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A 73-year-old woman presented to the ED complaining of chest pain and shortness of breath. The pain was in the left anterior chest and left flank. She had a nonproductive cough and slight wheezing. She had had the pain intermittently for 1 week. It had become more severe in the past few hours and was associated with vomiting. She had a history of COPD.

On examination, she was a frail, slender female who was in distress when the chest pain was present, but comfortable when it abated. Her blood pressure was 140/80 mm/Hg, pulse 104 beats/min, respirations 20 breaths/min, temperature 100.0°F (rectal), and O2 saturation 96% on 2 L/min of oxygen. Breaths sounds were diminished bilaterally and there were faint wheezes at both lung apices.

EKG showed voltage criteria for left ventricular hypertrophy and no acute ischemic changes. Morphine and albuterol were administered with improvement of her symptoms.

A chest radiograph revealed a massively dilated ascending, transverse, and descending thoracic aorta. The lungs were hyperexpanded and clear (Figure 1).

Her internist was contacted, who stated that she had a thoracic aortic aneurysm but because of her COPD, a cardiovascular surgeon felt that the operative risk for elective repair was too high.

A CT scan of the chest and abdomen was interpreted as showing a large thoracoabdominal aneurysm extending from the ascending aorta to the suprarenal abdominal aorta. Its widest dimension was 8.5 cm at the descending thoracic aorta. There was no evidence of aortic dissection. A small left pleural effusion was also noted that was not visible on the chest radiograph (Figure 2).

Figure 2

CT showing a markedly enlarged arota with surrounding mutal thrombus (asterisks) and a small pleural effusion (arrow). There was no aortic dissection.

A cardiovascular consultant recommended administering analgesic medication. The plan was to admit the patient to the hospital for continued observation.

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The second common disorder associated with dilation of the thoracic aorta, aside from aortic dissection, is an atherosclerotic thoracic aortic aneurysm. Atherosclerotic aortic aneurysms, both abdominal and thoracic, are complicated by leakage and rupture and are not generally associated with dissection (Table 1). In one series, thoracic aortic aneurysms were as common as aortic dissection (Clouse et al. 2004).

Table 1 Distinguishing Aortic Disorders

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