[Non-specific aortic arteritis with abdominal aortic coarctation]

The paper reports a lethal case of rupture of the 1st and 2nd lumbar arteries with formation of abdominal wall hematoma. Besides this, the unusual suprarenal site of the aorta coarctation was found.

Endothelial cell ultrastructure after aortic aneurysm rupture: an electron microscopy study

Endothelial cell activation as an early response to hypovolaemic shock may be important in the pathogenesis of coagulopathy and multiple organ failure after aortic aneurysm rupture. The aim of this study was to determine whether any evidence could be found of changes in endothelial cell ultrastructure in patients undergoing operation for ruptured aneurysm and to establish a model for future studies of endothelial cells in these patients. At the start of operation, fat samples from the anterior abdominal wall were taken from five patients with ruptured abdominal aortic aneurysms and in an identical fashion from five control patients undergoing elective surgery. Endothelial cells lining capillaries were examined by transmission electron microscopy. Photomicrographs were taken of all capillaries present and these were assessed blindly by three independent observers. When compared with controls it was found that the luminal surface of the endothelial cells in patients with aneurysm rupture was more convoluted, with more frequent processes projecting into the lumen of the capillary. Budding of the luminal surface of the endothelial cell was seen in 11 of 45 capillaries in the rupture group and in none of 44 capillaries in the control group (P < 0.005). Budding was seen in at least one capillary of all five patients presenting with rupture but in none of the control group (P < 0.05). In conclusion, at the ultrastructural level there are changes within endothelial cells in capillaries at an early stage after ruptured abdominal aortic aneurysm.

[Erdheim's disease as a cause of sudden death]

Morphologic findings in three cases are presented. Death was caused by Erdheim's disease which was complicated by rupture of a false aneurysm of the ascending part of the aorta. A typical dystrophic involvement of the aortic wall at late stages of the disease is shown to be associated with a manifest inflammatory process presenting as nonspecific aortoarteritis. To verify the diagnosis, histologic examination of the aortic wall at some distance from the site of rupture should be performed.

A leaking aortic aneurysm presenting as a recurrent neck swelling

We present a case of an 82-year-old lady with recurrent neck swelling and a history of intermittent stridor who subsequently developed a contusion over her lower neck and upper chest. The patient collapsed on her way to have a CT scan and died 24 hours later of a leaking aortic aneurysm. At initial presentation the complete resolution of poorly localizing symptoms and signs almost allowed her discharge from hospital.

Spontaneous non-traumatic rupture of the thoracic aorta

Spontaneous non-traumatic rupture of the aorta is a very rare condition that requires immediate surgery. However, correct preoperative diagnosis is difficult or impossible to establish. We report a case of spontaneous aortic rupture which was successfully treated by emergency surgical exploration following a transesophageal echographic diagnosis of hemopericardium. This case, as well as other reports, suggests that hemopericardium along with symptoms which suggest aortic dissection or rupture (e.g., acute chest or back pain) should raise a strong suspicion of spontaneous aortic rupture even in the absence of intimal flap or aortic dilatation, and the emergency surgery may be life-saving.

[Type B aortic dissections: surgical technique and results]

Between 1978 and 1992, 70 patients were operated for type B aortic dissection (tear in the descending aorta without involvement of the ascending aorta). 15/70 (21%) patients had an acute dissection (onset of symptoms < 24 h), 19/70 (27%) a subacute dissection (onset of symptoms < 14 days), and 36/70 (51) a chronic dissection (onset of symptoms > 14 days). The indications for surgery in cases of acute dissection were: hematothorax, oliguria, leg ischemia and persistent pain. Persistent hypertension was an additional indication in cases of subacute dissection. In large majority (93%) of chronic dissections the indication for surgery was enlarged aortic diameter. In 86% (60/70) graft replacement of the aorta was performed, in 6% (4/70) extra-anatomic bypass, in 3% (2/70) fenestration, in 3% (2/70) thrombendarterectomy, in 3% (2/70). The overall mortality was 17% (12/70); 27% of acute dissection, 26% for subacute dissection, and 8% for chronic dissection. The morbidity for acute dissection was 73%, of subacute dissection 43%, and of chronic dissection 12%. The most frequent complications were: leg ischemia (8 patients), renal failure (4 patients), paraparesis (4 patients) and sepsis (2 patients). No paraparesis was encountered in surgery of the chronic dissection. Conservative treatment was tried in all acute B-dissections, with surgical therapy being reserved for complications of the dissection, such as rupture, such as rupture, risk of rupture (hematothorax, large aortic diameter resp. expansion, persistent hypertension, persistent pain) or ischemia of distal vascular beds. Long-term survival for chronic type B dissections is good. Strong control of risk factors (hypertension) is essential.

[A case report of ruptured dissecting aneurysm with thrombosed false lumen]

A successful surgical repair was experienced for a 75 year old female patient with ruptured dissecting aneurysm at the descending aorta. She presented with severe chest pain and advancing anemia. CT scan showed haemorrhage from the descending aorta into the pleural cavity. Diffused and circumferrential thickening of the descending aorta was shown but those area was not enhanced by dye injection. An "ulcer like formation" was shown at the descending aorta by aortogram done before surgery. Surgical repair was done subsequently by left thoracotomy with cardiopulmonary bypass. Only a small intimal wall leakage at the bottom of the crater with size of 20 mm and organized (old) thrombi were seen by intraoperative observation. Other part of intima was thickened but had no damage. Replacement was done for the descending aorta by 8 cm length with woven dacron graft successfully. Microscopic finding of resected aortic tissue showed severe atherosclerotic change. In this case, dissection was initiated from the part of crater which had most severe degeneration by atherosclerotic change and oozing started there, too. Atherosclerotic change, dissection, and oozing rupture were occurred at the same part in this patient, which is quite instructive.

Canine model of acute aortic rupture: treatment with percutaneous delivery of a covered Z stent--work in progress

PURPOSE

To develop a percutaneous treatment for aortic rupture with use of a covered intraluminal stent.

MATERIALS AND METHODS

A transmural tear was created percutaneously in the thoracic aorta in six dogs with use of a 4-mm angioplasty balloon. Gianturco Z stents were covered with polytetrafluoroethylene, loaded into a 14-F sheath, and advanced through the femoral artery to the site of injury. Within 2 minutes after initiation of the injury, the stent was deployed. Homologous canine blood was given during the procedure. Dogs that survived 24 hours were then killed.

RESULTS

The first stent did not expand completely, and the dog died in 1 hour. At necropsy, the first two dogs (1-hour and 8-hour survival) had a large left hemothorax and extensive periaortic hematoma, indicating intrathoracic exsanguination. The next four dogs were treated with a modified stent and survived 2 hours (n = 1), 8 hours (n = 1), and 24 hours (n = 2). At necropsy hemothorax did not exceed 15 mL, and periaortic hematomas were small. The cause of death in the two early casualties with the modified stent is uncertain. There were no signs of spinal cord injury despite occlusion of three pairs of intercostal arteries.

CONCLUSION

The covered Z stent (in its modified form) tamponaded the aortic tear, preventing exsanguination. Long-term studies of biocompatibility of this device appear justified.

Cardiovascular lesions in bovine Marfan syndrome

Bovine Marfan syndrome is a genetic disease with many of the clinical and pathologic manifestations of human Marfan syndrome. Major manifestations include ectopia lentis and aortic dilatation, aneurysm, and rupture. Affected cattle have a defect in fibrillin metabolism similar to that in human patients. Ten cattle were followed and their disease progression and lesions documented. Ages ranged from a term fetus (No. 9) to a 4-year-old cow (No. 4); three animals were male (Nos. 1-3) and seven were female (Nos. 4-10). Of eight animals (80%) that died or were euthanatized (Nos. 1-3, 5-9), six (75%) had severe cardiovascular lesions identified at necropsy. Gross cardiovascular lesions of bovine Marfan syndrome included cardiac tamponade secondary to aortic rupture (animal Nos. 3, 6, 8), dissecting aneurysms of the aorta and pulmonary artery (animal No. 5), and intrauterine cardiac tamponade secondary to rupture of the pulmonary artery (animal No. 9). Microscopically, Verhoeff Van Gieson-stained sections of aorta contained severe fragmentation of the elastic laminae in the aortic media, but the cystic medial necrosis seen in human Marfan aortae was not identified, even in the chronic aortic dissection. Ultrastructurally, affected aortic tissue was characterized by thin, dark elastic fibers with abundant, tangled microfibrils on the periphery. Swirls of collagen fibers and bundles of hypertrophic smooth muscle cells replaced damaged elastic laminae. Gross and microscopic cardiovascular lesions in bovine Marfan syndrome are similar to those in human Marfan syndrome. Bovine Marfan syndrome is a valuable model for investigation of molecular pathogenesis and treatment of human Marfan syndrome.

Penetrating atherosclerotic ulcers of the aorta

The term penetrating atherosclerotic aortic ulcer describes a condition in which an atherosclerotic plaque ulcerates and burrows through the internal elastic lamina into the media, leading to a variable amount of intramural hematoma formation. The typical patient is elderly with multiple cardiac risk factors and presents with acute chest or back pain. Diagnosis of penetrating aortic ulcer may be confirmed by computed tomography, magnetic resonance imaging or aortography. Penetrating aortic ulcers usually occur in the mid- and distal descending thoracic aorta and may be complicated by transmural aortic rupture, embolization, pseudoaneurysm formation, or progressive aneurysmal dilatation. The patient with a penetrating ulcer requires close follow-up to detect the development of complications, and may require surgical therapy.

Morphology of small aneurysms: definition and impact on risk of rupture

BACKGROUND

Parietal characteristics of small aortic aneurysms predictive of increased risk of rupture are unknown.

METHODS

Prospective morphologic evaluation was performed in 135 consecutive cases of small (< 5 cm) abdominal aortic aneurysm. Twelve cases (9%) were found to be ruptured and sent for emergency surgery. The remaining 123 patients were evaluated with ultrasonography, angiography, and intraoperatively during elective surgery. Ninety-six (78%) also underwent computerized tomography (CT) scanning. The evaluation assessed the thickness of the endoluminal thrombus and arterial wall as well as the presence of saccular outpouchings ("blisters"). Also noted were any areas of impending rupture, defined as discontinuity of the arterial wall with only a thrombus preventing rupture.

RESULTS

Blisters were discovered intraoperatively in 12 aneurysms. Digital subtraction angiography (DSA) revealed 3 (25%) of these preoperatively. Eleven of the patients with blisters were examined preoperatively with CT scanning, which detected 3 blisters (27%). Both endoluminal thrombus and wall thickness were measurable by CT scan but not ultrasonography. The incidence of impending rupture was significantly greater in patients with blisters than in those without (71% versus 29%, P = 0.0001). The incidence of impending rupture was similar whether the amount of endoluminal thrombus was more or less than 2 cm (57% versus 40%, P = 0.386). Rupture was no more frequent when aneurysmal walls were thicker or thinner than 0.3 cm (14% versus 20%, P = 0.719). In an analysis using logistic regression, the presence of a blister was the only independent morphologic predictor of impending rupture (P = 0.001, Wald = 15).

CONCLUSION

In patients with small aneurysms, increased attention should be directed to the preoperative detection of blisters.

[Recurrent aneurysmal disease of the native arteries in subjects operated on for abdominal aortic aneurysm]

Abdominal aortic aneurysm repairs are presently increasing in number all over the western countries; long life expectancy and high quality of life, warranted to patients surviving operation, stressed the possibility that aneurysmal disease affects other arteries as well as the para-anastomotic aorta itself. OBJECTIVE. The observation that, in the last four years, five patients were operated on for recurrent aneurysms of native arteries, gives the opportunity to discuss the matter and review the literature on this topic. MATERIAL AND METHODS. Five cases of recurrent aneurysms of native arteries in patients that had undergone abdominal aortic aneurysmectomy 4 to 11 (mean: 8) years before are discussed. A total of 16 new aneurysms were found. Although all these patients regularly attended their clinical follow-up program, these observations have to be considered retrospective and incidental, because B-mode echography was not yet routinely requested by the followup protocol. RESULTS. Neither hypertension nor type of graft implanted in the first operation were correlated to the development of new aneurysms in these five subjects. Rupture as causative of the original aneurysmectomy was recorded in two cases (40%), that developed 8 recurrent aneurysms (50%), one of which ruptured. CONCLUSIONS. Although recurrent aneurysms are occasionally reported in the literature, the lack of prospective follow-up series, based on non invasive serial imaging of the arterial system, prevents clarifying whether these observations are isolated or recurrence is likely to be a long-term outcome of aneurysmal disease.

Modes of presentation and management of inflammatory aneurysms of the abdominal aorta

The preoperative diagnosis of inflammatory aneurysms of the abdominal aorta (IAAA) is seldom made, yet knowledge of its presence would be an aid to the surgeon. A heightened awareness of the variety of clinical presentations of IAAA should prompt the clinician to consider this entity in the differential diagnosis of back pain, weight loss and obstructive uropathy. Hypovolemic shock, gastrointestinal bleeding and asymptomatic IAAA have also occurred, albeit much less frequently. Patients who are hemodynamically stable might benefit from a short period of diagnostic and therapeutic measures before operation. Patients undergoing aneurysm repair on an "urgent" rather than "emergent" basis have been shown to have lower mortality and morbidity rates with enhancement of their cardiopulmonary and renal status. Computed tomographic scanning preoperatively in stable patients using careful supervision can confirm the diagnosis and allow more time for patient and surgical team preparation. Knowledge and avoidance of technical pitfalls intraoperatively further lessens mortality and complications.

Dual exposure and repair technique for ruptured aneurysms of aortic sinus of Valsalva

Thirteen patients with ruptured sinus of Valsalva aneurysm have been operated over a 3-1/2 year period. Right coronary sinus was predominantly involved and right ventricle was the most common site of rupture. Early surgery was performed in all cases. Both aorta and chamber of entry were explored for effective repair. Main repair was always done in the chamber of rupture either with a patch or interrupted pledgeted sutures followed by assessment at either end. Subannular ventricular septal defects in three cases were closed with a common patch with additional fixation in the middle at the aortic annulus to prevent aortic leak into the left ventricle. Three patients needed aortic valve replacement for gross aortic incompetence. Postoperative echocardiographic study revealed uniformly excellent results with good aortic valve or prosthetic function. One patient developed fatal pulmonary embolism two weeks following surgery. All other surviving patients are doing well and are in NYHA class I. We recommend dual exposure and repair technique for the repair of ruptured sinus of Valsalva aneurysms for optimal results.

Modifications of the extracellular matrix of aneurysmal abdominal aortas as a function of their size

Collagen and elastin are the main extracellular matrix proteins providing the aortic wall with adequate mechanical properties and resistance for proper function. Our study aimed at investigating the relationship between the elastin concentration of the wall of normal and aneurysmal abdominal aortas (AAA), the collagen concentration, and its extractability, as a function of their size. Infrarenal aortas were collected from 30 patients undergoing operative repair of abdominal aortic aneurysm. Age-matched control samples were obtained from eight autopsies of individuals without vascular disease. Samples were divided into five groups according to the aortic diameter: control group (group N, n = 8); < 50 mm (group I, n = 6; between 50-75 mm (group II, n = 10); > 75 mm (group III, n = 7); and ruptured (group IV, n = 7). The collagen concentration in samples from group I was similar to the controls. An increased collagen concentration was observed in group II and remained at the same level in the largest and ruptured aneurysms. Extractability of collagen was found to be increased in group III and was even higher in group IV. A highly significant reduction in elastin concentration was observed in group I and there was progressive reduction with increasing diameter and rupture. A significant correlation could be established between aortic diameter, increased collagen extractability and decreased elastin content.

Rupture of the thoracic aorta by broadside impacts in road traffic and other collisions: further angiographic observations and preliminary autopsy findings

Violent lateral blunt impacts to the chest, such as inflicted in broadside automobile collisions, can cause traumatic rupture of the thoracic aorta. Unfortunately, because this injury is among the least common in blunt chest trauma, and given that it is not caused by the expected "classic" frontal collision, its diagnosis is often delayed or altogether missed. In most of these events, quite unlike the classic isthmus rupture of deceleration accidents, the injury appears to be partial shearing of the distal aortic arch, probably just above the isthmus. The aortic injury is often part of a wounding pattern typical of a lateral collision, in which critical intra-abdominal injuries are located on the side of the patient that was on the receiving end of the impact. Findings in 13 such patients are presented and discussed. The point is also made that because seatbelts and air bags do not protect car occupants against broadside impacts, their mandatory use will not lower the rate of occurrence of aortic shearing in lateral collisions, and as a result the numerical prominence of these injuries compared with that of aortic isthmus ruptures in the statistics of road traffic collisions may be expected to increase.

Aortic aneurysm rupture into a retroaortic left renal vein

We report the case of a patient who was transferred to our facility after a CT scan obtained at a local hospital revealed a leaking abdominal aortic aneurysm. Review of the scan showed an aorto-left renal vein fistula. Knowing this fistula was present made the operative repair of the aneurysm and control of the fistula much more straightforward than might otherwise have been the case. Although relatively rare, major anomalies of the renal veins and perirenal vena cava should be borne in mind when operating on the abdominal aorta. This case illustrates the merit of contrast-enhanced CT scanning prior to aortic surgery.

Operative treatment of abdominal aortic aneurysms in octogenarians. When is it too much too late?

OBJECTIVE

This study evaluated the value of operation for treatment of all octogenarians with ruptured abdominal aortic aneurysms (AAA).

SUMMARY BACKGROUND DATA

Elective AAA resection in octogenarians is safe, with published operative mortality rates of approximately 5%. Published operative mortality rates of ruptured AAA in this age group, however, vary from 27 to 92%.

METHODS

To evaluate this question, we extracted the clinical course of the 34 octogenarians submitted to AAA resection by the authors from our total experience of 548 resections performed during the past 7 1/2 years. In this subgroup of octogenarians, 18 underwent elective AAA replacement, 5 were submitted to urgent resection of active but intact AAAs, and 11 had operations for ruptured AAAs. There were 23 males and 11 females in the group. The ages ranged from 80 to 91 years.

RESULTS

Operative mortality in the patients managed electively was 5.6%. Two of the five patients (40%) submitted to operation for active yet unruptured aneurysms died in the preoperative period. Finally, 10 of the 11 patients (91%) with ruptured AAAs were operative mortalities. All of these operative mortalities in the ruptured AAA subgroup had severe hypotension preoperatively (mean systolic blood pressure: 23 mm Hg). The charges associated with the management of the ruptured AAA group averaged $84,486 (range $12,537-$199,233).

CONCLUSIONS

Although elective replacement of AAA in properly selected octogenarians appears valuable to prolong worthwhile life expectancy, this experience leads us to consider observation only in the treatment of octogenarians with ruptured AAA who present with severe hemodynamic instability.

Rupture of a sinus of Valsalva aneurysm through the tricuspid septal leaflet

We report a case of rupture of an aneurysm of the noncoronary sinus of Valsalva with the tract of the fistula emerging through the tricuspid septal leaflet. This rare pathology created a diagnostic dilemma, as the direction of the jet of blood was alternating between the right atrium and the right ventricle.