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.

Impending rupture of the ascending aorta due to giant cell arteritis

Giant cell arteritis may occasionally lead to vessel perforation without previous dissection. At the level of the ascending aorta, however, such an event has been reported only three times. We report a fourth case of impending rupture of the ascending aorta due to a small and isolated lesion of giant cell arteritis. In contrast to previous reports, laboratory and clinical manifestations suggestive of giant cell arteritis were absent in this case so that the diagnosis could only be established on histologic examination of the operative specimen.

[Juvenile sudden death from spontaneous aortic rupture]

In the time interval 1979-1991, 150 cases of juvenile sudden death (< or = 35 years) were studied. Among these, 9 were due to aortic rupture within the pericardial cavity. Two were mycotic and 7 dissecting aneurysms. The latter, all male, age ranging from 17 to 31 years (mean 24), presented the following risk factors: Marfan syndrome in 2, isthmal coarctation associated with bicuspid aortic valve (BAV) in 3, isolated and normally functioning BAV in 2. Histology of the dissected aortic wall showed an equal severity of degenerative changes consisting of elastic fragmentation, cystic medial necrosis and medionecrosis. By reviewing our anatomical collection of dissecting aneurysm we found a 12% frequency of BAV. Taking into consideration that the frequency in normal population of BAV is near 1%, the association between bicuspid aortic valve and dissecting aneurysm should not be casual (p < 0.001).

IN CONCLUSION

a) natural history of BAV entails the risk of spontaneous aortic laceration and sudden death in the youth, either in the isolated form or in association with isthmal coarctation; b) the aortic tunica media in these conditions shows an intrinsic structural weakness very similar to that observed in Marfan syndrome, as to suggest a congenital, most probably genetic defect with phenotype expression not only at valve level, but also within the aortic wall; c) aortic dissection occurs nearly ten times more frequently in patients with BAV than in normal population.

An autopsy case review of 142 nonpenetrating (blunt) injuries of the aorta

This study retrospectively reviewed 142 fatal cases of aortic laceration. Data were collected from the autopsy reports (including toxicology results) and included the circumstances of the injury. In the case of automobile crashes this included the direction of impact, time of day, and vehicular damage. Seventy percent of the victims were men with a mean age of 37.5 years; 30% were women with a mean age of 46 years. Thirty-five percent of the 142 victims had elevated blood alcohol levels. Fifty-four percent of the lacerations were located at the classic site (the isthmus). The majority of the aortic lacerations (102) were sustained in automobile crashes. Of these, 42% were broadside collisions and 58% were head-on collisions. Seventy-three percent and 67% of the victims in broadside and head-on collisions, respectively, had aortic lacerations at the classic site. The results suggest that the pathogenesis of aortic rupture involves a lateral oblique compression impact to the chest, which causes thoracic mediastinal structures to shift and deflect the aortic arch, resulting in severe shearing and stretching at the isthmus. The use of seat belts and air bags may reduce the number of aortic injuries.

[A ruptured thoracic aortic aneurysm with 4 cm diameter]

The size of a thoracic aortic aneurysm (TAA) is an important factor of the operative indication. We experienced a ruptured TAA the diameter of which was only 4 cm. A 71 years old man was admitted due to the severe back pain under the shocked condition. We diagnosed him a ruptured TAA by CT scan. Because he had no progressive anemia and the hemodynamics was very stable, we followed him conservatively. Two months later, the operation was performed. We resected the aneurysm and inserted an aortic prosthetic graft. From the operative findings, the aneurysm was certified as a true aneurysm, and the maximal diameter was only 4 cm. First choice for the treatment of ruptured TAA is the emergent operation. But when the hemodynamics is extremely stable and the anemia does not progress at all, a conservative therapy can be selected. Even if the aneurysm is very small, the control of hypertension is quite important.

Infrarenal abdominal aortic aneurysms less than five centimetres in diameter: the surgeon's dilemma

A number of recent studies have brought new data and a better understanding of the risk versus benefit of abdominal aortic aneurysm repair. The present evidence indicates that the risk of rupture for non tender aneurysms less than 5 cm is so low that patients can generally be followed by 6 monthly ultrasound and not undergo immediate operation. Surgery should be the method of choice for most patients where the aneurysm is greater than 5 cm.

Two cases of unusual rupture of aortic aneurysm

Two cases of unusual rupture of aortic aneurysm with extravasation in the bronchus and duodenum are described. The clinical evolution of such aneurysm ruptures is associated with considerable diagnostic difficulties due to the absence of pathognomonic typical features and the short survival time after onset of pain symptoms.

Delayed rupture of spontaneous tear of the ascending aorta--report of two fatalities

A spontaneous tear of the ascending aorta, with or without medial dissection, can cause sudden death from hemorrhage due to aortic rupture. Two representative cases are described. Review of the clinical history and pathological changes showed that the terminal event was delayed allowing healing and reactive changes to occur in the aortic wall. A pathologist confronted with a fatal case of aortic rupture should be aware that death is not always immediate. Recognition of this has medicolegal importance, particularly if medical management is questioned because of a missed clinical diagnosis.

[Growth rate of abdominal aortic aneurysms as measured by Computerized tomography]

To evaluate the growth rate of abdominal aortic aneurysms, sequential computed tomography (CT) examinations were performed on 125 nonoperated patients (M/F 101/24, mean age 67 +/- 8 years, 129 lesions) at intervals of at least 6 months. Growth rates of aneurysms were obtained by subtracting the first from the last diameter and adjusting for examination interval. Mean growth rate was 0.28 +/- 0.26 cm/year. Aneurysms with an initial diameter exceeding 4 or 5 cm showed significantly faster growth than smaller aneurysms. There was no significant correlation between growth rate and atherosclerogenic factors, but systolic blood pressure was significantly higher in patients whose aneurysms ruptured. Our study showed quantitatively that aneurysms with a large diameter have a rapid growth rate, the growth rate of infrarenal aneurysms is significantly faster than that of suprarenal aneurysms, and blood pressure control is important to prevent rupture.

[A case of ruptured aortic arch aneurysm into the lung]

Successful surgical treatment of aortic arch aneurysm ruptured into the left lung was reported. The patient was a 74-year-old man suffering from recurrent hemoptysis. Computed tomography and aortic angiography demonstrated a giant aortic arch aneurysm. Emergency operation was performed. Arch reconstruction by a Dacron graft was performed with hypothermic circulatory arrest. The post operative course was uneventful and there was no evidence of cerebral complication. In the emergency operation for ruptured aortic arch aneurysm, hypothermic circulatory is very useful method for cerebral protection.

Determination of the expansion rate and incidence of rupture of abdominal aortic aneurysms

Expansion rate and incidence of rupture of abdominal aortic aneurysms in relation to their size is a source of debate. We studied 114 patients (out of a cohort of 752 consecutive patients admitted with abdominal aortic aneurysms) who were denied any immediate operation because of patient's refusal, high surgical risk, or small transverse diameter as assessed by CT scanning and ultrasonography. All patients not operated on underwent from two to six repeated examinations during an average follow-up period of 26.8 months (range, 3 to 132). Forty-seven patients (41.2%) were subsequently operated on electively because of marked increase of transverse diameter of the aneurysm (n = 44) or for other reasons (n = 3), with a death rate of 0%. Eighteen other patients underwent emergency operation for leaking or ruptured aneurysms, and there were five deaths. The incidence of rupture was clearly related to the final diameter value, rising from 0% in aneurysms less than 40 mm to 22% in large size aneurysms (greater than or equal to 50 mm). Among the 49 patients not operated on, one died of rupture before operation and five of causes unrelated to the disease. Using individual serial measurements, we determined the linear expansion rate of the aneurysm, which proved to be related to initial diameter values: 5.3 mm/year for diameters less than 40 mm (n = 49), 6.9 mm/year in the 40 to 49 mm group (n = 41), and 7.4 mm/year for diameters of 50 mm or more (n = 24).(ABSTRACT TRUNCATED AT 250 WORDS)

Ruptured aneurysm of the descending thoracic and thoracoabdominal aorta. Analysis according to size and treatment

Acute rupture was confirmed at operation in 117 patients treated for descending thoracic or thoracoabdominal aortic aneurysm. Descending thoracic (n = 80) aortic rupture occurred into lung or esophagus in 8, the pleural cavity in 49, and the mediastinum in 23. Upper abdominal aortic (n = 37) rupture occurred into peritoneal cavity in 3 and into retroperitoneal tissues in 34. Aneurysmal size (range, 5 to 17 cm; median, 8 cm) could be determined retrospectively in 86 patients; 59 (74%) descending thoracic and 27 (73%) abdominal aorta. Size (external diameter) in the former was 8 (14%), 5 to 6 cm; 21 (36%), 6 to 8 cm; 23 (39%), 8 to 10 cm; and 7 (12%) greater than 10 cm. Size at the abdominal site was similar. Thus size was not greater than 10 cm in 52 (88%) (range, 5 to 10 cm), which contradicts opinions that thoracic aneurysms rupture only when size exceeds 10 cm. Twenty-nine patients (25%) were hypotensive (systolic blood pressure less than 100 mmHg), of whom 16 (55%) had cardiac arrest before operation. Associated conditions included advanced age (greater than or equal to 75 years) in 26 (22%), coronary artery disease in 41 (35%), chronic obstructive pulmonary disease in 46 (39%), renal insufficiency in 25 (21%), and cardiovascular disease in 22 (18%). The overall early survival rate (30-day) was 89 of 117 patients (76%); 69% in patients with hypotension, 56% of patients with cardiac arrest, 88% in good-risk patients. Five-year (Kaplan-Meier) survival was 28%. Because elective operation is associated with 92% survival, this should be considered before rupture when aneurysm is 5 cm or larger in good-risk patients, in patients with symptomatic aneurysms, and in most patients with larger aneurysms.

Aortic dissection with the entrance tear in the descending thoracic aorta. Analysis of 40 necropsy patients

Clinical and necropsy findings are described in 40 patients who had aortic dissection with the entrance tear in the descending thoracic aorta. Their ages at death ranged from 39 to 91 years (mean, 66 years); 24 (60%) were men and 16 (40%) were women. Systemic hypertension was present by history in 33 patients (83%) and the hearts were of increased weight in 78%. Of the 40 patients, 31 (78%) had no operative intervention, while 9 (22%) underwent operation for aortic dissection. Of the 31 patients without operative therapy, the diagnosis of aortic dissection was established in life in 9 patients (29%) and at necropsy in 22 (71%). The interval from aortic dissection to death was 30 days or less in 13 patients (42%); rupture of the false channel was the cause of death in 9 patients (69%), renal failure in 2 (15%), and the cause was unclear in 2 (15%). The interval from aortic dissection to death was more than 30 days in 18 (58%) of the 31 patients without operative therapy. The cause of death in these 18 patients was related to the dissection in 11 (61%) (rupture of the false channel in 5; renal failure from dissection in 3, and rupture of the false channel of a second acute dissection in 3), but in the other 7 patients (39%) death was unrelated to the dissection but a nonfatal complication, specifically stenosis of the true channel from compression by a thrombus-filled false channel, occurred in 4 of these 7 patients. Thus only 3 (10%) of the 31 patients without operative therapy had no complications of aortic dissection. All nine patients who underwent operation had had an aortic dissection within 30 days, and the operation was performed because of a major complication of the dissection. Four patients survived 8 to 84 months after the operation. Thus early operative intervention (before the appearance of complications) appears justified in patients with aortic dissection with the entrance tear in the descending thoracic aorta to prevent rupture of the false channel acutely or after initial healing; to prevent renal failure from compression of renal arteries by an aneurysmal false channel; to prevent true channel stenosis from compression by a thrombus-filled false channel; and possibly to prevent the recurrence of acute dissection.

Cause of death in unsuccessful prehospital resuscitation

During 1987-1988, prehospital resuscitation was unsuccessful in 204 of 381 patients who suffered a witnessed cardiac arrest due to presumed coronary heart disease in Helsinki. The cause of death was verified by autopsy in 80 (39%) of the 204 patients. Their cause of death could not be estimated on the basis of previous patient history, and their autopsy diagnoses were then related to the initial cardiac rhythm recorded at the scene. At autopsy, coronary heart disease was considered to have been the cause of death in 78% of the patients with ventricular fibrillation, in 43% of the patients with electromechanical dissociation (EMD), and in 60% of the patients in asystole. Cardiac tamponade or massive pulmonary embolism was the cause of death in 15 of the 28 patients with EMD who underwent autopsy. These findings support previously noted relationships between some causes of cardiac arrest and the initial cardiac rhythm, and also in prehospital cardiac arrest patients with unsuccessful resuscitation.

Giant coronary aneurysm associated with aortic mucoid medionecrosis

A case of sudden death due to rupture of a dissecting aneurysm of the ascending aorta in a 38-year-old man is presented. The patient had a clinical history of severe hypertension. The autopsy also revealed the presence of a voluminous aneurysm of the right coronary artery and a solitary multilocular cyst of the right kidney. It is thought that a prodromal influenza-like syndrome and the renal lesion could have played a role in causing the vascular pathology.

Spontaneous rupture of the ascending aorta

A case of spontaneous non-traumatic rupture of the thoracic aorta in a hypertensive patient is presented. The clinical findings suggested acute aortic dissection, and a large pericardial effusion was detected by echocardiography. The typical angiographic features of aortic dissection were not found. Autopsy revealed a longitudinal intimal tear and a rupture in the postero-lateral aspect of the ascending aorta. No false lumen was seen in the ascending aorta. When acute intrapericardial or intrapleural bleeding develops with no evidence of aortic aneurysm or dissection, spontaneous aortic rupture should be suspected.