Case ReportDelayed Traumatic Aortic Pseudoaneurysm Formation Causing Vertebral Body Erosion and Back Pain: Case Report and Literature Review
Introduction
An aneurysm is defined as a dilatation of an artery contained by all 3 layers of the arterial wall: intima, media, and adventitia. A pseudoaneurysm, by contrast, may be confined by only 2 layers, only 1 layer, or only the surrounding connective tissue with persistent flow outside the vessel.1, 2, 3 Multiple causes of pseudoaneurysm formation have been reported in the literature, including iatrogenic, traumatic, anastomotic, or secondary to infection.1 Other pathologic features associated with generalized vascular inflammation such as atherosclerotic ulceration, in which an atherosclerotic plaque penetrates the media, have been reported in pseudoaneurysm formation.3 These pseudoaneurysms may undergo spontaneous thrombosis, may progress to compression of local neurovascular structures, or may even rupture.2
Traumatic pseudoaneurysms generally present acutely, although the literature describes rare cases of delayed presentation.4, 5 Back pain is the most common manifestation of traumatic pseudoaneurysm formation of the aorta and is frequently the only symptom.5, 6, 7, 8 Other signs and symptoms include a pulsatile mass with or without a bruit; thromboembolism causing distal ischemia and necrosis; and compression of adjacent structures such as the biliary tree causing jaundice, chest pain, abdominal pain, gastrointestinal bleeding, and rupture with subsequent hemorrhage and shock.4, 5, 9, 10, 11, 12 Typically, back pain is due to local neurovascular compression by the pseudoaneurysm. However, there are some rare cases of pseudoaneurysm erosion into the adjacent vertebral body (VB) and subsequent development of chronic back pain.6, 13, 14 Here we describe an interesting case of a 66-year-old man who presented with persistent back pain caused by VB erosion from a pseudoaneurysm arising from the abdominal aorta secondary to a gunshot wound that had occurred 27 years previously.
Section snippets
History
A 66-year-old man presented to his primary care physician because of new-onset lumbar back pain. The patient described the pain as sharp and constant, and he noted that the pain was worse with walking and was relieved by lying down. The patient stated that the pain had initially started as intermittent and variable in intensity but was typically worse in the morning and lessened in severity as the day progressed. The pain occasionally radiated from his back to his flank, but he did not describe
Discussion
Pseudoaneurysm formation is typically due to an iatrogenic, an traumatic, or an anastomotic event or can be secondary to infection or inflammation.1, 15 After trauma, a hematoma can form within the surrounding tissue and become encapsulated by fibrous tissue.9 A continued communication between the vessel and the hematoma results in a pseudoaneurysm.9 Specifically, the retroperitoneal location of the abdominal aorta may tamponade hemorrhage from aortic rupture, predisposing to pseudoaneurysm
Conclusions
Pseudoaneurysm of the abdominal aorta is associated with high morbidity and mortality. In patients with a history of penetrating trauma involving the abdomen and a delayed presentation of back pain, a traumatic pseudoaneurysm must be ruled out. Treatment for aortic pseudoaneurysms ranges from surgical to endovascular, depending on the morphology of the pseudoaneurysm and its location. In our patient, a combined surgical and endovascular approach led to the complete resolution of his back pain
Acknowledgments
Richard Neville, M.D., at George Washington University Hospital contributed to this report by providing the imaging and was actively involved in the clinical care of our patient.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.