Chronic Aneurysm of the Descending Thoracic Aorta Presenting with Right Pleural Effusion and Left Phrenic Paralysis

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Case Reports Chronic Aneurysm of the Descending Thoracic Aorta Presenting with Right Pleural Effusion and Left Phrenic Paralysis

Gregorio Rabago, MD A 62-year-old man was admitted to the emergency department with chronic dysphagia Alejandro Martin-Trenor, MD and lower back pain. Chest radiography revealed a wide mediastinal shadow and an Jose-Luis L6pez-Coronado, MD elevated left diaphragm, which proved to be secondary to left phrenic paralysis. The patient was diagnosed with an aneurysm of the descending thoracic aorta and was admitted to the hospital. After the patient was admitted, the aneurysm ruptured into the right chest. The patient underwent an emergency operation to replace the ruptured segment with a synthetic graft. Postoperative recovery and follow-up were uneventful. This report describes an unusual presentation of a thoracic aortic aneurysm. Hemi- diaphragmatic paralysis caused by compression of the phrenic nerve is an unusual complication that, to our knowledge, has not been previously reported. (Tex Heart Inst J 1999;26:96-8)

C ompression of the phrenic nerve and right pleural effusion appear to be unusual manifestations of a thoracic arteriosclerotic aneurysm. To the best of our knowledge, phrenic nerve compression secondary to thoracic aneurysm has not been reported before. We report the case of a patient who pre- sented with progressive dysphagia and chronic lower back pain. Case Report

In January of 1997, a 62-year-old man was admitted to our emergency department complaining of progressive dysphagia and weight loss. He had chronic pain in his chest and lower back, and hypercholesterolemia with normal blood pressure. Physical examination revealed a pulsating abdominal mass, but was other- wise unremarkable. Chest radiography showed an enlarged mediastinum and an elevated left diaphragm (Fig. 1). His white blood cell count was high (14,500 mm3), but all other parameters were normal. Key words: Aneurysm, Computed tomographic scanning of the chest and abdomen showed 2 aneu- ruptured; aneurysm/tho- rysms at different levels in the aorta. A thoracic aneurysm arose below the sub- racic; aorta, thoracic; aortic clavian artery and extended downward to the diaphragm. It measured 10 x 8 cm, aneurysm; aortic rupture; case report; diaphragm! and had a large intraluminal thrombus. The 2nd aneurysm was found in the ab- paralysis; phrenic nerve; domen below the kidneys. The abdominal aneurysm included the proximal seg- pleural effusion ments of both iliac arteries, and measured 7 x 7 cm. The patient was admitted to our unit and surgical repair was scheduled. Thirty From: The Department hours after admission, the patient experienced worsening of his chest pain. He of Cardiovascular Surgery, became hypotensive and diaphoretic, and eventually lost consciousness. Resusci- Cl[nica Universitaria, Pamplona, Spain tative maneuvers were established and the patient was transferred to the inten- sive care unit for management and control. Auscultation revealed decreased respiratory sounds in the right side, and chest radiography revealed a large pleu- Address for reprints: Gregorio Rabago, MD, ral effusion. An urgent computed tomographic scan showed that the thoracic an- Department of Cardio- eurysm had ruptured and had created a large right pleural effusion (Fig. 2). The vascular Surgery, Clfnica patient was moved to the operating room for urgent surgical repair of the rup- Universitaria, Avd. Pio XII s/n, Apartado, 4209, 31080 tured aorta. Pamplona, Spain A left thoracotomy was performed through the 5th intercostal space, and it revealed a large thoracic aneurysm that arose 3 cm below the subclavian artery o) 1999 by the Texas Heart" and extended downward to the diaphragm. There was no left pleural effusion, Institute, Houston but the left lung had a severe adhesion to the aneurysm. The left diaphragm was

96 Thoracic Aortic Aneurysm with Right Pleural Effusion and Left Phrenic Paralysis Volume 26, Number 1, 1999 Fig. 2 Computed tomographic scan with contrast agent shows the aneurysm of the descending thoracic aorta with intraluminal thrombus, a rupture into the right chest, and a Fig. 1 Preoperative chest radiograph (frontal view) shows a large pleural effusion. mass and elevation of the left diaphragm.

If the pain becomes sharp, it usually indicates a sud- flaccid. No evidence of rupture was seen on the left den expansion or rupture of the aneurysm: the pa- side of the aneurysm. tient's clinical situation is worsening rapidly, and the The aorta was cross-clamped near the subclavian risk of death is high. artery and again near the diaphragm, and the aneu- The symptoms and signs of a thoracic arterioscle- rysm was opened longitudinally without the use of rotic aneurysm depend on its location. A large aneu- circulatory bypass. A large tear was found on the rysm of the descending thoracic aorta can compress right side of the aorta. A massive hematoma ex- the recurrent laryngeal nerve and cause hoarseness tended from the aorta posterior to the esophagus (although this occurs more frequently in aneurysms and entered the right pleural space. The hematoma of the aortic arch). If it compresses the trachea or involved the left phrenic nerve and put direct pres- bronchi, it can cause coughing, hemoptysis, or wheez- sure on the esophagus. A 30-mm Hemashield® graft ing. Further, as shown in the present case, compres- (Boston Scientific Corporation; Natick, Mass) was in- sion of the esophagus can cause dysphagia. In our terposed. The total cross-clamp time was 22 minutes. patient, only progressive dysphagia and chronic back After adequate hemostasis was achieved, the chest pain were clearly related to the aneurysm. Hemidia- was closed. A suction tube was inserted into the phragmatic paralysis caused by compression of the right chest, and it evacuated 500 mL of blood. phrenic nerve is an unusual complication that, to our The postoperative course was uneventful and the knowledge, has not been previously reported. Com- patient was discharged from the hospital 15 days af- mon findings on chest radiography are a wide medi- ter the operation. His dysphagia disappeared in the astinum and, in the case of rupture, left pleural weeks following the operation. The abdominal an- effusion. Right pleural effusion is an uncommon pre- eurysm was treated surgically 2 months later, with sentation,4 and usually suggests a medial rupture of no complication. A routine follow-up visit showed the aorta with dissection of the posterior mediasti- improvement of his left phrenic paralysis 15 months num into the right hemithorax. Absolute indications after the 1st surgery. for surgical repair include all symptomatic aneurysms, a rapid increase in the size of an aneurysm, Discussion pleural effusion, or asymptomatic aneurysms larger than 5 cm in diameter. Most arteriosclerotic aneurysms are found in patients The surgical findings in this particular case were who are older than 60 years. Thoracic arterioscle- interesting. First, we found that the aneurysm had rotic aneurysms are frequently associated with le- expanded medially and was compressing the esoph- sions at other vascular sites.' Most are asymptomatic agus and the phrenic nerve. These findings accounted and are found as a mediastinal mass during routine for the patient's progressive dysphagia and elevated noninvasive exploration.2'3 When symptoms and signs hemidiaphragm at admission. The left diaphragm was do present, they are usually related to rapid enlarge- found to be flaccid and nonfunctional, and this ac- ment, which creates pressure on surrounding struc- tually facilitated the distal anastomosis. The ruptured tures or obstructs them. Chronic pain that becomes aneurysm dissected the tissue behind the esophagus unrelenting is the 1st and most common symptom. and drained into the right chest. This dissection pro-

Texas Heart Instituteiournal Thoracic Aortic Aneurysm with Right Pleural Effusion and Left Phrenic Paralysis 97 gressed slowly, and gave us time to make the cor- 2. Earnest F 4th, Muhm JR, Sheedy PF 2nd. Roentgenographic rect diagnosis and take the patient to the operating findings in thoracic aortic dissection. Mayo Clin Proc 1979; room for surgical repair. 54:43-50. 3. Harris RD, Usselman JA, Vint VC, Warmath MA. Computer- The patient's postoperative recovery was un- ized tomographic diagnosis of aneurysms of the thoracic aor- eventful. Although chest radiography continued to ta. Comput Tomogr 1979;3:81-91. show persistent elevation of the left diaphragm, we 4. Faraci PA, Payne DD, Cleveland RJ. Type III aortic dissec- hope that the phrenic nerve will continue to recover tion with rupture into the right hemithorax. J Cardiovasc function. We have already seen such recoveries in Surg (Torino) 1982;23:429-31. 5. Moreno-Cabral CE, Miller DC, Mitchell RS, Stinson EB, Oyer other patients who were injured during routine car- PE, Jamieson SW, et al. Degenerative and atherosclerotic diac surgery. Delayed recovery may persist at 12 to aneurysms of the thoracic aorta. Determinants of early and 14 postoperative months, in accordance with the late surgical outcome. J Thorac Cardiovasc Surg 1984;88: known rate of regeneration of peripheral nerves.6 1020-32. 6. Wilcox PG, Pare PD, Pardy RL. Recovery after unilateral phrenic injury associated with coronary artery revasculari- References zation. Chest 1990;98:661-6. 1. Svensson LG, Crawford ES. Aortic dissection and aortic aneurysm surgery: clinical observations, experimental investi- gations, and statistical analyses. Part I. Curr Probl Surg 1992; 29:817-911.

98 Thoracic Aortic Aneurysm with Right Pleural Effusion and Left Phrenic Paralysis Volume 26, Number 1, 1999