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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.
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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.
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EKG showed voltage criteria for left ventricular hypertrophy
and no acute ischemic changes. Morphine and albuterol were administered
with improvement of her symptoms.
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A chest radiograph revealed a massively dilated ascending, transverse,
and descending thoracic aorta. The lungs were hyperexpanded and
clear (Figure 1).
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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.
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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).
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A cardiovascular consultant recommended administering analgesic
medication. The plan was to admit the patient to the hospital for
continued observation.
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- Do you agree with this management?
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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).
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