A 51-year-old male, known to have BD with a history of popliteal aneurysm surgery, presented with abdominal pain mostly related to food intake.
In routine echocardiography, a large mobile mass (27mm x 14mm) in the right atrium was reported, which had an origin from the coronary sinus - albeit without any tricuspid dysfunction. CT Angiography of the aorta showed two pseudoaneurysms: a supra-celiacpseudoaneurysm- 66mm in diameter- and an infrarenal pseudoaneurysm- 55m in diameter (Figure 1). Both had a compressive affect on the aorta, and both were leaking. Within the first two days of admission, the hemoglobin level dropped from 13.2 to 8.0 mg/dl and, therefore, two units of pack cells were transfused.
An urgent endovascular plan was devised, followed by coronary angiography and digital subtraction angiography of the descending aorta and iliac arteries in a hybrid-suite. In the same session, the supra-celiac pseudoaneurysm was excluded endovascularly using a Zenith TX2 stent-graft extension cuff (TBE-30-80-PF). Also, the infrarenal pseudoaneurysm was excluded using a Zenith Renu aorto-uni-iliac stent graft (AX1-1-28-125) and extended into the right common iliac artery, and the left common iliac artery was occluded with a 14-mm iliac plug (Cook Medical Inc., Bloomington, Indiana). Subsequently, a femoral-femoral bypass was conducted to reestablish the flow to the left leg (Figure 2). An aorto-uni-iliac stent graft was chosen instead of a standard bifurcated endograft because the infrarenal pseudoaneurysm had compressed the diameter of the aorta to a mere 8mm, which would not allow the two iliac legs of the bifurcated device to fully deploy above the aortic bifurcation.
After endovascular repair, the patient was followed up with daily echocardiography for the right atrial mass and was placed under treatment with heparin and high-dose steroids (60 mg of oral prednisolone daily). Due to the large size of the right atrial mass and its hypermobility, the risk of pulmonary emboli was very high. Additionally, there was no response to the anti-coagulant and immunosuppressive treatments and the severe stenosis of the left anterior descending, left circumflex, and posterior descending artery was seen on angiography. Therefore, ten days later, the surgical removal of the right atrial mass performed, and it was followed immediately by coronary artery bypass graft surgery (CABG) (Figure 3). The pathology report of the right atrial mass was a fibrinous clot (Figure 4).
"One week later, the patient was discharged from the hospital in good clinical condition. Since then, he has been under strict clinical care of rheumatologist. After 6 months, his general condition was good, new CT angiography showed no residual aneurysm, endoleak or any sign of migration or new aneurysm formation and there was no new mass in his cardiac chambers".