Tortuous Descending Thoracic Aorta in a Patient with a History of Ascending Aorta Replacement as a Confounder in Transesophageal Echocardiographic Evaluation of the Left Atrium: A Procedural Challenge
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Abstract
Descending thoracic aorta tortuosity results from elongation of the descending aorta and is associated with aging. It acts as a risk factor for challenging endovascular procedures and has prognostic significance. It may, however, sometimes present as a vascular mass in the mediastinum, distorting nearby cardiac chambers, which may confuse physicians during transesophageal echocardiography.
We describe an elderly woman with severe descending thoracic aorta tortuosity presenting with a tubular vascular mass located behind the left atrium, exerting compression on it. Recognizing the potential echocardiographic presentation of aortic tortuosity can aid in the timely identification of this condition during transesophageal echocardiography.
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8. Meng Z, Cheng L, Liu W, Yu Y, Liu H, Yao G, et al. The sex-specific difference in age-related aortic regional morphological changes. Aging Clin Exp Res. 2025 Mar 11;37(1):76.
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11. Yip MF, Walsh BM. Hemorrhagic pericardial cyst diagnosis accelerated by emergency physician echocardiography: a case report. J Emerg Med. 2017 Apr;52(4):e105-e109.
12. Gadre A, Singhal M, Rohit M, Singh H, Mitra S, Sharma A, et al. Posterior mediastinal mass with intracardiac protrusion: a diagnostic conundrum resolved with multimodality imaging. JACC Case Rep. 2025 Jun 25;30(16):103902.
13. Deaño RC, Shah AM, Khan ZS, Bergman G, Roman MJ, Swaminathan RV, et al. Giant coronary aneurysm diagnosed as incidental mediastinal mass. JACC Cardiovasc Interv. 2015 Jan;8(1 Pt A):114-5.
14. Muhammad R, Lefi A, Ghassani DN, Mulia EPB. An atypical presentation of aortic dissection: echocardiography for accurate detection. J Ultrasound. 2022 Sep;25(3):737-43.
15. Qadri YJ, Kumar PA, Lateef B, Arora H. An unusual presentation of a mediastinal mass. J Cardiothorac Vasc Anesth. 2016 Jan;30(1):269-72.
16. Zhang Z, Zhang L, Xie F, Wang B, Sun Z, Kong S, et al. Echocardiographic diagnosis of anomalous pulmonary venous connections: Experience of 84 cases from 1 medical center. Medicine (Baltimore). 2016 Nov;95(44):e5389.
17. Nonaka T, Kato K, Sato K, Osawa T, Okawa H, Sakurai H. An adult case of giant congenital left atrial wall aneurysm. J Cardiol Cases. 2023 Jul 12;28(5):181-4.
18. Lin J, Maisano F, De Bonis M. Giant left atrial appendage aneurysm: a source of multiple thrombotic events despite medical therapy. Eur Heart J. 2025 Apr 1;46(13):1272.
19. Bidmead D, Madrazo JA, Mathews L, Hailu T, Barth AS, Shapiro EP, et al. Conservative management of left atrial dissection and associated complete heart block following cardiac surgery. JACC Case Rep. 2025 Jun 4;30(13):103557.
20. Belvroy VM, Romarowski RM, van Bakel TMJ, van Herwaarden JA, Bismuth J, Auricchio F, et al. Impact of aortic tortuosity on displacement forces in descending thoracic aortic aneurysms. Eur J Vasc Endovasc Surg. 2020 Apr;59(4):557-64.
21. Franken R, El Morabit A, de Waard V, Timmermans J, Scholte AJ, van den Berg MP, et al. Increased aortic tortuosity indicates a more severe aortic phenotype in adults with Marfan syndrome. Int J Cardiol. 2015 Sep 1;194:7-12.
22. Gross BD, Cho LD, Taubenfeld E, Tadros RO, Faries PL, Marin ML, et al. High thoracic tortuosity is associated with CT-markers of degeneration of the descending thoracic aortic wall. Vasc Endovascular Surg. 2023 Jul;57(5):425-32.
23. Hejazi M, Choi SH, Phani AS, Hsiang YN. Evaluation of aortic tortuosity as a negative predictor of abdominal aortic aneurysm rupture. J Vasc Surg. 2022 Nov;76(5):1238-1243.e1.
24. Chen CK, Liang IP, Chang HT, Chen WY, Chen IM, Wu MH, et al. Impact on outcomes by measuring tortuosity with reporting standards for thoracic endovascular aortic repair. J Vasc Surg. 2014 Oct;60(4):937-44.
25. Palumbo MC, Redaelli A, Wingo M, Tak KA, Leonard JR, Kim J, et al. Impact of ascending aortic prosthetic grafts on early postoperative descending aortic biomechanics on cardiac magnetic resonance imaging. Eur J Cardiothorac Surg. 2022 Mar 24;61(4):860-8.
26. Palumbo MC, Rong LQ, Kim J, Navid P, Sultana R, Butcher J, et al. Prosthetic aortic graft replacement of the ascending thoracic aorta alters biomechanics of the native descending aorta as assessed by transthoracic echocardiography. PLoS One. 2020 Mar 12;15(3):e0230208.
27. Morgant MC, Miteran J, Lin S, Laubriet A, Cochet A, Lalande A, et al. Impact of ascending aorta replacement by graft on elastic properties of descending thoracic aorta evaluated by cardiac magnetic resonance imaging. MAGMA. 2020 Oct;33(5):641-7.
2. Luta X, Zanchi F, Fresa M, Porceddu E, Keller S, Bouchardy J, et al. Tortuosity in non-atherosclerotic vascular diseases is associated with age, arterial aneurysms, and hypertension. Orphanet J Rare Dis. 2024 Jun 7;19(1):227.
3. Bonnet M, Maxo L, Mangin L, Courand PY, Ricard C, Bouali A, et al. Comprehensive assessment and periprocedural prognostic significance of aortic tortuosity in transfemoral transcatheter aortic valve implantation. Circ Cardiovasc Imaging. 2024 Jul;17(7):e016814.
4. Yang Y, Yang H, Pan J, Zhang G. Strategies to address extreme aortic tortuosity during transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2022 Apr 11;15(7):791-2.
5. Saremi F, Hassani C, Lin LM, Lee C, Wilcox AG, Fleischman F, et al. Image predictors of treatment outcome after thoracic aortic dissection repair. Radiographics. 2018 Nov-Dec;38(7):1949-72.
6. Kurisu S, Nitta K, Sumimoto Y, Ikenaga H, Ishibashi K, Fukuda Y, et al. Effects of aortic tortuosity on left ventricular diastolic parameters derived from gated myocardial perfusion single photon emission computed tomography in patients with normal myocardial perfusion. Heart Vessels. 2018 Jun;33(6):651-6.
7. Belvroy VM, de Beaufort HWL, van Herwaarden JA, Bismuth J, Moll FL, Trimarchi S. Tortuosity of the descending thoracic aorta: Normal values by age. PLoS One 2019 Apr 23;14(4):e0215549.
8. Meng Z, Cheng L, Liu W, Yu Y, Liu H, Yao G, et al. The sex-specific difference in age-related aortic regional morphological changes. Aging Clin Exp Res. 2025 Mar 11;37(1):76.
9. Nekkanti R, Nanda NC, Ahmed S, Sanders C. Normal lymph nodes mimicking a mediastinal mass during transesophageal echocardiography. Echocardiography. 2003 Jul;20(5):443-7.
10. de Oliveira KF, Rodrigues MM, Lopes GP, de Almeida RS, Lusvarghi JL, Dos Santos JP. Massive thymoma of the mid-posterior mediastinum: an unprecedented case in a young adult. Radiol Bras. 2016 Nov-Dec;49(6):403-5.
11. Yip MF, Walsh BM. Hemorrhagic pericardial cyst diagnosis accelerated by emergency physician echocardiography: a case report. J Emerg Med. 2017 Apr;52(4):e105-e109.
12. Gadre A, Singhal M, Rohit M, Singh H, Mitra S, Sharma A, et al. Posterior mediastinal mass with intracardiac protrusion: a diagnostic conundrum resolved with multimodality imaging. JACC Case Rep. 2025 Jun 25;30(16):103902.
13. Deaño RC, Shah AM, Khan ZS, Bergman G, Roman MJ, Swaminathan RV, et al. Giant coronary aneurysm diagnosed as incidental mediastinal mass. JACC Cardiovasc Interv. 2015 Jan;8(1 Pt A):114-5.
14. Muhammad R, Lefi A, Ghassani DN, Mulia EPB. An atypical presentation of aortic dissection: echocardiography for accurate detection. J Ultrasound. 2022 Sep;25(3):737-43.
15. Qadri YJ, Kumar PA, Lateef B, Arora H. An unusual presentation of a mediastinal mass. J Cardiothorac Vasc Anesth. 2016 Jan;30(1):269-72.
16. Zhang Z, Zhang L, Xie F, Wang B, Sun Z, Kong S, et al. Echocardiographic diagnosis of anomalous pulmonary venous connections: Experience of 84 cases from 1 medical center. Medicine (Baltimore). 2016 Nov;95(44):e5389.
17. Nonaka T, Kato K, Sato K, Osawa T, Okawa H, Sakurai H. An adult case of giant congenital left atrial wall aneurysm. J Cardiol Cases. 2023 Jul 12;28(5):181-4.
18. Lin J, Maisano F, De Bonis M. Giant left atrial appendage aneurysm: a source of multiple thrombotic events despite medical therapy. Eur Heart J. 2025 Apr 1;46(13):1272.
19. Bidmead D, Madrazo JA, Mathews L, Hailu T, Barth AS, Shapiro EP, et al. Conservative management of left atrial dissection and associated complete heart block following cardiac surgery. JACC Case Rep. 2025 Jun 4;30(13):103557.
20. Belvroy VM, Romarowski RM, van Bakel TMJ, van Herwaarden JA, Bismuth J, Auricchio F, et al. Impact of aortic tortuosity on displacement forces in descending thoracic aortic aneurysms. Eur J Vasc Endovasc Surg. 2020 Apr;59(4):557-64.
21. Franken R, El Morabit A, de Waard V, Timmermans J, Scholte AJ, van den Berg MP, et al. Increased aortic tortuosity indicates a more severe aortic phenotype in adults with Marfan syndrome. Int J Cardiol. 2015 Sep 1;194:7-12.
22. Gross BD, Cho LD, Taubenfeld E, Tadros RO, Faries PL, Marin ML, et al. High thoracic tortuosity is associated with CT-markers of degeneration of the descending thoracic aortic wall. Vasc Endovascular Surg. 2023 Jul;57(5):425-32.
23. Hejazi M, Choi SH, Phani AS, Hsiang YN. Evaluation of aortic tortuosity as a negative predictor of abdominal aortic aneurysm rupture. J Vasc Surg. 2022 Nov;76(5):1238-1243.e1.
24. Chen CK, Liang IP, Chang HT, Chen WY, Chen IM, Wu MH, et al. Impact on outcomes by measuring tortuosity with reporting standards for thoracic endovascular aortic repair. J Vasc Surg. 2014 Oct;60(4):937-44.
25. Palumbo MC, Redaelli A, Wingo M, Tak KA, Leonard JR, Kim J, et al. Impact of ascending aortic prosthetic grafts on early postoperative descending aortic biomechanics on cardiac magnetic resonance imaging. Eur J Cardiothorac Surg. 2022 Mar 24;61(4):860-8.
26. Palumbo MC, Rong LQ, Kim J, Navid P, Sultana R, Butcher J, et al. Prosthetic aortic graft replacement of the ascending thoracic aorta alters biomechanics of the native descending aorta as assessed by transthoracic echocardiography. PLoS One. 2020 Mar 12;15(3):e0230208.
27. Morgant MC, Miteran J, Lin S, Laubriet A, Cochet A, Lalande A, et al. Impact of ascending aorta replacement by graft on elastic properties of descending thoracic aorta evaluated by cardiac magnetic resonance imaging. MAGMA. 2020 Oct;33(5):641-7.
| Files | ||
| Issue | Vol 21 No 2 (2026) | |
| Section | Case Report(s) | |
| Keywords | ||
| Echocardiography Mediastinal Mass Descending Aorta Aortic Tortuosity | ||
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How to Cite
1.
Asl-fallah S, Hosseinsabet A, Shirani S, Hajizeinali A. Tortuous Descending Thoracic Aorta in a Patient with a History of Ascending Aorta Replacement as a Confounder in Transesophageal Echocardiographic Evaluation of the Left Atrium: A Procedural Challenge. Res Heart Yield Transl Med. 2026;21(2):169-173.
