–3
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Figure 2. Chest x-ray shows the needle (arrow), at the 5° body of the thoracic vertebra level, near the trachea and the superior mediastinum enlargement.
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Figure 3. Contrast-enhanced MDCT scan of the thorax shows the needle (arrow) in the mediastinum, behind the trachea, and laterally left of the esophagus and right of the aortic arch.
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Figure 4. Contrast-enhanced MDCT scan of the thorax shows the presence of a pseudoaneurysm of the medial aortic arch wall (arrow heads).
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Figure 5. Right sagittal Contrast-enhanced MDCT volume-rendering technique reconstruction shows the pseudoaneurysm of the aortic arch (arrow heads) and the needle (arrow).
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According to the American Society of Anesthesiologists classification, the patient was considered as a "class 3 preoperative risk" for conventional thoracic open surgery. A less-invasive procedure was thought to be the implantation of a thoracic aortic endoprosthesis, with subsequent removal of the needle through mediastinoscopy.4 Doppler ultrasound was performed and showed normal blood flow of vertebral, carotid, and Willis arteries, and an aortic arch angiogram demonstrated the pseudoaneurysm arising just behind (<1 cm from) the left subclavian artery (Figure 6).
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Figure 6. Left sagittal thoracic aorta angiogram shows the pseudoaneurysm of the aortic arch (arrow heads) and the needle (arrow).
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The patient underwent endovascular repair under general anesthesia. The thoracic aortic stent graft was inserted under fluoroscopic guidance just distal to the left common carotid artery, covering the left subclavian artery origin. The final aortogram revealed the complete exclusion of the aortic arch pseudoaneurysm without endoleak and a delayed revascularization of the left subclavian artery by the omolateral vertebral artery (Figure 7).
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Figure 7. Left sagittal thoracic aorta angiogram after implantation of the thoracic endoprosthesis, which shows the complete exclusion of the pseudoaneurysm and the continued presence of the needle (arrow).
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Contrast-enhanced MDCT scan of the thorax confirmed, 3 days after the thoracic endoprosthesis implantation, the exclusion of the pseudoaneurysm and showed that the bottom of the sewing needle had been moved into the esophageal lumen (Figure 8). An upper gastrointestinal endoscopy was performed, under thoracic fluoroscopy, with identification of the bottom of the sewing needle, which was easily removed with no complications (Figures 9 through 11).
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Figure 8. Contrast-enhanced MDCT scan of the thorax 3 days after implantation of the thoracic endoprosthesis confirms the exclusion of the pseudoaneurysm and shows the sewing needle (arrow) with the bottom in the esophagus (arrow heads).
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Figure 9. Upper gastrointestinal endoscopy reveals the bottom of the sewing needle (arrow) piercing the thoracic esophagus.
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Figure 10. Thoracic fluoroscopy after the implantation of the thoracic aorta endoprosthesis shows the tip of the gastroscope in the esophagus with the polypectomy snare that grabs the bottom of the sewing needle.
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Disclosures
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None.
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References
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1. Schumacher KJ, Weaver DL, Night MR, Presberg HJ. Aortic pseudoaneurysm due to ingested foreign body.
South Med J. 1986; 79: 246–248.
[Medline]
[Order article via Infotrieve]2. Vosloo S, Reichart B, Morgan JA. False aneurysm of the descending thoracic aorta caused by an inhaled foreign body. S Afr Med J. 1986; 70: 628–629.[Medline]
[Order article via Infotrieve]
3. Bullaboy CA, Derkac WM, Johnson DH, Jennings RB. False aneurysm of the aorta secondary to an esophageal foreign body. Ann Thorac Surg. 1985; 39: 275–276.[Abstract]
4. Lin PH, Bush RL, Lumsden AB. Traumatic aortic pseudoaneurysm after airbag deployment: successful treatment with endoluminal stent-graft placement and subclavian-to-carotid transposition. J Trauma. 2005; 58: 1282–1284.[Medline]
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References