The diagnosis of delayed expanding traumatic pseudoaneurysm of thoracic aorta caused by self-inflicted penetrating injury with crossbow bolt: A case report

Introduction and importance: Penetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up. Case presentation: A 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day. Clinical discussion: Emergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury. Conclusion: This case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection

Mirizzi Syndrome with a Biliobiliary Fistula : a case report

Mirizzi syndrome is a rare complication of cholelithiasis, which is defined as a common bile duct obstruction due to stones impacted in Hartman’s pouch or the cystic duct of the gallbladder. The impacted stones and surrounding inflammation can lead to a biliobiliary fistula. We herein present the case of a 73-year-old Japanese man with a biliobiliary fistula that was diagnosed peroral cholangiography (POCS). We performed partial cholecystectomy and choledochoplasty as the stone had eroded almost the entire circumference of the bile duct. Postoperative complications included a minor bile leak from the repaired common bile duct apparent on postoperative day 1, which was managed conservatively. The patient was discharged on postoperative day 9. Based on this experience, POCS is useful for detecting the existence of a biliobiliary fistula in cases of Mirizzi syndrome. Once a biliobiliary fistula is confirmed, it is important to select an appropriate surgical procedure based on the extent of common bile duct involvement in the inflammatory process