Intimal aortic sarcoma mimicking ruptured thoracoabdominal type IV aneurysm. a rare case report and review of the literature

Primary aortic malignant tumors are rare and have poor prognosis. The most frequent site of origin is the thoracic part of the aorta and the most common growth pattern is intimal sarcoma [1], which usually presents with embolic events, renovascular hypertension or back pain. We report an extremely rare case of an intimal sarcoma that presented as a ruptured thoracoabdominal type IV aneurysm, which was successfully operated on. We also review the literature and discuss the diagnosis and treatment options.A 51-year-old man was transferred to Evaggelismos Hospital, Athens, Greece, with recent onset of sharp, acute and persistent back pain. His medical history was significant for an ascending aortic aneurysm sized 5.5 cm, with concomitant significant aortic insufficiency. The patient underwent composite valve-graft replacement and implantation of the coronaries (Bentall operation) one year prior to the current admission.Computed tomography (CT) of the chest and abdomen with contrast enhancement showed typical findings of a ruptured thoracoabdominal type IV aortic aneurysm (Figure 1). An enhanced extraluminal formation of the aorta was present, along with left-sided pleural effusion. The remaining part of the aorta was normal in size and typical postoperative findings of the previously operated side were recognized. Emergency angiography (Figure 2) confirmed the CT findings and the patient was transferred to the operating room. The patient was intubated with a double-lumen endotracheal tube and was positioned in the right lateral decubitus position. A cerebrospinal fluid (CSF) drainage catheter was placed to enhance spinal cord protection and somato-evoked potentials were monitored during rewarming. After half-dose of heparin, the left common femoral artery and vein were exposed. A 30F long cannula was inserted in the femoral vein and advanced to the right atrium. The femoral artery was cannulated with the new 18F Edwards cannula, which is longer in size and was easily a