Thoracic Aortic Aneurysm (C0302)

Atheromas

Thrombus Over Ulceration

Ulceration

Laminated Thrombus

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Atheromas

Thrombus Over Ulceration

Laminated Thrombus

Ulceration

C0302

Pathological Story

Description

The thoracic aorta is mounted. Note the large aneurysm which is filled with a laminated thrombus and has small fragments of lung tissue stuck to the periphery. There are severe atheromatous changes with ulcerative lesions with overlying thrombosis on the intimal surface. The perforation is not present.

Clinical History

This 87 year old male presented with back pain and hemoptysis. He was cyanotic with a BP of 50/0. Xrays revealed a large mass in his left chest. Peripheral pulses were present at all sites. He died suddenly on the day of admission.

Autopsy Findings

Although he had severe coronary atherosclerosis there was no myocardial infarct. In the distal portion of his thoracic aorta, there was a large aneurysm which had bled into the adjacent left lung and the pleural cavity. There was blood in the bronchus from the left lower lobe. The aorta was severely atherosclerotic.

Flash Card

Definition of aneurysm

a weakened area in the wall of a blood vessel resulting in a bulge (abnormal ballooning exceeding 50% of the vessel’s normal diameter.)

Outline the path of the thoracic aorta

continuation of the aortic arch, within the posterior mediastinal cavity on the left of the vertebral column (it approaches midline as it descends, becoming the descending thoracic aorta)

What is the significance of a diastolic blood pressure of 0mmHg?

0mmHg means there is zero pressure being exerted on arterial walls during diastole. This suggests that the blood vessels have very, very low blood volume.

Questions

For an undergraduate anatomy/pathology class

What structure would be posterior to this thoracic aorta specimen? It would be in intimate contact with the surface marked here?

thoracic vertebral bodies of the spine

For a medical student CBL case

You see this patient with your family practice preceptor. He is a 87 yo patient complaining of back pain and hemoptysis. You take his bp twice and notice it is 50/0mmHg. You assess his peripheral pulses which are present at all sites. When auscultation, you hear abnormal sounds in the left lower lobe which does not sound like consolidation. What are your hypotheses for the hemoptysis? Please give rationale

Given the diastolic of 0mmHg, one must think of a bleed somewhere in addition to his hemoptysis. So a bleed into the airways, possibly due to fragile tissue (tumour) or vessel (aneurysm). Note that even his peripheral pulses are present which doesn’t mean he is stable.

For a pathology resident

You are doing a post-mortem on this 87 yo patient who died suddenly, 2 hours upon admission. He was admitted for back pain with hemoptysis, with a bp of 50/0 mmHg. The thoracic aorta is presented here with evident ulcerations & thromboses. What is the cause of the laminated thrombus?

Damage to the endothelial layer initiateted clotting. As the bulge formed, that left static blood, apart from thoracic aortic flow, that forms distinct layers of fibrin & platelets that accumulated

For an Emergency nurse

This 87 yo patient is presenting with back pain and hemoptysis. As part of triage, HR & RR were abnormally high, BP was measured at 50/0mmHg, and peripheral pulses were present at all sites. He appears cyanotic, esp in his extremities which are cool. What is your priority action?

Ask the patient if he is experiencing any chest pain and order an EKG and cardiac panel.
Ask the patient to return to the waiting room and give him an oral analgesic/
XConsult immediately with the ER physician as you are concerned about his BP
Call a Code Blue

Additional Resources

If you would like to learn more about the path of the normal thoracic aorta in the sagittal plane, please visit our free teaching module https://www.clinicalanatomy.ca/thorax/Mediastinum/story_html5.html

If you would like to develop more skills in hypothesis formation and clinical reasoning, please visit our free Open Education text on Pathology

Post-Test on Cirrhosis

DISCLAIMER: we currently don’t have a chapter on aneurysm. But the above link is an example of our clinical reasoning exercises.