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Background: Aortic pseudoaneurysms are rare but life-threatening vascular complications that can develop after cardiac surgery. While most postoperative pseudoaneurysms involve a single location, occurrence at multiple aortic segments is exceptional. Case Presentation: We report a 56-year-old male who developed multiple pseudoaneurysms in both the thoracic and abdominal aorta within one month of undergoing cardiac surgery. The patient presented with progressive chest pain and breathlessness. CT aortogram demonstrated two anterior thoracic pseudoaneurysms (T7: 14 × 12 mm; T9: 26 × 24 mm) and a large abdominal pseudoaneurysm near the left renal artery (45 × 30 mm) containing mural thrombus. Associated findings included moderate cardiomegaly and significant right atrial enlargement. Lower limb arteries were normal. Results: Given the high rupture risk, the patient was evaluated in a multidisciplinary heart team meeting to plan definitive repair. The etiological differential included chronic atherosclerosis, iatrogenic injury, and mycotic aneurysm. Conclusion: This case illustrates the importance of early postoperative surveillance in high-risk cardiac surgery patients, the role of high-resolution CT imaging in diagnosis, and the necessity of multidisciplinary decision-making for complex pseudoaneurysm presentations.
Aortic pseudoaneurysm represents a contained rupture of the aortic wall, with blood leakage confined by the adventitia or surrounding mediastinal/retroperitoneal tissues rather than by the intact vessel wall layers (1). Post-cardiac surgery pseudoaneurysms occur in <0.5% of cases but carry high mortality if unrecognized (2,3).
Most reported postoperative pseudoaneurysms are localized to a single aortic segment. Simultaneous occurrence in multiple locations spanning thoracic and abdominal segments is exceptionally rare (4,5). The risk of rupture is compounded by location, size, infection status, and hemodynamic stress (1,2).
We present a case of triple-site pseudoaneurysm diagnosed one month after cardiac surgery — an unusual and high-risk scenario that emphasizes the role of vigilant follow-up and multidisciplinary management
A 56-year-old male presented to the Cardiothoracic & Vascular Surgery (CTVS) department with a one-month history of progressive chest pain and dyspnoea following recent cardiac surgery.
The patient was hemodynamically stable on examination, with clinical features suggestive of chronic volume overload. Cardiovascular assessment indicated right atrial enlargement.
On CT Aortogram (384-slice Siemens SOMATOM Force) following findings were obtained:
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Figure 1 Dilated thoracic aorta and a pseudoaneurysm at T7 vertebral level (Red arrow - pseudoaneurysm) |
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Figure 2 Pseudoaneurysm observed at the T9 vertebral level (red arrow) |
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Figure 3 Large left-sided pseudoaneurysm at the L2 level, adjacent to the left proximal renal artery, with a non-enhancing component suggesting partial thrombosis or mural hematoma (red arrow) |
Differential Diagnosis:
Aortic pseudo aneurysm following cardiac surgery is most often related to iatrogenic injury, infection, or degeneration of atherosclerotic plaques at cannulation or suture sites (2,4). The occurrence of multiple pseudoaneurysms involving both the thoracic and abdominal aorta within weeks of surgery is exceedingly rare and suggests either systemic vessel wall fragility or an underlying infectious etiology (5). Clinical presentation is often nonspecific, with symptoms such as chest or back pain and dyspnea, and a high index of suspicion is essential, particularly in postoperative patients with persistent or unexplained symptoms (3). Computed tomography angiography (CTA) remains the gold standard for assessing the size, morphology, and location of pseudoaneurysms and for guiding treatment planning (1,2). Because of the high risk of rupture, management requires a multidisciplinary approach involving cardiac surgery, vascular surgery, and interventional radiology. Open surgical repair is preferred for infected or anatomically complex pseudoaneurysms (3), while endovascular repair (TEVAR/EVAR) is increasingly employed in patients at high surgical risk (4,5). The occurrence of multiple pseudoaneurysms affecting both thoracic and abdominal segments within one month of surgery is exceptionally uncommon, underscores the importance of early postoperative surveillance imaging in at-risk patients, and highlights the combined role of timely imaging and multidisciplinary decision-making in preventing catastrophic rupture.
Postoperative aortic pseudoaneurysm, though rare, should be considered in any cardiac surgery patient presenting with unexplained chest or back pain. Multiple pseudoaneurysms carry exponentially higher rupture risk. Prompt CT angiography and team-based management are essential to prevent catastrophic outcomes.
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