Diagnostic dilemma: Saccular aneurysm or pseudoaneurysm of the ascending aorta with dissection above level of leaflets
An 85-year-old Kurdish man lived in Iran, had been referred for elective coronary angiography and was admitted because of typical chest pain but with mild intensity. One year ago he had experienced an episode of chest pain accompanied by troponin elevation that had been considered acute coronary syndrome. However, he had not been underwent coronary angiography, with any reason that we do not know. After that event, he did not have typical coronary symptoms until current presentation. He was scheduled for angiography because of typical chest pain and old electrocardiographic (ECG) changes.\nInitially, His physical exam was unremarkable, ECG showed normal sinus rhythm with Q waves and inversion of T waves in II, III and aVF leads without any acute or new findings. Chest X-ray revealed the bulge aortic knob contour (). Routine transthoracic echocardiography, including the suprasternal view, showed dilated ascending aorta (4.6 cm) () and mild commissural aortic regurgitation preserved left ventricular systolic function. During catheterization, the left Judkins catheter passed without any problem, but we could not pass the right Judkins catheter, hence pigtail catheter was inserted and aortic root angiography showed the localized bulging of ascending aorta, but we were not sure whether it is dissection with true aneurysm or pseudoaneurysm? The findings on coronary artery angiography were unremarkable.\nMultislice spiral CT angiography revealed aneurysmal dilation of ascending aorta from sinotubular junction with the saccular aneurysm at the proximal part of arch with a 37 mm per 56 mm maximum diameter (). There was extension of thrombosis into the proximal part of right brachiocephalic artery, but ostia of both arteries did not involve with the aneurysm. The patient had been referred for surgery.\nDuring surgery we found the dissection of ascending aorta till distal to brachiocephalic artery (transverse arch involvement). Dissection flap was composed of some parts of intima and media layers (). Replacement of ascending and transverse aorta was performed with interposition tubular graft 30 and valve sparing. The operation and recovery was uneventful.