Abstract

A 78-year-old patient presented with shortness of breath after falling down. Transthoracic echocardiogram showed an extensive thrombus in the right atrium (RA), extensive thrombosis of the inferior vena cava (IVC), and abdominal aortic aneurysm (AAA). A magnetic resonance confirmed the thrombosis of the RA extending to the IVC, which was apparently fused to the abdominal aortic aneurysm (compression? erosion?). This case illustrates a severe and rare complication of a non-treated AAA. There probably was IVC erosion by the aortic aneurysm, leading to blood stasis and extensive thrombosis of the IVC and right cardiac chambers.

Keywords:
Aortic Aneurysm, Abdominal / complications; Thrombosis; Heart Atria; Echocardiography

Resumo

Uma paciente de 78 anos procurou o serviço de emergência apresentando dispneia após sofrer queda da própria altura. O ecocardiograma transtorácico mostrou um extenso trombo no átrio direito (AD), trombose extensa da veia cava inferior (VCI), e aneurisma de aorta abdominal (AAA). A ressonância magnética confirmou a trombose do AD estendendo-se até a VCI, a qual aparentemente apresentava fusão ao aneurisma da aorta abdominal (compressão? erosão?). Este caso ilustra uma complicação grave e rara de um AAA não tratado. Provavelmente houve uma erosão da VCI pelo aneurisma da aorta resultando em estase sanguínea e trombose extensa da veia cava inferior e cavidades cardíacas direitas.

Palavras-chave:
Aneurisma da Aorta Abdominal / complicações; Trombose; Átrios do Coração; Ecocardiografia

Case Report

A 78-year-old female patient presented with shortness of breath after falling down. She reported a history of systemic hypertension, stable coronary artery disease and abdominal aorta aneurysm undergoing clinical surveillance. The laboratory exams evidenced thrombocytopenia (22.000 mm³) with no other abnormalities. Transthoracic echocardiogram showed a heterogeneous hyper-echogenic mass at the right atrium, protruding into the right ventricle, highly mobile, suggestive of thrombus.¹1 Asinger RW, Herzog CA, Dick CD. Echocardiography in the evaluation of cardiac sources of emboli: the role of transthoracic echocardiography. Echocardiography. 1993;10(4):373-96.

2 Leitman M, Rahanani E, Wassermann I, Rosenblatt S, Peleg E, Krakover R, et al. Unusual right-sided cardiac masses. Echocardiography. 2010;27(9):1151-5.^-33 Roudaut E, Gosse P, Aouizerarte E. The diagnosis of intraatrial masses with two-dimensional echocardiography: experience with 64 patients. Echocardiography. 1987;4(5):431-6. Extensive thrombosis of the inferior vena cava (IVC) (Figure 1), and abdominal aorta aneurysm (AAA) of around 10 cm in diameter was also observed. The patient underwent thoracic, abdominal and pelvic computed tomography (CT). CT evidenced irregular, tortuous supra and infra-renal aortic aneurysm. There were paravertebral as well as ventral abdominal wall collaterals, indicating venous obstruction and signs of probable erosion of the IVC by the aneurysm. An aortic magnetic resonance was performed to better evaluate the aorta anatomy, which confirmed the extensive thrombosis of the IVC, in the segment related to the AAA, with extension of the thrombosis to the right cardiac chambers (Figure 2). Anticoagulation therapy was contraindicated due to the thrombocytopenia and a discrete increase in platelet count was observed after corticosteroid and immunoglobulin therapy. The patient was discharged on request and died of sudden death ten days after dismissal.

Right atrial masses are very rare findings. This case illustrates a severe and rare complication of a non-treated AAA. Enteric erosion is a well-known complication of aortic aneurysm or aortic dissection. Arteriovenous fistula has been described as a graft-related complication after AAA repair,⁴4 Sonmez B, Kargi A, Yagan N, Onursal E, Cesmeci S, Barlas C. Ruptured abdominal aortic aneurysm with fistula into the right iliac vein. J Cardiovasc Surg (Torino). 1988;29(4):486-7. but to the best of our knowledge, this has not been reported for the native aorta and IVC. Unfortunately, this diagnosis was suspected in this patient by means of cardiovascular imaging techniques but not confirmed by anatomical pathological analysis.

The video is available online: Movie clip for Figure 1A.

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