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BACKGROUND: Morphologically, the risk of aortic aneurysm rupture is mainly evaluated based on its type (e.g., fusiform or saccular) and diameter. Based on the finite element analysis, peak wall stress has been identified as a more sensitive and specific predictor of rupture in recent years. Moreover, in finite analysis, the neck of aneurysm is the highest peak wall stress and is associated with the rupture point.
METHODS: A saccular aortic aneurysm (84 mm) was incidentally detected during preoperative examination for chronic empyema in a 74-year-old male patient with a history of polycythemia. Aortic arch graft replacement using an open stent was performed.
CONCLUSIONS: Morphologically, this case was associated with a very high risk of rupture; nevertheless, it did not rupture. In this case, a mural thrombus (likely formed due to polycythemia) covered the neck of aneurysm that is experiencing the highest peak wall stress and is associated with the rupture point. The mural thrombus decreased peak wall stress and could reduce the risk of rupture even for huge saccular aneurysms. Furthermore, the mural thrombus was fully occupied in aneurysms, such as during coil embolization. Thus, polycythemia could decrease the risk of rupture of huge saccular aneurysms.

Myocardial infarction (MI) can lead to a wide spectrum of mechanical complications. Left ventricular pseudoaneurysm (LVP) is a rare but serious complication of MI.
UNASSIGNED: A 69-year-old woman with prior coronary artery bypass grafting and a remote history of inferolateral ST-elevation MI (STEMI) with failure to revascularize the left circumflex artery presented with gangrenous right toes that appeared 2 years after her STEMI. A computed tomography angiogram of the right lower extremity showed arterial occlusion and mild atherosclerotic disease. Echocardiography revealed a pseudoaneurysm with an adherent mural thrombus as the underlying cause of acute limb ischemia. The patient was started on heparin and cardiothoracic surgery was consulted but did not operate as the risk of surgery outweighed the benefit. On hospital day 3, the patient underwent amputation of her gangrenous toes as the tissue was nonviable. The patient remained stable during her hospital stay and was discharged on day 5 on long-term anticoagulation.
UNASSIGNED: LVPs have a wide spectrum of presentations, from asymptomatic or nonspecific symptoms to thromboembolism with end-organ damage, such as in our case. Therefore, early diagnosis and management are of paramount importance. Our patient\'s prior coronary artery bypass grafting most likely helped in forming a fibrous pericardium that sealed the pseudoaneurysm and prevented its rupture.
UNASSIGNED: STEMI requires close follow-up, especially in cases where revascularization is not achievable, as the risk of mechanical complications and mortality is high. Physicians should have a high suspicion for LVP in patients with prior MI, given its wide spectrum of presentations.

Aortic arch thrombus is a rare entity that can result in catastrophic sequelae. This is a case report of a 65-year-old female patient who presented with chest pain that started one day prior to arrival at the emergency department. Acute coronary syndrome (ACS) and pulmonary embolism (PE) were ruled out. A filling defect at the distal aortic arch evident on chest computed tomography angiography (CTA) was confirmed to be a floating distal aortic arch thrombus on transesophageal echocardiogram (TEE). There was no evidence of an underlying aneurysm, dissection, or significant atherosclerosis. The patient was considered to be at high risk for surgical intervention, hence, a decision was made to start the patient on chronic anticoagulation with direct oral anticoagulants (DOACs). A follow-up CTA three months later showed total resolution of the thrombus. The report highlights this treacherous pathology and provides an overview of the predisposing factors, radiologic findings, as well as management strategies for floating aortic arch thrombi.

Left ventricular mural thrombus (LVMT) is a life-threatening complication in patients with left ventricular dysfunction.
A 67-year-old man had a history of penetrating myocardial infarction and left ventricular aneurysm (LVA). The patient was scheduled for a non-cardiac surgery and stopped aspirin for 10 days to reduce the risk of bleeding. Fresh LVMT was revealed via the transesophageal echocardiography (TEE) after the preoperative discontinuation of aspirin.
Perioperative repeated evaluation for the thrombosis by echocardiography is essential in cases of patients with cardiovascular disease undergoing non-cardiac surgery. In high risk patient, during temporary interruption of antiplatelets, bridging with perioperative low-molecular-weight heparin is advisable.

Abdominal aortic aneurysm (AAA) may present with subtle clinical findings. Recognition of the imaging features of an impending rupture is key for timely diagnosis. This report reviews the classic computed tomography findings of impending AAA rupture and presents a recent case which illustrates the key features.