5. Thoracoabdominal Aortic Aneurysm

45 A 72-year-old white male presented to his primary-care physician with a history of left chest pain for the past month. The pain was dull and constant, and radiated to the back, medial to the scapula. He denied new cough or worsening shortness of breath. He had no recent weight loss, and his appetite was good. He has a history of hypertension that was currently controlled medically. He had a smoking history of 60 packs a year. In addition, he suffered a myocardial infarction (MI) 5 years ago. The patient denied any history of claudication, transient ischaemic attacks or stroke. He had undergone surgery in the past for bilateral inguinal hernias, and he underwent cardiac catheterisation after his MI. On physical examination, the patient was thin but did not appear malnourished. Vital signs were respiratory rate 18/min, heart rate 72 bpm, blood pressure 140/80 mm Hg and temperature 36.8°C. His head and neck examination was remarkable only for bilateral carotid bruits. Cardiac examination revealed a regular rate and rhythm without murmurs. Abdominal examination revealed no bruits and an infrarenal aortic diameter of approximately 2.5 cm by palpation. His femoral and popliteal pulses were normal. Posterior tibial pulses were 1+ bilaterally, and dorsalis pedis were detectable only by Doppler. Routine blood work was unremarkable, and an electrocardiogram (ECG) revealed changes consistent with an old inferior wall MI and left ventricular (LV) hypertrophy. Chest X-ray (Fig. 5.1) was remarkable for a tortuous aorta, which had calcification within the wall and appeared dilated. There were no pleural effusions, there was some flattening of both hemidiaphragms, and bony structures were normal. Lung fields were clear of masses or consolidation.