A patient with a medical history of dyslipidemia and arterial hypertension was admitted to the Cardiology department of our hospital due to acute onset chest pain. His vital signs were normal, with no significant findings from the physical examination, ECG, chest X-Ray and heart echocardiogram. D-dimers and HS trop I were mildly elevated. During his hospitalization, the patient suffered an episode of massive hematemesis. After being hemodynamically stabilized four hours later, an urgent endoscopy of the upper gastrointestinal tract revealed the presence of a blood clot at the proximal esophageal tract with erosion from a pulsative mass (Figure 1A), and a part of the thrombus within the gastric lumen (Figure 2), with no signs of active hemorrhage due to peptic ulcer or malignancy. An emergent computed tomography angiography of the aorta and thorax showed a saccular descending aortic aneurysm at the level of the tracheal carina with a maximal diameter of 54 mm and mural thrombus. Remarkable was the presence of air within the thrombus's layers, and an aortoesophageal fistula blocked by a part of the thrombus, protruding into the esophagus lumen (Figure 1B, C, D, E). As a result, a thoracic endovascular aortic repair procedure was performed. The aneurysm was successfully covered with an endovascular stent graft (32 mmx10 cm) (Figure 1F). The patient had an uneventful post-operative course and was discharged on sixth postoperative day. Our patient was lucky to survive because a potentially life-threatening hematemesis was staunched by the presence of a tamponing thrombus within the lumen of the aortoesophageal fistula.
A. Endoscopy of the upper gastrointestinal tract, revealing the presence of blood clot at the proximal esophageal tract (red arrow) with erosion from a pulsative mass. B. Computed tomography angiography of aorta and thorax with intravenous contrast agent, axial view, depicting the presence of a saccular descending aortic aneurysm at the level of the tracheal carina, with mural thrombus (red arrow), and an aortoesophageal fistula blocked by a part of the thrombus, protruding into the esophagus lumen (yellow arrow). C. Computed tomography angiography of aorta and thorax, three dimensional reconstruction, depicting the presence of the descending aortic aneurysm. D. Computed tomography angiography of aorta and thorax with intravenous contrast agent, axial view, depicting the presence of a saccular descending aortic aneurysm at the level of the tracheal carina with the presence of air within the thrombus's layers (red arrows). E. Computed tomography angiography of aorta and thorax with intravenous contrast agent, sagittal view, depicting the aneurysm's mural thrombus (red arrow), protruding into the esophagus lumen (yellow arrow). F. Invasive angiography, showing the result of the thoracic endovascular aortic repair procedure with coverage of the aneurysm with endovascular stent graft (red arrow).
The authors have no conflicts of interest to declare.
