Giant Ascending Aortic Aneurysm Causing Central Venous Occlusion

HomeRadiologyVol. 305, No. 1 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyGiant Ascending Aortic Aneurysm Causing Central Venous OcclusionPedro V. Staziaki , Sandeep S. HedgirePedro V. Staziaki , Sandeep S. HedgireAuthor AffiliationsFrom the Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114.Address correspondence to P.V.S. (email: [email protected]).Pedro V. Staziaki Sandeep S. HedgirePublished Online:Jul 19 2022https://doi.org/10.1148/radiol.220414MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In An 82-year-old woman with hypertension presented with epistaxis and hemoptysis. Physical examination revealed distended veins in the chest and abdominal wall, which prompted chest radiography followed by a CT angiography (CTA) of the chest, abdomen, and pelvis. CTA showed a giant ascending thoracic aortic aneurysm (TAA) measuring 10.5 × 10 cm at its largest dimension, with normal-sized sinuses of Valsalva (Fig 1). The aneurysm was notably compressing the superior vena cava, bilateral brachiocephalic vein, and right internal thoracic (internal mammary) vein, resulting in multiple superficial collateral veins in the thoracic and abdominal wall. The patient was referred to cardiothoracic surgery for repair but declined surgical intervention, and a decision was made to continue medical therapy with antihypertensives.Figure 1: (A) CT angiogram in the axial plane in an 82-year-old woman shows a large saccular ascending thoracic aortic aneurysm with wall calcifications and a partially thrombosed lumen (*). The right internal thoracic vein, superior vena cava, and azygos arch are not visualized due to extrinsic compression, whereas the left internal thoracic vein can still be seen (arrow). Notice a right lateral thoracic vein (white arrowhead) and large bilateral superficial venous tributaries (black arrowheads) coursing in the subcutaneous tissue. (B) CT angiogram in the coronal plane depicts the large size of the thoracic aortic aneurysm and the eccentric thrombus (*).Figure 1:Download as PowerPointOpen in Image Viewer Giant ascending TAAs are defined as aneurysms greater than 10 cm in size (1,2). Here, we show an example of a giant ascending TAA resulting in central venous occlusion and development of multiple collateral vessels throughout the chest and abdominal walls. Venous collateral pathways include deep or superficial venous pathways (3–5). In this case, the predominant collateral pathway was by means of superficial veins (Fig 2).Figure 2: Cinematic rendering of the same CT angiogram in Figure 1 of the chest, abdomen, and pelvis reveals the extent of superficial collateral veins throughout the torso. Because the bilateral brachiocephalic veins, superior vena cava, and right internal thoracic vein were extrinsically compressed by the ascending thoracic aortic aneurysm, the collateral venous pathway on the right is superficial, with enlargement of multiple superficial venous tributaries in the upper chest, right lateral thoracic and thoracoepigastric veins (arrowheads), and right superficial epigastric vein (white arrow). Because the left internal thoracic vein (black arrow) is still present, the superficial pathway on the left is from the left internal thoracic vein to the multiple superficial tributaries to the left superficial epigastric vein (white arrow). The azygos system was not available as a collateral option because the azygos arch was also compressed by the large thoracic aortic aneurysm.Figure 2:Download as PowerPointOpen in Image Viewer Disclosures of conflicts of interest: P.V.S. Member of the Radiology: Artificial Intelligence Trainee Editorial Board. S.S.H. Member of the RadioGraphics Social Media and Digital Innovation Team.AcknowledgmentCinematic rendering access was provided in cooperation with Siemens Healthineers.References1. Okura T, Kitami Y, Takata Y, Fukuoka T, Arimitsu J, Hiwada K. Giant unruptured aneurysm of the thoracic aorta--a case report. Angiology 1999;50(10):865–869. Crossref, Medline, Google Scholar2. Agarwal V, Yaliwal C, Ofo E, Kolvekar S. Giant ascending aortic aneurysm--a case report and review. Heart Lung Circ 2007;16(5):385–388. Crossref, Medline, Google Scholar3. Meier A, Alkadhi H. Venous Collateral Pathways in Superior Thoracic Inlet Obstruction: A Systematic Analysis of Anatomy, Embryology, and Resulting Patterns. AJR Am J Roentgenol 2019;213(1):200–210. Crossref, Medline, Google Scholar4. Bashist B, Parisi A, Frager DH, Suster B. Abdominal CT findings when the superior vena cava, brachiocephalic vein, or subclavian vein is obstructed. AJR Am J Roentgenol 1996;167(6):1457–1463. 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Link, Google ScholarArticle HistoryReceived: Feb 23 2022Accepted: Mar 14 2022Published online: July 19 2022Published in print: Oct 2022 FiguresReferencesRelatedDetailsRecommended Articles Venous Anatomy and Collateral Pathways of the Pelvis: An Angiographic ReviewRadioGraphics2022Volume: 42Issue: 5pp. 1532-1545Adult Partial Anomalous Pulmonary Venous Return Repair and Superior Vena Cava Syndrome: A Delayed Complication of the Warden ProcedureRadiology: Cardiothoracic Imaging2022Volume: 4Issue: 54D Contrast-enhanced MR Angiography with the Keyhole Technique in Children: Technique and Clinical ApplicationsRadioGraphics2016Volume: 36Issue: 2pp. 523-537Fetal Cardiac US: Techniques and Normal Anatomy Correlated with Adult CT and MR ImagingRadioGraphics2017Volume: 37Issue: 4pp. 1290-1303Non–Catheter-related Venous Thromboembolism in Children: Imaging Review from Head to ToeRadioGraphics2017Volume: 37Issue: 6pp. 1753-1774See More RSNA Education Exhibits A Guide to Collateral Pathways in Superior and Inferior Vena Cava OcclusionDigital Posters2019What All Radiologists Need To Know About Caval Obstruction And Venous CollateralsDigital Posters2021Tortuous Path: Congenital Anomalies of the Systemic Thoracic VeinsDigital Posters2022 RSNA Case Collection Superior Vena Cava SyndromeRSNA Case Collection2020Right upper PAPVR and persistent left SVCRSNA Case Collection2020Infra-diaphragmatic Total Anomalous Pulmonary Venous ReturnRSNA Case Collection2021 Vol. 305, No. 1 Metrics Altmetric Score PDF download