Trivial Chest Injury Leading to Azygos Vein Pseudoaneurysm
2010; Elsevier BV; Volume: 123; Issue: 10 Linguagem: Inglês
10.1016/j.amjmed.2010.03.032
ISSN1555-7162
AutoresZbigniew Juraszyński, Dariusz Zieliński, Barbara Burakowska,
Tópico(s)Vascular Anomalies and Treatments
ResumoBlunt chest trauma sustained in automobile accidents is a common problem with many potentially lethal associated injuries, but isolated trauma to the azygos vein is rare.1Baldwin J.C. Oyer P.E. Guthaner D.F. Stinson E.B. Combined azygos vein and subclavian artery injury in blunt chest trauma.J Trauma. 1984; 24: 170-171Crossref PubMed Scopus (16) Google Scholar A pseudoaneurysm after a trivial chest injury is exceedingly rare. To date, this observation represents, to our knowledge, the first reported case.A 70-year-old woman had suffered a blunt chest injury, and complained of occasional pain in that area. A radiograph performed after 3 months revealed an enlarged cardiac silhouette and a large spherical shadow with clear-cut margins in the right upper zone (Figure, A ). Nuclear magnetic resonance imaging performed before admission to the hospital revealed evidence of a large pseudoaneurysm (46/56/60 mm) involving the superior vena cava (Figure, B).At admission, the patient was in good general health with no sign of functional respiratory impairment. Her past medical history was uneventful. Physical examination revealed good clinical status. Angiography performed after admission to the hospital confirmed the diagnosis of a giant saccular pseudoaneurysm arising from the junction of the superior vena cava and vena azygos.The patient was scheduled for operative closure of the pseudoaneurysm. During surgery, a thinned aneurysmatic sack (4/6 cm) arising from the superior vena cava was found.The postoperative course was uneventful. At a follow-up visit 2 months later, the patient reported a substantial increase in exercise tolerance and a return to her usual daily activities.DiscussionMost aneurysms of the azygos vein are asymptomatic, incidentally discovered; they are typically located at the junction of the trachea and the upper right lobe bronchus.2Olbert F. Kobinia G. Denck H. Aneurysmal bulb dilation of the azygos vein: radiological and clinical significance.Diagn Imaging. 1980; 49: 237-258PubMed Google Scholar Although azygos vein aneurysms are a rare clinical problem, their consideration in the diagnosis of a posterior mediastinal mass is important.Differential diagnosis of a mediastinal paratracheal mass in the adult includes malignancy of the lung, mesothelium, lymphatic system, or nervous system; aneurysm or vascular malformation; a bronchogenic cyst and esophageal tumors or duplications.3Chiu S.S. Lau S. Kam C.K. Azygous vein aneurysm: CT scan follow-up.J Thorac Imaging. 2006; 21: 66-68Crossref PubMed Scopus (18) Google ScholarThe radiological criteria listed by Fleischner and Udis4Fleischner F.G. Udis S.W. Dilatation of the azygos vein: a roentgen sign of venous engorgement.Am J Roentgenol Radium Ther Nucl Med. 1952; 67: 569-575PubMed Google Scholar to enable azygos and hemiazygos aneurysms to be distinguished from tumors are useful in differentiating between the 2 entities. Angiography would seem to be essential to confirm its aneurismal nature and the anatomical relationships. Potential clinical consequences, such as pulmonary embolism, as a result of thrombus formation within the aneurysm, can occur.5Jain A. Blebea J.S. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation.J Comput Assist Tomogr. 1994; 18: 647-648Crossref PubMed Scopus (22) Google ScholarAn appropriate therapeutic strategy is not clear. The aneurysm can remain intact or can rupture, thereby causing detrimental effects. Although there are not many data on the natural progression of this kind of aneurysm, it is clear that aneurismal rupture can result in sudden death.6Podbielski F.J. Sam 2nd, A.D. Halldorsson A.O. Iasha-Sznajder J. Vigneswaran W.T. Giant azygos vein varix.Ann Thorac Surg. 1997; 63: 1167-1169Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Past reports have clearly described the safety of resection in cases that are not related to increased azygos flow or portal hypertension. Surgery is usually simple and should be proposed even to asymptomatic patients because of the risk of thromboembolism and rupture.3Chiu S.S. Lau S. Kam C.K. Azygous vein aneurysm: CT scan follow-up.J Thorac Imaging. 2006; 21: 66-68Crossref PubMed Scopus (18) Google Scholar, 5Jain A. Blebea J.S. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation.J Comput Assist Tomogr. 1994; 18: 647-648Crossref PubMed Scopus (22) Google Scholar Blunt chest trauma sustained in automobile accidents is a common problem with many potentially lethal associated injuries, but isolated trauma to the azygos vein is rare.1Baldwin J.C. Oyer P.E. Guthaner D.F. Stinson E.B. Combined azygos vein and subclavian artery injury in blunt chest trauma.J Trauma. 1984; 24: 170-171Crossref PubMed Scopus (16) Google Scholar A pseudoaneurysm after a trivial chest injury is exceedingly rare. To date, this observation represents, to our knowledge, the first reported case. A 70-year-old woman had suffered a blunt chest injury, and complained of occasional pain in that area. A radiograph performed after 3 months revealed an enlarged cardiac silhouette and a large spherical shadow with clear-cut margins in the right upper zone (Figure, A ). Nuclear magnetic resonance imaging performed before admission to the hospital revealed evidence of a large pseudoaneurysm (46/56/60 mm) involving the superior vena cava (Figure, B). At admission, the patient was in good general health with no sign of functional respiratory impairment. Her past medical history was uneventful. Physical examination revealed good clinical status. Angiography performed after admission to the hospital confirmed the diagnosis of a giant saccular pseudoaneurysm arising from the junction of the superior vena cava and vena azygos. The patient was scheduled for operative closure of the pseudoaneurysm. During surgery, a thinned aneurysmatic sack (4/6 cm) arising from the superior vena cava was found. The postoperative course was uneventful. At a follow-up visit 2 months later, the patient reported a substantial increase in exercise tolerance and a return to her usual daily activities. DiscussionMost aneurysms of the azygos vein are asymptomatic, incidentally discovered; they are typically located at the junction of the trachea and the upper right lobe bronchus.2Olbert F. Kobinia G. Denck H. Aneurysmal bulb dilation of the azygos vein: radiological and clinical significance.Diagn Imaging. 1980; 49: 237-258PubMed Google Scholar Although azygos vein aneurysms are a rare clinical problem, their consideration in the diagnosis of a posterior mediastinal mass is important.Differential diagnosis of a mediastinal paratracheal mass in the adult includes malignancy of the lung, mesothelium, lymphatic system, or nervous system; aneurysm or vascular malformation; a bronchogenic cyst and esophageal tumors or duplications.3Chiu S.S. Lau S. Kam C.K. Azygous vein aneurysm: CT scan follow-up.J Thorac Imaging. 2006; 21: 66-68Crossref PubMed Scopus (18) Google ScholarThe radiological criteria listed by Fleischner and Udis4Fleischner F.G. Udis S.W. Dilatation of the azygos vein: a roentgen sign of venous engorgement.Am J Roentgenol Radium Ther Nucl Med. 1952; 67: 569-575PubMed Google Scholar to enable azygos and hemiazygos aneurysms to be distinguished from tumors are useful in differentiating between the 2 entities. Angiography would seem to be essential to confirm its aneurismal nature and the anatomical relationships. Potential clinical consequences, such as pulmonary embolism, as a result of thrombus formation within the aneurysm, can occur.5Jain A. Blebea J.S. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation.J Comput Assist Tomogr. 1994; 18: 647-648Crossref PubMed Scopus (22) Google ScholarAn appropriate therapeutic strategy is not clear. The aneurysm can remain intact or can rupture, thereby causing detrimental effects. Although there are not many data on the natural progression of this kind of aneurysm, it is clear that aneurismal rupture can result in sudden death.6Podbielski F.J. Sam 2nd, A.D. Halldorsson A.O. Iasha-Sznajder J. Vigneswaran W.T. Giant azygos vein varix.Ann Thorac Surg. 1997; 63: 1167-1169Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Past reports have clearly described the safety of resection in cases that are not related to increased azygos flow or portal hypertension. Surgery is usually simple and should be proposed even to asymptomatic patients because of the risk of thromboembolism and rupture.3Chiu S.S. Lau S. Kam C.K. Azygous vein aneurysm: CT scan follow-up.J Thorac Imaging. 2006; 21: 66-68Crossref PubMed Scopus (18) Google Scholar, 5Jain A. Blebea J.S. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation.J Comput Assist Tomogr. 1994; 18: 647-648Crossref PubMed Scopus (22) Google Scholar Most aneurysms of the azygos vein are asymptomatic, incidentally discovered; they are typically located at the junction of the trachea and the upper right lobe bronchus.2Olbert F. Kobinia G. Denck H. Aneurysmal bulb dilation of the azygos vein: radiological and clinical significance.Diagn Imaging. 1980; 49: 237-258PubMed Google Scholar Although azygos vein aneurysms are a rare clinical problem, their consideration in the diagnosis of a posterior mediastinal mass is important. Differential diagnosis of a mediastinal paratracheal mass in the adult includes malignancy of the lung, mesothelium, lymphatic system, or nervous system; aneurysm or vascular malformation; a bronchogenic cyst and esophageal tumors or duplications.3Chiu S.S. Lau S. Kam C.K. Azygous vein aneurysm: CT scan follow-up.J Thorac Imaging. 2006; 21: 66-68Crossref PubMed Scopus (18) Google Scholar The radiological criteria listed by Fleischner and Udis4Fleischner F.G. Udis S.W. Dilatation of the azygos vein: a roentgen sign of venous engorgement.Am J Roentgenol Radium Ther Nucl Med. 1952; 67: 569-575PubMed Google Scholar to enable azygos and hemiazygos aneurysms to be distinguished from tumors are useful in differentiating between the 2 entities. Angiography would seem to be essential to confirm its aneurismal nature and the anatomical relationships. Potential clinical consequences, such as pulmonary embolism, as a result of thrombus formation within the aneurysm, can occur.5Jain A. Blebea J.S. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation.J Comput Assist Tomogr. 1994; 18: 647-648Crossref PubMed Scopus (22) Google Scholar An appropriate therapeutic strategy is not clear. The aneurysm can remain intact or can rupture, thereby causing detrimental effects. Although there are not many data on the natural progression of this kind of aneurysm, it is clear that aneurismal rupture can result in sudden death.6Podbielski F.J. Sam 2nd, A.D. Halldorsson A.O. Iasha-Sznajder J. Vigneswaran W.T. Giant azygos vein varix.Ann Thorac Surg. 1997; 63: 1167-1169Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Past reports have clearly described the safety of resection in cases that are not related to increased azygos flow or portal hypertension. Surgery is usually simple and should be proposed even to asymptomatic patients because of the risk of thromboembolism and rupture.3Chiu S.S. Lau S. Kam C.K. Azygous vein aneurysm: CT scan follow-up.J Thorac Imaging. 2006; 21: 66-68Crossref PubMed Scopus (18) Google Scholar, 5Jain A. Blebea J.S. Post-traumatic pseudoaneurysm of the azygous vein in a patient with azygous continuation.J Comput Assist Tomogr. 1994; 18: 647-648Crossref PubMed Scopus (22) Google Scholar
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