Thorac cardiovasc Surg 2012; 60(S 02): e28-e30
DOI: 10.1055/s-0031-1295580
Vascular Surgery
Georg Thieme Verlag KG Stuttgart · New York

Unusual Cause of Acute Back Pain Mimicking Aortic Dissection: A Case Report

Markus Czesla
1  Sana Herzchirurgie Stuttgart, Stuttgart, Germany
,
Olga Karnari
1  Sana Herzchirurgie Stuttgart, Stuttgart, Germany
,
Julia Götte
1  Sana Herzchirurgie Stuttgart, Stuttgart, Germany
,
Bernhard Schulte
2  Robert Bosch Krankenhaus Stuttgart, Stuttgart, Germany
,
Ulrich Pfeilsticker
3  Klinikum Sindelfingen-Böblingen, Sindelfingen, Germany
,
Anita Narr
1  Sana Herzchirurgie Stuttgart, Stuttgart, Germany
,
Nicolas Doll
1  Sana Herzchirurgie Stuttgart, Stuttgart, Germany
› Author Affiliations
Further Information

Address for correspondence

Dr. Markus Czesla, M.D.
Sana Herzchirurgie Stuttgart GmbH
Herdweg 2, Stuttgart 70174
Germany   

Publication History

18 June 2011

20 June 2011

Publication Date:
29 December 2011 (eFirst)

 

Abstract

We report the case of a 62-year-old woman who initially presented with symptoms suggesting acute type A aortic dissection. Imaging studies revealed hemorrhagic pericardial fluid without the evidence of dissection. Foreign body material was noted floating in the inferior vena cava (IVC) and also piercing the right ventricular wall. Upon surgical exploration, the extracted material could be identified to be acrylic bone cement (palacos). The patient had reported a history of kyphoplasty in 2008.


#

Hemopericard in combination with acute back pain typically raises the concern for acute type A aortic dissection. It is important to recognize that according to the recent case reports, a wide variety of rare conditions can mimic aortic dissections. Our case illustrates that prompt assessment and appropriate surgical care are fundamental in the management of these patients.

Case Presentation

A 62-year-old woman admitted to the hospital complaining of acute chest pain. She described sudden onset of stabbing pain between her shoulder blades. Her medical history was unremarkable, except for spine surgery in 2008. The clinical symptoms appeared to be consistent with the diagnosis of acute aortic dissection. Transthoracic echocardiography and a CT scan of the chest revealed a 7 to 16 mm pericardial effusion without the evidence of a dissection flap in the ascending aorta, dilation of the aortic root, or aortic valve insufficiency. Coronary angiography did not show any signs of coronary artery disease. Three irregular shaped, 8 to 15 cm long and thin pieces of foreign body material appeared to be located in the IVC ([Figs. 1], [2]), the right atrium, and the right ventricular wall. Another piece was found in a branch of the right pulmonary artery. These structures could clearly be identified on CT images. The patient was taken to the operating room. Intraoperative findings included a small amount of hemorrhagic pericardial effusion as well as foreign body material perforating the inferior wall of the right ventricle close to the posterior descending coronary artery. The 2 to 3 mm thick foreign body could be extracted completely from the right ventricle. The two pieces in the IVC could not be entirely removed from the inferior vena cava because they appeared adherent to the vessel wall distally. The extracted material was sent to the pathology for further examination. During her postoperative course, no relevant complications occurred. The patient was discharged within 3 weeks.

Zoom Image
Figure 1 2D reconstruction: palacosstick inside the IVC, illustration of both augmented vertebral bodies.
Zoom Image
Figure 2 3D reconstruction: palacosstick compared with aorta.

#

Discussion

Although acute type A aortic dissection should lead to rapid surgical treatment, a thorough history, clinical exam, and work-up are of major importance to identify the correct diagnosis and provide appropriate care. Eagle et al analyzed 55 patients who admitted to the emergency department complaining of symptoms initially suggesting acute aortic dissection.[1] Negative aortograms prompted further testing and revealed a wide variety of entities including myocardial infarction, aneurysms, mediastinal tumors, as well as rare findings such as cholecystitis. Several case reports describe rare conditions like ingested fish bones, and dislodged transcatheter closure devices causing symptoms masquerading acute dissections.[2] [3]

More than 8 cm long, thin and almost entirely straight cement sticks in the IVC and right ventricular wall is a very seldom finding. Our question was: how did it get there? The patient had undergone kyphoplasty 2 years prior to the presentation, the only possible reason for the cement finding in her body. The procedure is used for pain relief of osteoporotic vertebral body compression fractures. After percutaneous injections of palacos the material solidifies. This process generates temperatures as high as 70°C with the potential of causing tissue damage allowing leakage of bone cement into surrounding structures. In her case, we must assume that the cement application was difficult. Besides the palacos pieces in the IVC and right heart, a relatively large pulmonary embolus can be identified on CT images, suggesting palacos embolization into a branch of the right pulmonary artery ([Fig. 3]). Similar observations have been reported in the recent publications.[4] [5] [6] [7] [8] [9] We assume that over time one of the spiky cement sticks has worked itself through the right ventricular wall eventually causing a perforation with hemopericard and acute onset of symptoms resembling an aortic dissection.

Zoom Image
Figure 3 Palacos embolus into a branch of right pulmonary artery.

Our case report illustrates a rare condition initially suggesting a wrong diagnosis. The described scenario emphasizes the importance of a thorough history and unbiased review of imaging tests. Missing out on the correct diagnosis in our patient could have resulted in a life-threatening condition or death.


#
#

Address for correspondence

Dr. Markus Czesla, M.D.
Sana Herzchirurgie Stuttgart GmbH
Herdweg 2, Stuttgart 70174
Germany   


  
Zoom Image
Figure 1 2D reconstruction: palacosstick inside the IVC, illustration of both augmented vertebral bodies.
Zoom Image
Figure 2 3D reconstruction: palacosstick compared with aorta.
Zoom Image
Figure 3 Palacos embolus into a branch of right pulmonary artery.