Nonsurgical abolition of thoracic aortic aneurysm.

A67-year-old woman presented with clinical evidence of expansion of an aortic aneurysm previously acquired after a deceleration trauma. The patient complained of frequently recurring interscapular and back pain and beginning hoarseness. In the differential diagnostic workup, pneumothorax and pulmonary embolism were excluded. The patient underwent MRI of the thoracic aorta and gadolinium-enhanced 3-dimensional MR angiography (MRA) that demonstrated morphological evidence of a fist-size intrathoracic aortic aneurysm (Figure 1A). Selective angiography excluded significant coronary artery disease and confirmed the diagnosis of a true aneurysm of the descending thoracic aorta (Figure 2A). Because dimensional evaluation of the aneurysm revealed a transverse diameter .5.0 cm and because recurrent episodes of back pain suggesting potential expansion were evident, elective interventional stent-graft placement was offered to the patient to exclude the aneurysm and stabilize the thoracic aorta. On the basis of the MRA, a custom-made stent graft was manufactured according to the dimensional requirements of the patient’s aorta; the nitinol stent with Dacron cover was inserted under general anesthesia and under transesophageal guidance in the catheter laboratory via a transfemoral access. Intraprocedural transesophageal echocardiography confirmed the aneurysm (Figure 3A) and was extremely helpful for both exact positioning of the stent graft and documentation of complete exclusion of the aneurysm. Moreover, transesophageal echocardiography demonstrated echogenetic “smoke” as evidence of beginning thrombosis in the aneurysmatic sac (Figure 3B). Perfect stent placement was confirmed by repeat selective contrast angiography via a pigtail catheter in the left subclavian artery (Figure 2B). Recovery and clinical follow-up were uneventful, and MRA 10 days later confirmed persistent exclusion of the aneurysm and a perfectly reconstructed thoracic aorta (Figure 1B).