Rupture of an Aneurysmal Aortic Diverticulum Associated With Coarctation and Bicuspid Aortic Valve

A28-year-old soccer player presented with collapse and left-sided chest pain during a prematch warm-up. Pain was also present in the left side of the neck. He had not suffered from chest pain before. A cardiac murmur had been described in childhood and attributed to pulmonary stenosis but never followed up. On initial examination, he was hypotensive, with a systolic murmur in the aortic area and a pulsatile mass in the left supraclavicular fossa (Figure 1A). There was no blood pressure differential between arms, but the femoral pulses could not be felt. A chest radiograph (the first the patient had ever received) revealed widening of the left upper mediastinum (Figure 1B). Contrast-enhanced computed tomography showed an aneurysmal diverticulum of the aorta that extended into the neck and gave rise to a normal-sized left subclavian artery (Figure 1C). The wall was markedly thickened, with high attenuation before contrast, in keeping with an intramural hematoma. Coarctation of the aorta was identified distal to the aneurysm (Figure 1C). There was no rib notching.