Thoracic Aortic Dissection and Mycotic Pseudoaneurysm in the Setting of an Unstable Upper Thoracic Type B2 Fracture

Thoracic type B2 fractures are high-energy injuries. It is crucial to maintain a high index of suspicion for concomitant visceral injuries. A 33-year-old man presented after a motor vehicle accident with a T4 type B2.3 fracture with an associated sternum fracture. He was treated with a T4 corpectomy and an expandable titanium cage and lateral plate construct at T3-T5. Two months later he developed focal kyphosis and loosening of his screws. This was addressed with an instrumented posterior fusion from T1 to T8 complicated by a wound infection, pneumonia, and fungal esophagitis requiring several debridements and vacuum assisted closure therapy. Worsening back pain prompted a thoracic computed tomography scan, revealing a dissecting thoracic-aortic aneurysm, which was treated with an endovascular stent graft. Few months later, he presented with fevers, chills, and hemoptysis secondary to Staphylococcus aureus bacteremia, endovascular leak, and T3-T5 osteomyelitis. He was transferred to our institution and restented by the cardiothoracic service. Subsequently, he underwent a thoracotomy, evacuation of infected aneurysmal hematoma with removal of instrumentation. A revision corpectomy with iliac crest autograft reconstruction was performed without complications. The patient's infection and thoracic pain resolved. However, there was a significant delay in treatment, resulting in substantial morbidity. Patients with thoracic type B2 fractures require careful evaluation for concomitant aortic and visceral injuries. Missed associated injuries result in increased morbidity and mortality.