Multidisciplinary Challenges in Managing a Ruptured Ascending Aortic Aneurysm with Concurrent Pulmonary Pathology: A Case Report

Daud Yudhistira Sukanto ¹, Danang Himawan Limanto ¹*

This case highlights the challenges of managing ruptured aortic aneurysms with comorbidities, emphasizing multidisciplinary care and TEVAR’s limitations in complex cases.

Abstract

Background: Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive technique for managing acute aortic dissection. While it is an essential tool in aortic emergencies, timely intervention is critical, especially in life-threatening cases. Case Presentation: A 65-year-old female presented with severe shortness of breath and initially stable hemodynamics. A contrast-enhanced computed tomography (CT) scan revealed a ruptured ascending aortic aneurysm with a contrast-filled hematoma occupying the pleural space, causing compression atelectasis in the right middle and lower lobes. Additionally, a solid mass in the left upper lung suggested a mycotic aneurysm, while multiple pulmonary nodules raised suspicion of metastatic disease (AJCC TNM 8th Edition: T2N2M1a, Stage IIIA). Due to hemodynamic instability during hospitalization, rapid ventricular pacing TEVAR was performed, successfully deploying a thoracic stent graft, followed by chest tube placement. The patient was transferred to the intensive care unit (ICU) but developed recurrent desaturation. Despite intensive monitoring, the patient and her family opted for a Do Not Resuscitate (DNR) order, and she passed away on the fourth day of treatment. Discussion: This case underscores the complexity of managing ruptured ascending aortic aneurysms, particularly in patients with concurrent thoracic pathologies. Despite successful TEVAR, the presence of suspected metastatic disease and a possible mycotic aneurysm contributed to a poor prognosis. The case highlights the importance of timely intervention in aortic emergencies while demonstrating the challenges of managing critically ill patients with multiple severe comorbidities. It also emphasizes the need for a multidisciplinary approach in similar cases.

Keywords: Ruptured Ascending Aortic Aneurysm, Mycotic Aneurysm, Thoracic Endovascular Aortic Repair (TEVAR), Aortic Dissection, Pulmonary Mass, Metastatic Lung Disease, Rapid Ventricular Pacing

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