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J Thorac Cardiovasc Surg 2009;137:e10-e12
© 2009 The American Association for Thoracic Surgery

Brief Communication

Penetrating ulcer of the aortic arch presenting with hemoptysis

^a Department of Cardiothoracic Surgery, Lancashire Cardiac Centre, Blackpool, United Kingdom
^b Department of Radiology, Lancashire Cardiac Centre, Blackpool, United Kingdom

Received for publication March 11, 2008; accepted for publication March 23, 2008.

^_* Address for reprints: Vassilios S. Avlonitis, PhD, Level 9, Plateau Building, Derriford Hospital, Derriford Rd, Plymouth, PL6 8DH, United Kingdom. (Email: avlonitis{at}hotmail.com).

Penetrating aortic ulcers (PAUs) are increasingly recognized as a separate entity. We report a PAU with unusual presentation and discuss difficulties in diagnosis and management.

Clinical Summary

A 58-year-old nonsmoker presented with a 6-month history of hemoptysis and a 1-month history of left-sided chest pain. He was known to have poorly controlled hypertension. Physical examination was unremarkable. Chest radiographic analysis showed a lesion in the left lung apex lying against the aortic arch. Contrast computed tomographic (CT) scanning demonstrated continuity between the lesion and the aortic lumen. Positron emission tomographic analysis confirmed high uptake in the lesion, and the patient was referred to us as having a case of lung cancer with extension into the aorta ( Figure 1). However, multislice CT analysis with 3-dimensional reconstruction clarified the presence of a PAU in the arch leaking into the lung, with surrounding hematoma ( Figure 2). The patient continued to experience pain, and we proceeded to surgical intervention.

View larger version (68K): [in this window] [in a new window]   Figure 1. Positron emission tomogram demonstrating high uptake in a left upper lobe lung lesion extending into the aortic arch. The lesion was thought to be lung cancer with aortic invasion.

View larger version (61K): [in this window] [in a new window]   Figure 2. Computed tomographic and 3-dimensional reconstruction showing an aortic ulcer penetrating into the lung.

The patient was extubated within 24 hours and discharged from the intensive care unit. The clot culture grew Staphylococcus aureus. He was started on flucloxacillin for 4 weeks and discharged on day 11. He was readmitted 2 months later with malaise, rigors, fever, and a C-reactive protein level of 80 mg/L. CT scanning showed soft tissue thickening around the graft, resolution of the lung hematoma, and no fluid collection. The results of blood cultures were negative. Based on the previous history, he was started on intravenous flucloxacillin, rifampicin, and gentamicin for 4 weeks. He responded well and was discharged. One year later, he remains well.

Discussion

PAUs result from atheroma, ulcerating and disrupting the internal elastic lamina, burrowing through all aortic layers.¹ They can remain quiescent or lead to dissection, intramural hematoma, aneurysm or pseudoaneurysm formation, fistulation into adjacent organs, or free wall rupture.² The most common presentation is with anterior chest pain or intrascapular pain caused by dissection or intramural hematoma.³ Hemoptysis is an extremely rare manifestation. We could only find one case presenting with hemoptysis in the literature.⁴ That case was managed with hypertension control, and the pulmonary hematoma gradually disappeared. In our case, because of persistent pain, we proceeded to surgical intervention. We did not perform a pulmonary resection, expecting the lung hematoma to resolve after aortic repair.

The ulcer penetrating into the lung raises a diagnostic dilemma and can be mistaken for lung cancer invading the aorta. Positron emission tomographic scanning showing activity in the lung suggested the latter. Multislice CT scanning was more accurate in delineating the exact pathology.

At surgical intervention, there was loss of tissue planes between the lung and aortic arch caused by hematoma and inflammation. The thickening of the aortic intima made construction of a hemostatic suture line impossible when patching was attempted. Therefore we excluded the abnormal area with an elephant trunk procedure. Ongoing coagulopathy obliged us to use Factor VII to achieve hemostasis, with impressive results. There are increasing reports of its successful use in cardiac surgery, and we would recommend its use in aortic surgery cases with coagulopathy unresponsive to standard blood product transfusion.⁵

The postoperative course of this patient was uneventful, with the exception of the graft infection. Contamination of the area with lung pathogens was inevitable. In such cases proactive and aggressive management is recommended. Specimens for microbiologic cultures should be obtained intraoperatively, and a prolonged course of antibiotics might be required.

In conclusion, PAUs involving the lung can be mistaken for lung malignancy invading the aorta. Surgical management can be technically challenging, and the possibility of postoperative graft infection must be considered and managed aggressively.

References

1. Stanson AW, Kazmier FJ, Hollier LH, Edwards WD, Pairolero PC, Sheedy PF, et al. Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations. Ann Vasc Surg 1986;1:15-23.[Medline]
   
2. Troxler M, Mavor AI, Homer-Vanniasinkam S. Penetrating atherosclerotic ulcers of the aorta. Br J Surg 2001;88:1169-1177.[Medline]
   
3. Coady MA, Rizzo JA, Hammond GL, Pierce JG, Kopf GS, Elefteriades JA. Penetrating ulcer of the thoracic aorta: What is it? How do we recognize it? How do we manage it?. J Vasc Surg 1998;27:1006-1016.[Medline]
   
4. Fukushima M, Seino Y, Yoshikawa M, Ueda Y, Takano T. A case of penetrating aortic atherosclerotic ulcer with hemoptysis. Jpn Heart J 2000;41:781-785.[Medline]
   
5. Raivio P, Suojaranta-Ylinen R, Kuitunen AH. Recombinant factor VIIa in the treatment of postoperative hemorrhage after cardiac surgery. Ann Thorac Surg 2005;80:66-71.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Vassilios S. Avlonitis Andrew J. Duncan Joseph Zacharias Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Avlonitis, V. S. Articles by Zacharias, J. Search for Related Content PubMed Articles by Avlonitis, V. S. Articles by Zacharias, J.