Ruptured Aortic Arch Aneurysm Without Surgical Intervention Resulting in 11-Day Survival in a Woman: An Autopsy-Proven Aortoesophageal Fistula

In general, rupture of an aortic aneurysm causes immediate death and seldom sustains the patient's life without surgical intervention. Here, we report a rare case of a 79-year-old woman on maintenance hemodialysis with a ruptured aortic arch aneurysm who survived more than one week without persistent shock status and surgical intervention. She was transferred to our hospital with her complaints of fever, dyspnea, and chest oppression. Laboratory data showed elevated inflammatory reaction and increased fibrinolysis. On her examination, plain computed tomography (CT) showed thickening of the esophageal wall and mediastinal mass shadow, implying esophageal cancer with its tracheal invasion and its lymph node metastasis in addition to pneumonia. Gastrointestinal fiberscope (GIF) on the fourth day showed extrinsic compression of the esophagus, and the patient complained of augmented chest pain immediately after starting hemodialysis. The repeated plain CT showed an enlarged mediastinal mass, and contrast-enhanced CT showed findings of a ruptured aortic arch aneurysm. She and her family did not want to undergo a surgical operation due to the high risk of intraoperative death, and the maintenance hemodialysis was discontinued for fear of relapse or rupture. Melena was observed from the 10th day, and she finally died on the 11th day. The autopsy revealed marked atherosclerosis of the aorta, a 35 mm diameter aortic aneurysm in the aortic arch, and aortoesophageal fistula. Even in cases of chest pain without immediate death or sustained shock status, a rupture of an aortic aneurysm should be considered for the differential diagnosis.