Hoarseness and vocal cord paralysis is an unusual manifestation of thoracic arch aneurysms due to recurrent laryngeal nerve injury. Co-morbid coronary artery disease and arch aneurysms represent significant diagnostic and treatment dilemmas among these patients. Hybrid thoracic endovascular aortic repair (TEVAR) for high-risk patients represents viable, effective, novel and less invasive options for care.
A 65-year old male, with known history of hypertension, diabetes mellitus II, 40-pack year smoker, chronic obstructive pulmonary disease, dyslipidemia as well as prior resection of urothelial cancer presented with a 3-month history of hoarseness and laryngoscopic findings of left vocal cord paralysis. Computed tomography demonstrated a large saccular, arch aneurysm measuring 4.4 x 5.1 x 3.4 cm with a 2 cm neck, mural thrombus, minimal wall calcifications and no evidence of dissection or rupture. Coronary angiography demonstrated severe atherosclerotic disease involving the left anterior descending and left circumflex arteries.
Following HEART team assessment, he was deemed at high risk for combined coronary artery bypass plus total arch repair. He underwent successful Hybrid repair with Type 1 supra-aortic debranching plus 2-vessel off-pump coronary artery bypass graft and staged TEVAR repair with Valiant (Medtronic) thoracic graft implantation at the mid-ascending aorta (Zone 0) proximally extending to the proximal descending aorta (Zone 3) distally. He also underwent injection laryngoplasty. After 2 months there is partial improvement in hoarseness of voice. He remains asymptomatic and in functional class I.
Vocal cord paralysis and hoarseness is a rare manifestation of an expanding, potentially life-threatening aneurysm of the thoracic aorta. Its work-up should include assessment for underlying aortic pathology. Hybrid repair of the aortic arch is a feasible, challenging, less invasive and promising treatment option among high-risk patients. Successful outcomes require skilled operators, multispecialty management and experienced centers of care.
