1Department of General Surgery, Oman Medical Specialty Board, Muscat, Oman; 2Department of Vascular Surgery, McGill University, Montreal, Canada; Department of 3Vascular Surgery and 4Radiology, Sultan Qaboos University Hospital, Muscat, Oman; Department of 5Radiology and 6Vascular Surgery, The Royal Hospital, Muscat, Oman *Corresponding Author’s e-mail: sara93916@gmail.com إصاابت رضحية كليلة مزمنة يف األهبر الصدري تقرير عن ثالث حاالت من ُعمان �سارة العدوية، احمد نعيم، ابراهيم عبد الهادي، را�سد ال�سكيتي، حممود الهاجري، ادوين �ستيفن، �سليمان ال�سام�سي، خليفة الوهيبي abstract: Blunt thoracic aortic injuries are potentially lethal. Those who survive may form an organised haematoma in the periadventitial space resulting in a pseudoaneurysm, which may be identified incidentally decades later. While the role of thoracic endovascular aortic repair (TEVAR) in acute settings has been established, its role in chronic cases is yet to be defined. We report three cases that were diagnosed incidentally six, nine and 18 years after the injury. Two were managed by TEVAR while the third declined intervention and is on annual follow- up. Patients with asymptomatic and stable pseudoaneurysms of the descending thoracic aorta should be offered surveillance versus TEVAR because the risk of rupture is not negligible, whilst taking into account the patient’s level of physical activity. These three cases highlight the importance of early diagnosis of aortic injuries in blunt trauma and its grading. Keywords: Thoracic Aortic Aneurysm; Endovascular Procedures; False Aneurysm; Nonpenetrating Wounds; Traffic Accidents; Oman. امللخ�ص: تكمن خطورة اإ�سابات ال�رشيان الأورطي ال�سدري يف اإمكانية اإف�سائها اإىل الوفاة. ويتكون عادًة ورم دموي منظم يف املنطقة املحيطة بالإ�سابة يوؤدي اإىل متدد �رشياين ُيكت�سف بال�سدفة بعد فرتة طويلة من الزمن. وعلى الرغم من اأهمية دور عملية اإ�سالح متدد الأوعية الدموية يف الإ�سابات احلادة٬ اإل اأن دورها يف الإ�سابات املزمنة غري وا�سح. نقدم هنا تقريراَ عن ثالثة حالت مت ت�سخي�سها بال�سدفة بعد انق�ساء فرتة ترتاوح بني 6، 9 و 18 عاًما من الإ�سابة. مت عالج حالتني جراحيَا٬ بينما رف�ض املري�ض الثالث التدخل اجلراحي وتتم متابعته �سنويَا. يجب اأن يخ�سع املر�سى للمراقبة الدورية بعد الت�سخي�ض بتمدد �رشياين يف ظل خلوهم من الأعرا�ض٬ مع و�سع التدخل اجلراحي كخياٍر مهم ب�سبب خطر حدوث مزق اأورطي. كما يجب مراعاة م�ستوى الن�ساط البدين للمري�ض عند اإختيار اخلطة العالجية. يهدف هذا البحث اإىل ت�سليط ال�سوء على اأهمية الت�سخي�ض املبكر لإ�سابات ال�رشيان الأورطي ال�سدري املزمنة. الكلمات املفتاحية: متدد الأوعية الدموية لل�رشيان الأورطي؛ عمليات الأوعية الدموية؛ متدد الأوعية الدموية؛ اجلروح؛ احلوادث، حركة املرور؛ ُعمان. Chronic Blunt Traumatic Thoracic Aortic Injuries Report of three cases from Oman *Sara S.H. Al-Adawi,1 Ahmed Naiem,2 Ibrahim Abdelhady,3 Rashid Al-Sukaiti,4 Mahmood Al-Hajeri,5 Edwin Stephen,3 Sulaiman Al-Shamsi,6 Khalifa Al-Wahaibi3 Sultan Qaboos University Med J, February 2021, Vol. 21, Iss. 1, pp. e120–123, Epub. 15 Mar 21 Submitted 26 Feb 20 Revision Req. 21 Apr 20; Revision Recd. 3 Jun 20 Accepted 5 Jul 20 a widened mediastinum on a chest X-ray performed for a routine health screening for his promotion as an army officer. He denied any chest pain, hoarseness of voice, shortness of breath or other symptoms. The patient had a history of a motor vehicle collision (MVC) 18 years prior to presentation when he had undergone a laparotomy and splenectomy. Following these surgeries, he carried on regular official and recreational activities in the army with no restrictions. He had no family history suggestive of connective tissue disorder. A subsequent computed tomography angiography (CTA) revealed a 3.8 cm pseudoaneurysm at the proximal descending thoracic aorta at the origin of the left subclavian artery with partial calcification [Figure 1]. Having discussed the risks and benefits of endovascular intervention, a thoracic endovascular aortic repair (TEVAR) was performed using a 30 × 100 mm Zenith Alpha™ Thoracic Endovascular Graft Blunt thoracic aortic injuries (btai) are potentially fatal. Those with lesser degrees of injury may survive with a haematoma formation in the periadventitial space followed by subsequent pseudoaneurysm formation. With the advent of better radiological imaging, cases have emerged where individuals survive the initial injury and live with a pseudoaneurysm for decades until its incidental discovery on imaging. The management of such cases has not been clearly established as it is underreported. We report three cases of chronic pseudoaneurysms detected six, nine and 18 years after the initial injury. Case One In 2015, a 37-year-old male patient was referred to Sultan Qaboos University Hospital (SQUH) with findings of This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. https://doi.org/10.18295/squmj.2021.21.01.017 case report https://creativecommons.org/licenses/by-nd/4.0/ Sara S.H. Al-Adawi, Ahmed Naiem, Ibrahim Abdelhady, Rashid Al-Sukaiti, Mahmood Al-Hajeri, Edwin Stephen, Sulaiman Al-Shamsi and Khalifa Al-Wahaibi Case Report | e121 (Cook Medical, Bloomington, Indiana, USA) through a femoral cutdown. He has been under annual follow up with CTA. In 2018, a linear intra-stent thrombus was seen [Figure 2]. He was started on rivaroxaban 15 mg twice daily for three weeks, followed by 20 mg once daily for nine weeks. Repeat CTA in 2019 showed no progression of the thrombus, so he was switched to clopidogrel 75 mg once daily. His latest CTA in January 2020 showed no thrombus progression and no complications related to the stent-graft. He will be continued on antiplatelet therapy as long as there is evidence of thrombus on annual imaging. Meanwhile, he continues his army activities with a reduction in physical intensity and contact sport. Case Two In January 2017, a 37-year-old mother of four pres- ented at SQUH and underwent a CT imaging of the abdomen for peritonitis. She was diagnosed with an acutely inflamed appendix and an incidental finding of a 7.5 cm right-sided diaphragmatic defect containing a herniated right lobe of the liver. A CT chest scan was performed to assess the diaphragmatic hernia further. It revealed a saccular pseudoaneurysm at the aortic isthmus, measuring 3 × 3 cm, that was distal to the left subclavian artery by 1.5 cm and with a curvilinear wall calcification [Figure 3]. Her history revealed an MVC nine years prior. She had occasional stabbing chest pain and tenderness over the left chest wall, which was managed with analgesics; otherwise, she lived an active lifestyle and had two of her children after the MVC. Following a discussion, she underwent a successful TEVAR through a femoral cutdown using a 28 × 100 mm Valiant™ thoracic stent graft with the Captivia™ delivery system (Medtronic, Minneapolis, Minnesota, USA) under fluoroscopic guidance. She has been on aspirin 75 mg once daily and under annual follow-up since. Her latest CTA in November 2019 showed the stent-graft in place and no endoleak or in- stent thrombus. Case Three In May 2019, a 29-year-old male patient was referred to SQUH with an incidental finding of a pseudo- aneurysm of the descending thoracic aorta [Figure 4]. The patient denied any symptoms, had normal blood pressure readings and his examination was unrem- arkable. He was working with the military and regularly Figure 1: 3D reconstructed image of (A) anterior and (B) posterior view of an incidentally detected pseudoaneurysm of the descending thoracic aorta in a 37-year-old male patient, 18 years after initial trauma. Figure 3: (A) Computed tomography scan showing an incidentally detected saccular pseudoaneurysm at the aortic isthmus, and (B) right diaphragmatic hernia containing the right lobe of the liver in a 37-year-old female patient, nine years after initial trauma. Figure 2: A linear intra-stent thrombus in a 37-year-old male patient seen on computed tomography angio- graphy after thoracic endovascular aortic repair. Figure 4: 3D reconstructed image of (A) anterior and (B) posterior view of an incidentally detected pseudoaneurysm of the descending thoracic aorta in a 29-year-old male patient, six years after initial trauma. Chronic Blunt Traumatic Thoracic Aortic Injuries Report of three cases from Oman e122 | SQU Medical Journal, February 2021, Volume 21, Issue 1 participating in intense physical activity. His history was significant for an MVC six years prior. After exploring all options and its associated risks and benefits, the patient opted to decline any intervention. He was given a follow-up appointment and instructions to report back if he developed any symptoms such as chest pain, inter-scapular pain, hoarseness of voice, dysphagia, dyspnoea or haemoptysis. Discussion We report three cases of pseudoaneurysms diagnosed incidentally on imaging several years after the initial trauma. All were young, otherwise healthy members of society. Two were regularly performing strenuous physical activities associated with their job as military personnel. The third was a female of childbearing age who had two pregnancies between the time of trauma until the pseudoaneurysm diagnosis. BTAI can be classified into four grades: grade 1 signifies intimal tear; grade 2 is an intramural haema- toma; grade 3 is a pseudoaneurysm; and grade 4 is the free rupture of the aorta.1 The presence of shock, higher injury severity scores and concomitant brain injury are associated with a poor outcome from BTAI.2 The Society of Vascular Surgery and Eastern Assoc- iation for the Surgery of Trauma recommend endo- vascular repair over open surgery, given the reduced rates of complications in the acute setting for grade 2–4 injuries. Grade 1 injuries may be managed non- operatively, but newer studies have emerged to suggest further that non-operative management for grade 2 injuries may also be acceptable.3–6 Late complications of conservative treatment of aortic injuries include dissection, free rupture and pseudoaneurysms.7 Chronic pseudoaneurysms have been reported to develop years after the injury.7–9 In the current patients, these pseudoaneurysms were incidentally discovered several years after the trauma. Still, they could have led to free rupture when exposed to increased intra-abdominal and thoracic pressure during military exercise or labour. There has been documented success of TEVAR in chronic traumatic pseudoaneurysms of the thoracic aorta.10,11 This is not free of complications including endoleak, stroke, paraplegia, intra-graft thrombus and mortality.5,10,12,13 Left subclavian artery coverage requiring carotid-subclavian bypass or use of fenes- trated or chimney grafts must also be considered.13 While there are continuous improvements in profile and structure of stent-grafts, only time will tell whether the newer stent-grafts would have decreased re-intervention rates than their predecessors. Non-operative management could be considered if the pseudoaneurysm remains stable in size, asymp- tomatic, densely calcified and with no connective tissue disease history. Literature in this regard is limited to earlier experience in this field.14 The role of open surgical therapy in acute and chronic cases cannot be ruled out. However, it is associated with higher morbidity and is reserved for those patients who are unsuitable for TEVAR. Literature is limited to case reports concerning open repair.15 In the current report, the risks of free rupture versus complications of TEVAR were weighed. Considering their lifestyles, all three patients were offered TEVAR. One patient developed intra-stent thrombus, which was managed with anticoagulant therapy. The second patient did not have any compl- ications after TEVAR. The third patient refused intervention, so he was offered regular follow-up to ensure adequate blood pressure control with a CT angiogram every two years, followed by a yearly trans- oesophageal echocardiogram.16 Conclusion Chronic, stable and a calcified wall are features that might support successful non-operative management of pseudoaneurysms formed after BTAI. Non- operative management of BTAI should only be offered with imaging surveillance and regular follow-up. The level of physical activity and its impact on exertional arterial pressure changes should be considered in decision-making. References 1. Azizzadeh A, Keyhani K, Miller 3rd CC, Coogan SM, Safi HJ, Estrera AL. Blunt traumatic aortic injury: Initial experience with endovascular repair. J Vasc Surg 2009; 49:1403–8. https:// doi.org/10.1016/j.jvs.2009.02.234. 2. Lin C-C, Liu K-S, Chen H-W, Huang Y-K, Chu J-J, Tsai F-C, et al. Blunt aortic injury: Risk factors and impact of surgical approaches. Surg Today 2016; 46:188–96. https://doi.org/10.10 07/s00595-015-1152-0. 3. Lee WA, Matsumura JS, Mitchell RS, Farber MA, Greenberg RK, Azizzadeh A, et al. Endovascular repair of traumatic thoracic aortic injury: Clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 2011; 53:187–92. https://doi. org/10.1016/j.jvs.2010.08.027. 4. Fox N, Schwartz D, Salazar JH, Haut ER, Dahm P, Black JH, et al. Evaluation and management of blunt traumatic aortic injury: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Nurs 2015; 22:99–110. https://doi.org/10.1097/JTN.0000000000000118. 5. Soong TK, Wee IJY, Tseng FS, Syn N, Choong AMTL. A syst- ematic review and meta-regression analysis of non-operative manage- ment of blunt traumatic thoracic aortic injury in 2897 patients. J Vasc Surg 2019; 3:941–53.e13. https://doi.org/10.1016/j.jvs.20 18.12.045. https://doi.org/10.1016/j.jvs.2009.02.234 https://doi.org/10.1016/j.jvs.2009.02.234 https://doi.org/10.1007/s00595-015-1152-0 https://doi.org/10.1007/s00595-015-1152-0 https://doi.org/10.1016/j.jvs.2010.08.027 https://doi.org/10.1016/j.jvs.2010.08.027 https://doi.org/10.1097/JTN.0000000000000118 https://doi.org/10.1016/j.jvs.2018.12.045 https://doi.org/10.1016/j.jvs.2018.12.045 Sara S.H. Al-Adawi, Ahmed Naiem, Ibrahim Abdelhady, Rashid Al-Sukaiti, Mahmood Al-Hajeri, Edwin Stephen, Sulaiman Al-Shamsi and Khalifa Al-Wahaibi Case Report | e123 6. Sandhu HK, Leonard SD, Perlick A, Saqib NU, Miller 3rd CC, Charlton-Ouw KM, et al. Determinants and outcomes of non- operative management for blunt traumatic aortic injuries. J Vasc Surg 2018; 2:389–98. https://doi.org/10.1016/j.jvs.2017.07.111. 7. Mosquera VX, Marini M, Lopez-Perez JM, Muñiz-Garcia J, Herrera JM, Cao I, et al. Role of conservative management in traumatic aortic injury: Comparison of long-term results of conservative, surgical, and endovascular treatment. J Thorac Cardiovasc Surg 2011; 3:614–21. https://doi.org/10.1016/j. jtcvs.2010.10.044. 8. Rabin J, DuBose J, Sliker CW, O’Connor JV, Scalea TM, Griffith BP. Parameters for successful non-operative management of trau- matic aortic injury. J Thorac Cardiovasc Surg 2014; 1:143–9. https://doi.org/10.1016/j.jtcvs.2013.08.053. 9. Finkelmeier BA, Mentzer Jr RM, Kaiser DL, Tegtmeyer CJ, Nolan SP. Chronic traumatic thoracic aneurysm. Influence of operative treatment on natural history: An analysis of reported cases, 1950-1980. J Thorac Cardiovasc Surg 1982; 84:257–66. 10. Szostek MM, Jakuczun W, Alagbari A, Pogorzelski R, Szostek M, Osęka M, et al. Chronic traumatic thoracic aortic aneurysms- results of endovascular treatment. Fourteen-year single-center experience. Int Angiol 2015; 34:506–13. 11. Fattori R, Napoli G, Lovato L, Russo V, Pacini D, Pierangeli A, et al. Indications for, timing of, and results of catheter-based treatment of traumatic injury to the aorta. AJR Am J Roentgenol 2002; 179:603–9. https://doi.org/10.2214/ajr.179.3.1790603. 12. Abdoli S, Ham SW, Wilcox AG, Fleischman F, Lam L. Sympt- omatic intragraft thrombus following endovascular repair of blunt thoracic aortic injury. Ann Vasc Surg 2017; 42:305.e7–12. https://doi.org/10.1016/j.avsg.2016.12.007. 13. DuBose JJ, Leake SS, Brenner M, Pasley J, O’Callaghan T, Luo- Owen X, et al. Contemporary management and outcomes of blunt thoracic aortic injury: A multicenter retrospective study. J Trauma Acute Care Surg 2015; 78:360–9. https://doi.org/10.10 97/TA.0000000000000521. 14. Katsumata T, Shinfeld A, Westaby S. Operation for chronic traumatic aortic aneurysm: When and how? Ann Thorac Surg 1998; 66:774–8. https://doi.org/10.1016/S0003-4975(98)00519-0. 15. Miller S, Kumar P, Van den Bosch R, Khanafer A. Chronic Thoracic Aortic Aneurysm Presenting 29 Years following Trauma. Case Rep Surg 2015; 2015:470917. https://doi.org/10.1155/2015/470917. 16. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/ SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the american college of cardiology foundation/ american heart association task force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:266–369. https://doi. org/10.1161/CIR.0b013e3181d4739e. https://doi.org/10.1016/j.jvs.2017.07.111 https://doi.org/10.1016/j.jtcvs.2010.10.044 https://doi.org/10.1016/j.jtcvs.2010.10.044 https://doi.org/10.1016/j.jtcvs.2013.08.053 https://doi.org/10.2214/ajr.179.3.1790603 https://doi.org/10.1016/j.avsg.2016.12.007 https://doi.org/10.1097/TA.0000000000000521 https://doi.org/10.1097/TA.0000000000000521 https://doi.org/10.1016/S0003-4975%2898%2900519-0 https://doi.org/10.1155/2015/470917 https://doi.org/10.1161/CIR.0b013e3181d4739e https://doi.org/10.1161/CIR.0b013e3181d4739e