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KEY FACTS

Terminology
- Traumatic disruption of aortic wall that goes undiagnosed in acute setting
- Chronic traumatic aortic injury (CTAI)
Imaging
- Radiography - AP window mass - Curvilinear calcification typically lining caudad portion of aortic arch - Rightward tracheal deviation
- CTA - Saccular dilatation at isthmus arising from inferior aspect of aortic arch - Curvilinear mural calcification along saccular dilatation
- Ancillary findings of remote trauma - Healed rib, clavicular or scapular fractures - Thoracic vertebral body wedge fractures
Top Differential Diagnoses
- Nontraumatic aortic aneurysm - In atherosclerosis, calcification often lines superoexternal portion of aortic arch and other locations - Mycotic aneurysm often lacks calcifications - Penetrating aortic ulcer is not common at isthmus; often with extensive atherosclerosis
- Mediastinal mass
- Ductus aneurysm - Often indistinguishable from CTAI on imaging
Clinical Issues
- Asymptomatic; incidental finding on imaging
- Unknown incidence
- 1/3 of CTAI may rupture and cause death if untreated
- Preferred treatment: Endovascular repair, if anatomically suitable (often complex with arch involvement, may need branched device)
- Alternative treatment: Open surgical repair.

TERMINOLOGY

Synonyms
- Chronic traumatic aortic injury (CTAI)
- Late or unsuspected posttraumatic pseudoaneurysm
Definitions
- Traumatic disruption of aortic wall
- Not containing 3 vascular wall layers
- Contained by adventitia or thrombus and fibrous tissue

IMAGING

General Features

Best diagnostic clue

- Saccular aneurysm with wall calcification at level of aortic isthmus

Location

- Near aortic isthmus, typical location of acute traumatic aortic injury; e.g., at undersurface of distal aortic arch, or proximal descending thoracic aorta

Morphology
```
- Saccular, acute margins with aorta
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Imaging Recommendations

Best imaging tool
```
- CTA
```

Protocol advice

- Use of multiplanar reformations on CTA or MRA may be helpful; 3D processing for treatment planning (TEVAR)

Radiographic Findings

Radiography

- Frontal projection
        - AP window mass
        - Curvilinear calcification typically lining distal portion aortic arch/proximal descending aorta
        - Rightward tracheal deviation
- Lateral projection
        - Curvilinear calcified convexity (mass) at aortic isthmus

CT Findings

CTA

- Saccular dilatation near aortic isthmus
- Acute margins with aorta, narrow ostium
- Curvilinear mural calcification at saccular dilatation
- May contain low-density thrombus
- May cause extrinsic compression of left main bronchus
- Remainder of aorta may be normal
- Ancillary findings of remote trauma
        - Healed rib, clavicular or scapular fractures
        - Thoracic vertebral body wedge fractures
        - Traumatic diaphragmatic hernia

MR Findings

MRA

- Contrast-filled saccular dilatation at aortic isthmus in continuity with aorta
- Intraluminal thrombus appears hypointense

Black-blood and bright-blood (e.g., SSFP) are as accurate as CTA
Used when CTA is contraindicated

Angiographic Findings
- Rarely required (often part of endovascular treatment)
- Angiography lacks visualization of surrounding extraaortic tissues

DIFFERENTIAL DIAGNOSIS

Nontraumatic Aortic Pseudoaneurysm
- May be secondary to infection (i.e., mycotic), atherosclerosis/penetrating aortic ulcer (PAU), surgery - In atherosclerosis, calcification often lines superoexternal portion of aortic arch and is also found in other locations - Mycotic aneurysm often lacks calcifications - PAU is uncommon at isthmus and often has extensive atherosclerosis
- There is history of remote trauma in CTAI, and calcifications are limited to saccular dilatation
- May be impossible to differentiate from pseudoaneurysm [i.e., acute traumatic aortic injury (ATAI) or CTAI] on imaging
Ductus Aneurysm
- May be difficult to distinguish from CTAI on imaging
- Smooth obtuse margins, wide ostium
Mediastinal Mass
- e.g., lung cancer, bronchogenic cyst
- CT with contrast is often diagnostic

PATHOLOGY

General Features

Etiology
```
- Posttraumatic
```

Associated abnormalities

- Osseous fractures (rib, clavicle, sternum, thoracic spine)
        - Rib
        - Clavicle
        - Sternum
        - Thoracic spine
- Diaphragmatic hernia

Gross Pathologic & Surgical Features
- Pseudoaneurysm - Not containing 3 vascular wall layers - Contained by adventitia or thrombus and fibrous tissue
- Mural calcifications

CLINICAL ISSUES

Presentation

Most common signs/symptoms

- Asymptomatic; incidental finding on imaging
- Chest pain, dysphagia, dyspnea, cough, hoarseness
- Symptoms
        - Chest pain
        - Dysphagia
        - Dyspnea
        - Cough
        - Hoarseness (recurrent laryngeal nerve irritation); a.k.a. Ortner syndrome
        - Hemoptysis (aortoesophageal fistula)

Demographics

Epidemiology

- Unknown incidence
- Majority of patients with ATAI die at scene
- Majority of patients with ATAI who reach hospital are treated acutely
- Small minority of ATAI cases remain undiagnosed and may become CTAI

Natural History & Prognosis
- 1/3 of CTAI rupture and cause death if untreated - May rupture even years after acute injury
- Other complications - Aortopulmonary fistula, aortoesophageal fistula - Bacterial endocarditis
- 10-year survival rate: < 70% without surgery, > 85% with surgery
Treatment
- Small, asymptomatic aneurysms > 2 years after trauma can followed with CT imaging surveillance
- Traditional treatment: Open surgical repair
- Alternative treatment: Endovascular repair, if anatomically suitable

DIAGNOSTIC CHECKLIST

Consider
- CTAI in patients with isthmic saccular dilatation

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References

Selected References

Cases

{'cases': [{'authors': [{'key': '2cd036e9-d3d3-4b44-93f1-c0f8bf83ac5e', 'value': None}, {'key': 'd69a0534-8989-4b83-b19d-c3b640f22e53', 'value': 'Megan R. Saettele, MD'}, {'key': '2e78a4ff-418e-46f9-93e4-c6d95d960e35', 'value': 'Brandt C. Wible, MD'}], 'caseVersionId': '35400fe6-4d8d-474c-a7e9-d4a4f87253ba', 'description': "CTA axial images (#1-2) show a peripherally calcified outpouching (arrows) arising just distal to the left subclavian take-off. Note that there is no mass effect on adjacent structures. CTA reconstructions (#3-4) again show a large saccular peripherally calcified outpouching arising in the region of the aortic isthmus (arrows) consistent with a pseudoaneurysm. Given this patient's history of prior motor vehicle collision, this most likely represents post-traumatic pseudoaneurysm. The patient was also found to have an incidental simple liver cyst (open arrow, #3).\n\nComment: Post-traumatic aortic pseudoaneurysms are commonly found as incidental findings on radiographs or computed tomography examinations. Patients may be asymptomatic at the time of diagnosis. This is not a benign finding however, and there is a 30% mortality rate within the first 10 years without surgical or endovascular repair. Endovascular therapy offers a less invasive alternative to surgery, as well as an option for patients who are not surgical candidates.", 'history': 'Patient with a remote history of motor vehicle collision who presented to the emergency room with cough and shortness of breath; initial chest radiograph displayed AP window fullness and a subsequent CT was ordered to evaluate, as well as rule out PE. ', 'imagePoolId': 'f6bafd5f-46b6-44f7-a757-3991862a4ee4', 'name': 'Saccular aortic pseudoaneurysm', 'teachingPoint': None, 'demographics': '54 Years old male'}, {'authors': [{'key': '2cd036e9-d3d3-4b44-93f1-c0f8bf83ac5e', 'value': None}, {'key': 'd69a0534-8989-4b83-b19d-c3b640f22e53', 'value': 'Megan R. Saettele, MD'}, {'key': '2e78a4ff-418e-46f9-93e4-c6d95d960e35', 'value': 'Brandt C. Wible, MD'}], 'caseVersionId': '4bebe581-ec8b-469c-b557-e67b410544fe', 'description': 'A single axial unenhanced CT image of the chest (#1) demonstrates a large hematoma (arrows) and metallic fragments (open arrows) in the infraclavicular region. The patient was taken emergently to the angiography suite. An aortic angiogram with a pigtail catheter in the ascending aorta (#2) demonstrates a short-segment irregularity involving the left subclavian artery just distal to the vertebral origin (arrow). An aneurysm of the right brachiocephalic artery was incidentally noted (curved arrow). Images from selective left subclavian angiograms (#3-4) demonstrate a 2 cm pseudoaneurysm involving the left subclavian artery (arrows). Subsequent treatment of the injured subclavian artery was performed with a covered stent-graft. Post-deployment left subclavian angiographic images (#5-6) show the covered stent-graft to be widely patent and well positioned. There is no evidence of contrast extravasation, this finding consistent with successful exclusion of the pseudoaneurysm (arrows). Note the widely patent vertebral artery (open arrow, #6) following stent placement.\n\nComment: As opposed to a true aneurysm, which contains all three vascular wall layers, a pseudoaneurysm is contained only by adventitia or thrombus/fibrous tissue. Subclavian pseudoaneurysms most frequently result from complications of subclavian vein cannulation; blunt trauma is a less common etiology. Prior to the advent of endovascular treatments, treatment of this entity typically required resection or bypass of the aneurysm, often requiring sternotomy secondary to the vessel’s intra-thoracic course. Endovascular stenting represents a safe, minimally invasive alternative.', 'history': 'Patient presented status post gunshot trauma.', 'imagePoolId': '012e0805-f4f3-44e8-a86a-9d05b2e4515a', 'name': 'Subclavian artery pseudoaneurysm', 'teachingPoint': None, 'demographics': '42 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}

Images

Selected Images

$PA radiograph of the chest in a young asymptomatic patient with chronic traumatic aortic injury (CTAI) and right diaphragmatic hernia shows curvilinear calcification lining the caudad part of the aortic arch . There is elevation of the right hemidiaphragm form chronic undiagnosed right diaphragmatic hernia . Note remote rib fractures .$ PA radiograph of the chest in a young asymptomatic patient with chronic traumatic aortic injury (CTAI) and right diaphragmatic hernia shows curvilinear calcification lining the caudad part of the aortic arch . There is elevation of the right hemidiaphragm form chronic undiagnosed right diaphragmatic hernia . Note remote rib fractures .

Lateral radiograph of the chest in the same patient shows aortic bulging with intrinsic mural calcification at the isthmus.

Axial chest CTA in the same patient demonstrates saccular isthmic aortic dilatation with some mural calcifications in continuity with the aortic lumen.

Axial chest CTA in the same patient reveals extensive calcifications along the wall of the pseudoaneurysm. This constitutes the most common imaging appearance of CTAI. The presence of other stigmata of trauma is often helpful to differentiate from ductus aneurysm.

Oblique sagittal chest CTA in an asymptomatic patient with CTAI and right diaphragmatic hernia shows a well-defined aortic pseudoaneurysm at the aortic isthmus. Note characteristic sudden change in caliber of the aorta distally, a common finding.

Coronal chest CTA in the same patient demonstrates characteristic right diaphragmatic rupture with the hourglass sign of the liver and a frank hemidiaphragmatic defect .

Posterior sagittal chest 3D reformation in the same patient demonstrates the aortic pseudoaneurysm and its relationship with the pulmonary artery and the left atrium. 3D reformations may be helpful for better anatomic understanding and appropriate surgical planning.

PA chest radiograph in an asymptomatic patient with CTAI and a pseudoaneurysm shows curvilinear calcifications along the inferior aspect of the aortic arch.

Axial chest CTA in the same patient demonstrates well-marginated saccular dilatation of the aorta at the level of the isthmus.

Oblique sagittal reformation chest CTA in the same patient shows an isthmic pseudoaneurysm with intrinsic curvilinear wall calcifications. A ductus aneurysm can be difficult to differentiate from a CTAI on imaging. However, they both have similar clinical and prognostic considerations as well as treatment.

PA chest radiograph in an asymptomatic patient with CTAI shows mild widening of the mediastinum.

Lateral chest radiograph in the same patient demonstrates that, given a lack of significant amount of wall calcification, the abnormality (i.e., the pseudoaneurysm) is difficult to appreciate on chest radiography. While surgery has traditionally been the preferred treatment for CTAI, conservative treatment may be used in asymptomatic individuals with densely calcified pseudoaneurysms.

Axial NECT in the same patient reveals contour abnormality at the level of the aortic isthmus.

$Axial CTA in the same patient shows a saccular aneurysm at the level of the aortic isthmus. In general, some clues that support the diagnosis include a positive clinical history of significant trauma, lack of atherosclerotic changes elsewhere, location of abnormalities at the level of the aortic isthmus, and stigmata of trauma (e.g., healed fractures, diaphragmatic hernia, etc.).$ Axial CTA in the same patient shows a saccular aneurysm at the level of the aortic isthmus. In general, some clues that support the diagnosis include a positive clinical history of significant trauma, lack of atherosclerotic changes elsewhere, location of abnormalities at the level of the aortic isthmus, and stigmata of trauma (e.g., healed fractures, diaphragmatic hernia, etc.).

Oblique CTA candy cane reformations in the same patient make the identification of the saccular aneurysm easier. The lack of mediastinal hemorrhage and other associated injuries support the chronicity of the finding.

Oblique sagittal DSA in a patient with CTAI shows contrast filling the saccular outpouching . The CT and angiographic features, along with the patient's history, are consistent with a posttraumatic thoracic aortic pseudoaneurysm.

Additional Images

Sagittal volume-rendered CTA shows a posttraumatic pseudoaneurysm with eccentric peripheral calcification .

Left anterior oblique aortogram in the same patient shows contrast filling the aortic pseudoaneurysm . The location of the pseudoaneurysm allowed for successful endovascular treatment with an aortic stent graft.

Sagittal CECT in a patient with prior trauma shows a large saccular pseudoaneurysm along the aortic isthmus with peripheral rim calcification , consistent with a posttraumatic pseudoaneurysm.

Sagittal CECT in the same patient shows that the stent graft extends from immediately distal to the left subclavian arterial origin to the descending aorta . The pseudoaneurysm is thrombosed , and there is no endoleak.

Axial CECT of the same patient shows a thrombosed saccular pseudoaneurysm sac that has been excluded by an endovascular aortic stent graft used for treatment. The endovascular graft lumen is widely patent .

Axial CECT shows a peripherally calcified enhancing saccular outpouching from the distal aortic arch with compression of the left main stem bronchus . Patients may develop clinical symptoms, such as dyspnea, from compression of adjacent structures by a pseudoaneurysm.

Sagittal DSA in the same patient shows contrast filling the saccular outpouching . The CT and angiographic features, along with the patient's history, are consistent with a posttraumatic thoracic aortic pseudoaneurysm.

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KEY FACTS

Terminology

Imaging

Top Differential Diagnoses

Clinical Issues

TERMINOLOGY

Synonyms

Definitions

IMAGING

General Features

Best diagnostic clue

Location

Morphology

Imaging Recommendations

Best imaging tool

Protocol advice

Radiographic Findings

Radiography

CT Findings

CTA

MR Findings

MRA

Angiographic Findings

DIFFERENTIAL DIAGNOSIS

Nontraumatic Aortic Pseudoaneurysm

Ductus Aneurysm

Mediastinal Mass

PATHOLOGY

General Features

Etiology

Associated abnormalities

Gross Pathologic & Surgical Features

CLINICAL ISSUES

Presentation

Most common signs/symptoms

Demographics

Epidemiology

Natural History & Prognosis

Treatment

DIAGNOSTIC CHECKLIST

Consider

References

Selected References

Cases

Images

Selected Images

Additional Images

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