Aortic blisters: diagnosis and evolution

In order to evaluate the incidence, the diagnostic modalities and significance of blisters of the abdominal aortic aneurysm wall, in a retrospective review, 14 patients (2.6%) having these lesions were identified between 1983 and 1995. At preoperative examination, aortography had less accuracy (1 case = 20%) than CT scan (3 cases = 27.2%) or MRI angiography (6 cases = 85.7%) to detect blisters; others were discovered intraoperatively in the remaining four patients. Most blisters were located on the anterior or antero-lateral wall of aneurysms; its area ranged from 0.8 to 2.6 cm2. One patient with a suspected blister diagnosed at aortography, during chest physiotherapy for his COPD, presented sudden abdominal pain: at urgent laparotomy, an acute contained rupture of a large blister, without extraluminal blood loss, was found. All patients underwent aneurysm repair, with no postoperative deaths. Occurrence of rupture in one patient clearly indicates the natural course of aortic blisters. MRI angiography may accurately detect these lesions; surgical treatment is necessary for preventing imminent rupture.

What is the appropriate size criterion for resection of thoracic aortic aneurysms?

Although many articles have described techniques for resection of thoracic aortic aneurysms, limited information on the natural history of this disorder is available to aid in defining criteria for surgical intervention. Data on 230 patients with thoracic aortic aneurysms treated at Yale University School of Medicine from 1985 to 1996 were analyzed. This computerized database included 714 imaging studies (magnetic resonance imaging, computed tomography, echocardiography). Mean size of the thoracic aorta in these patients at initial presentation was 5.2 cm (range 3.5 to 10 cm). The mean growth rate was 0.12 cm/yr. Overall survivals at 1 and 5 years were 85% and 64%, respectively. Patients having aortic dissection had lower survival (83% 1 year; 46% 5 year) than the cohort without dissection (89% 1 year; 71% 5 year). One hundred thirty-six patients underwent surgery for their thoracic aortic aneurysms. For elective operations, the mortality was 9.0%; for emergency operations, 21.7%. Median size at time of rupture or dissection was 6.0 cm for ascending aneurysms and 7.2 cm for descending aneurysms. The incidence of dissection or rupture increased with aneurysm size. Multivariable regression analysis to isolate risk factors for acute dissection or rupture revealed that size larger than 6.0 cm increased the probability by 32.1 percentage points for ascending aneurysms (p = 0.005). For descending aneurysms, this probability increased by 43.0 percentage points at a size greater than 7.0 cm (p = 0.006). If the median size at the time of dissection or rupture were used as the intervention criterion, half of the patients would suffer a devastating complication before the operation. Accordingly, a criterion lower than the median is appropriate. We recommend 5.5 cm as an acceptable size for elective resection of ascending aortic aneurysms, because resection can be performed with relatively low mortality. For aneurysms of the descending aorta, in which perioperative complications are greater and the median size at the time of complications is larger, we recommend intervention at 6.5 cm.

[Spontaneous rupture of the ascending aorta disclosing inflammatory arteritis]

The authors report the case of a 74 year old man with no known medical history who died of spontaneous rupture of the thoracic aorta due to giant cell arteritis. The description of the macro and microscopic lesions confirmed the severity of the disease of the large arteries and explained the cause of death. The authors emphasize the clinical features of this case and discuss its place in the classification of aortitis. The type, incidence and severity of the aortic disease in inflammatory arteritis are also analysed. Spontaneous rupture of the aorta without dissection or aneurysm formation does not seem to have been previously reported and could be the mechanism of some cases of sudden death.

Spontaneous rupture of non-aneurysmal ascending aorta

Two autopsy cases with pericardial tamponade and spontaneous rupture of non-aneurysmal ascending aorta are described. In case 1, no apparent predisposing factor was clinically noticed in a 74 year old male patient, but postmortem examination revealed laceration of the ascending aorta associated with aortic valvular deformity and slight dilatation of the ascending aorta. In case 2, a 61 year old man, a mild to moderate grade of aortic regurgitation was noticed clinically 5 months before death. Postmortem examination revealed a slight dilatation of the aortic annulus and post-valvular portion of the ascending aorta. These two cases emphasize the clinical significance of aortic valvular disease with subsequent disordered blood flow, even when asymptomatic, as a potential causative factor for spontaneous rupture of the ascending aorta.

Incidence and histologic characteristics of blebs in patients with abdominal aortic aneurysms

PURPOSE

Aortic blebs-focal outpouchings within aortic aneurysms-may contribute to their eventual rupture. In this study we determine the incidence of aortic blebs and describe their microscopic features.

METHODS

Computed tomographic scans of the abdominal aorta were obtained in 188 patients with aortic diameters measuring > or = 3 cm and were independently evaluated by a radiologist. The number and location of blebs were recorded, and each was measured with calipers. Sixteen blebs, with an adjacent uninvolved aneurysmal segment of aorta, and tissue from two patients with ruptured aneurysms were examined by light microscopy and immunohistochemical analysis. Specimens from six blebs and five aneurysms were examined for alpha 1 (I) procollagen messenger RNA by in situ hybridization.

RESULTS

Twenty blebs, ranging in size from 5 to 30 mm (mean, 12 +/- 7 mm), were detected in 11% (20 of 188) of computed tomographic scans. Blebs were observed in 10% (11 of 111) of patients with aortic diameters between 3.0 and 4.9 cm, 10% (6 of 61) of patients with aneurysms between 5.0 and 6.9 cm, and 19% (3 of 16) of patients with aortic diameters > or = 7 cm. Histologically, the major difference between the aneurysmal aortic wall and blebs was found in the media. In aneurysmal aortas, the media consisted of multiple layers of fragmented elastic lamellae, whereas the number of elastic tissue elements along the circumference of the blebs progressively decreased; only a few isolated fragments of elastic tissue were present at the apices. Histologic evidence of rupture was evident in two specimens. A chronic inflammatory cell infiltrate composed of T and B lymphocytes, plasma cells, and macrophages, common to both the aneurysmal and the blebs, was most prominent in the adventitia of aneurysmal tissue, but involved both the media and adventitia of the blebs. In situ hybridization demonstrated the presence of alpha 1 (I) procollagen messenger RNA in four of the five aneurysm segments that were evaluated, compared with only one of six blebs.

CONCLUSIONS

Blebs were discovered in aneurysms of all sizes; their frequency appeared to be unrelated to aneurysm size. The presence of inflammatory cell infiltrates and absence of alpha 1 (I) procollagen messenger RNA in five of six blebs suggest that a local imbalance of matrix degradation and repair plays a role in the cause of these lesions. Attenuation of the aortic wall accompanying the formation of blebs may predispose these sites to rupture.

Spontaneous perforation of a non-aneurysmal atherosclerotic abdominal aorta or femoral artery

The spontaneous perforation of a non-aneurysmal atherosclerotic abdominal aorta or femoral artery is reported. Over the past 14 years, four perforations have been found in the abdominal aorta and one in the femoral artery; the incidence of each was 1.1% and 5.9%, respectively. Computed tomography scanning was useful for diagnosing pseudoaneurysms in all cases, since it revealed haematoma outside the arterial wall. One of these cases presented with an aortoduodenal fistula. The arteries were severely atherosclerotic with calcification. All of the patients underwent a graft replacement. Operative findings confirmed pseudoaneurysm. One patient died from pneumonia 4 months after the operation, and the other four have remained well during the follow-up period ranging from 2-9 years.

[A rare cause of recurrent upper gastrointestinal hemorrhage: aortoesophageal fistula in aneurysma spurium of the descending aorta]

An aneurysma of the distal thoracic aorta developed in an 65 year old man. Several weeks later, the man was admitted to hospital because of upper gastrointestinal bleeding. The diagnosis of an aortoesophageal fistula was made not until several endoscopic investigations. The patient died from a major bleeding soon after. The aneurysm proved to be an aneurysma spurium.

Spontaneous rupture of thoracic aorta through an atheromatous plaque: case report and literature review

Spontaneous rupture of thoracic aorta without aneurysm formation is extremely rare. A case of spontaneous rupture through an atheromatous plaque in an 82-year-old woman is reported. She presented with atypical chest pain, and chest radiography revealed no evidence of aneurysm. She died suddenly in the hospital within 24 h after admission. At autopsy, there was an intimal tear and rupture of the descending aorta through an atheromatous plaque, resulting in massive hemothorax. The previous reported cases of spontaneous aortic rupture were reviewed. The pathology of spontaneous aortic rupture are discussed with emphasis on the dating of the rupture, which may have significant medicolegal importance.

[Aortic aneurysms in Ullrich-Turner syndrome]

BACKGROUND

Adolescents and young adults with Marfan-syndrome, Ehlers-Danlos-syndrome and with coarctation of the aorta are at risk of developing dissecting aortic aneurysms. The rupture of an aortic aneurysm has a poor prognosis.

PATIENTS

We report on two adolescents with Ullrich-Turner-syndrome (UTS) who died from dissection of an aneurysm of the aorta.

RESULTS

Including these two case reports we reviewed the literature concerning congenital heart disease and development of aortic aneurysms in UTS. Patients with UTS are at increased risk to develop an aortic aneurysm. Beside the basic chromosomal anomaly additional risk factors like coarctation of the aorta, aortic valve defects or arterial hypertension are frequently present in the affected girls. The rupture of dissecting aortic aneurysms is one major reason for the shorter life expectancy of patients with UTS compared to the normal population.

CONCLUSION

Annual echocardiographic surveillance of the diameter of the ascending aorta is necessary in all patients with UTS. A sudden increase of the diameter or a diameter of 5-6 cm are criteria for the elective surgical replacement of the aortic root. Vigorous treatment of arterial hypertension is mandatory. Patients with dilated ascending aorta or coarctation of the aorta should avoid competitive sports and all sports associated with the risk of trauma to the thorax, i.e. boxing or jumping from diving platforms.

[Delayed surgical therapy of acute aortic rupture]

Immediate surgical treatment of traumatic aneurysms of the aorta is in our point of view in most cases problematic, also because of the combination with life threatening injuries of other organ systems. In our own patient-collection seven patients out of 44 with traumatic transsection were immediately operated. Six patients died in tabula, three of them due to uncontrollable hemorrhage. An analysis of over 5,000 post mortem findings from the department of forensic medicine in Hamburg revealed that injuries of the aorta lead in 98.3% to death in the first two hours after the accident. This shows that only a small number of injured victims survive. The danger of a two stage rupture is judged differently. We did not observe this problem in the patients with aortic lesion following blunt chest trauma and stable conditions who had first undergone treatment for other injuries and therefore operated in the interval period after two to ten weeks. With this strategy the lethality involving surgical management of aortic injuries in our unit decreased to 13%.

Morphometric features of ruptured congenital sinus of Valsalva aneurysm: implication for surgical treatment

Five hearts with ruptured congenital sinus of Valsalva aneurysm were studied. In 3 hearts of Caucasian patients, the sinus of Valsalva aneurysms were located in the immediate vicinity of the commissure between the noncoronary and right aortic cusps with rupture from the noncoronary sinus to the right atrium (n = 2) and from the right sinus to the right ventricle (n = 1). In 2 hearts of indigenous North Americans, the defects were sited in the immediate vicinity of the commissure between right and left aortic cusps with rupture into the right ventricle; both patients had an associated conal septal hypoplasia ventricular septal defect and aortic insufficiency. The diameters of the rupture holes at the base of the sinus of Valsalva aneurysms in the five hearts ranged from 0.4 to 1.1 cm (mean 0.7 cm). Histologic examination of longitudinal sections through the ruptured sinus of Valsalva showed 0.8 to 1.7 cm (mean 1.1 cm) wide areas in which there was lack of continuity between the aortic media and the aortic annulus. Conclusions. This study shows that the site of congenital weakness in sinus of Valsalva aneurysm in indigenous North American patients may be similar to that in Oriental patients, whereas the site tends to be different in Occidental patients. It also emphasizes the importance of patch closure rather than suture closure of ruptured sinus of Valsalva aneurysms.

[A surgical treatment of ruptured aortic dissection with non-opacified false lumen]

A 63-year-old woman was admitted to our intensive care unit suffering from severe chest pain and shock. Emergency CT scan demonstrated an acute type A aortic dissection with non-opacified false lumen and cardiac tamponade. The aortography showed ulcer like projection at the ascending aorta. An emergency operation was performed to replace the ascending aorta with a woven double-velour Dacron graft of 30 mm in diameter. It seems that an acute type A aortic dissection with non-opacified false lumen has good prognosis. The presence of other complications, however, suggests that surgical treatment should be decided upon at an early stage.

[A clinicopathological study of ruptured infectious aneurysms]

We investigated 952 consecutive autopsy cases between January 1990 and May 1994 to identify ruptured infectious aneurysms (IAs) of the aorta or iliac artery. Twenty patients (2.1%) died of artrial rupture, including 9 men and 11 women. The cause of rupture was IA in four cases (0.42%), atherosclerotic aneurysm (AA) in nine (0.95%), dissection (D) in six (0.63%), and aortoenteric fistula due to irradiation in one (0.11%). Infection of pre-existing aneurysms was considered to be AA rather than IA and the patient with aorto-enteric fistula was excluded from the study. Patients with IA were significantly older than other patients (IA: 85.8 +/- 4.3, AA: 80.2 +/- 4.1, and D: 77.7 +/- 5.0 years old), and were less frequently accompanied by leukocytosis than patients with AA, although this difference was not significant (11,100 vs 13,000). The four patients with IA consisted of one man and three women, all of whom died suddenly. Two patients had perforation in the atherosclerotic descending aorta and the other two had perforation in the atherosclerotic common iliac artery. Histological examinations revealed marked neutrophilic infiltration in all four cases, and bacterial colonies in three cases. In conclusion, IAs were not rare. Since they often cause sudden death, special attention should be given to elderly patients who develop infection.

Geographical variations in the presentation of ruptured aneurysms of sinuses of valsalva: evaluation of surgical repair

From 1981 to 1992, 13 male and 7 female patients underwent surgical correction for ruptured aneurysms of sinus of valsalva. A total surgical experience of 22 procedures including 2 reoperations is presented, accounting for 1.37% of open heart surgery for congenital heart disease at PGIMER Chandigarh. Ninety percent were in the 20- to 40-year age group. Forty-five percent of patients had symptoms of > 1-year duration (range 2 months to 20 years) and catastrophic onset of symptoms was noted in four (18%). All patients had localized aneurysms originating either in right coronary sinus (14 pts) or noncoronary sinus (8 pts). Sites of origin and rupture are detailed. Associated congenital abnormalities such as ventricular septal defect (VSD) (13 pts), aortic regurgitation (3 pts), and left superior vena cava and atrial septal defect (ASD) (1 pt each) were noted. The data pertaining to Oriental and Western groups of patients were analyzed, and the differences in age, mode of presentation, site of origin, rupture, and the spectrum of associated abnormalities were elucidated. The majority of the patients (86.4%) were operated by the Bicameral approach. Repair was tailored according to the extent and severity of the defect in the sinus of Valsalva and aortic valve annulus and also the presence and site of VSD.

Aortitis with dissection complicating systemic lupus erythematosus

A 31 yr old female under treatment for systemic lupus erythematosus complained of episodes of atypical chest pain radiating to the back. Subsequently she suddenly collapsed and died. Post mortem revealed a well-defined, localized area of non-giant cell aortitis extending from the supra-aortic ridge of the aortic valve to the ligamentum arteriosum. Active arteritis with fibrinoid necrosis and obliterative endarteritis of vasa vasorum had resulted in multiple infarcts of differing ages with associated inflammation and disruption of the aortic wall, culminating in aortic dissection and cardiac tamponade.

[Fatal outcome of a congenital aneurysm of the right sinus valsalvae ruptured into the right atrium]

In a 24-year-old female patient with sudden collapse an acute tricuspid insufficiency was presumed by echocardiography after the exclusion of pulmonary embolism. Aortography, however, revealed an aneurysm of the right sinus of Valsalva which had ruptured into the right atrium. Despite emergency surgery the patient died in protracted cardiac shock. Biopsy and autopsy showed pathognomonic findings of a congenital aneurysm (medial degeneration, reduction of elastic lamellae). Aneurysms of the sinuses of Valsalva are mainly caused by a rare connatal defect of the aortic wall; the right aortic sinus is involved most frequently, the sudden rupture uncovers the lesion. The characteristics of the reported case are compared with the literature under special consideration of etiology and pathologic anatomy of this unusual entity.

[Unusual posture-dependent backache as leading symptom of a thoracic aortic aneurysm]

The clinical investigation of a 71 year old male patient, suffering from chronic recurrent back pain, shows an unusual, position-dependent symptomatology of the pain. A penetrating, inoperable aneurysm of the thoracic aorta can be proved to be responsible for the patients complaints and causing his death in the course. Regarding the findings of the clinical investigation and the computed tomography as well as the postmortal findings, the pain-causing mechanisms are discussed.