Guilt by association: paradigm for detecting a silent killer (thoracic aortic aneurysm)

Recent studies have confirmed a close association between various medical conditions (intracranial aneurysm, abdominal aortic aneurysm, temporal arteritis, autoimmune disorder, renal cysts), certain aortic anatomic variants (bovine aortic arch, direct origin of left vertebral artery from aortic arch, bicuspid aortic valve), and family history of aneurysm disease with thoracic aortic aneurysm and dissection. This paper reviews these associations. We propose to capitalise on these associations as powerful and expanding opportunities to diagnose the virulent but silent disease of thoracic aortic aneurysm. This can be accomplished by recognition of this 'guilt by association' with the other conditions. Thus, patients with associated diseases and anatomic variants should be investigated for silent aortic aneurysms. Such a paradigm holds substantial potential for reducing death from the silent killer represented by thoracic aortic aneurysm disease.

Aortic dissection associated with blunt chest trauma diagnosed by elevated D-dimer

INTRODUCTION

Similar to spontaneous aortic dissection, traumatic aortic dissection is diagnosed with a careful history and physical exam, chest radiograph, and ultimately, dedicated aortic imaging. The diagnosis of spontaneous aortic dissection may be aided by using the serum D-dimer test. The use of D-dimer for diagnosing aortic injury in the setting of blunt trauma has not previously been reported.

PRESENTATION OF CASE

We present a case of aortic dissection in a 61-year-old male diagnosed when the patient presented with chest pain after blunt chest trauma.

DISCUSSION

The patient had no known history or risk factors for aortic disease. None of the classic findings were present by history, physical examination or chest radiograph and the diagnosis was made as the result of an elevated D-dimer. We discuss how the D-dimer test fortuitously led to the diagnosis in this case, and the implications.

CONCLUSION

D-dimer could be helpful in diagnosing aortic injuries in low-risk chest trauma patients.

Atypical aortic arch branching variants: A novel marker for thoracic aortic disease

OBJECTIVE

To examine the potential of aortic arch variants, specifically bovine aortic arch, isolated left vertebral artery, and aberrant right subclavian artery, as markers for thoracic aortic disease (TAD).

METHODS

We screened imaging data of 556 patients undergoing surgery due to TAD for presence of aortic arch variations. Demographic data were collected during chart review and compared with a historical control group of 4617 patients.

RESULTS

Out of 556 patients with TAD, 33.5% (186 patients) demonstrated anomalies of the aortic arch, compared with 18.2% in the control group (P < .001). Three hundred seventy (66.5%) had no anomaly of the aortic arch. Bovine aortic arch emerged as the most common anomalous branch pattern with a prevalence of 24.6% (n = 137). Thirty-five patients (6.3%) had an isolated left vertebral artery, and 10 patients (1.8%) had an aberrant right subclavian artery. When compared with the control group, all 3 arch variations showed significant higher prevalence in patients with TAD (P < .001). Patients with aortic aneurysms and anomalous branch patterns had hypertension less frequently (73.5% vs 81.8%; P = .048), but had a higher rate of bicuspid aortic valve (40.8% vs 30.6%; P = .042) when compared with patients with aneurysms but normal aortic arch anatomy. Patients with aortic branch variations were significantly younger (58.6 ± 13.7 years vs 62.4 ± 12.9 years; P = .002) and needed intervention for the aortic arch more frequently than patients with normal arch anatomy (46% vs 34.6%; P = .023).

CONCLUSIONS

Aortic arch variations are significantly more common in patients with TAD than in the general population. Atypical branching variants may warrant consideration as potential anatomic markers for future development of TAD.

Synchronous hybrid repair for ruptured aneurysm of bovine aortic arch

Rupture of an aortic arch aneurysm is a life-threatening emergency with the risk of mortality escalating by the hour. We describe the successful hybrid repair of a ruptured bovine aortic arch aneurysm in a 75-year-old man, which involved aortic arch debranching by ascending aorta-bicarotid bypass followed by relining of the aortic lumen with a stent-graft. The procedure was not only lifesaving but also resulted in an active gentleman at 2-year follow-up. Considering the morbidity and mortality of open surgery using circulatory arrest, state-of-the-art synchronous hybrid repair seems to be an effective alternative for ruptured aortic arch aneurysms.

Statistical Challenges in Identifying Risk Factors for Aortic Disease

Being largely asymptomatic, thoracic aortic aneurysms pose a challenge for the physician to identify and intervene in time to prevent death or a major complication. Knowing how to accurately analyze the available clinical data is vital to informing the proper management of these patients. This paper seeks to provide an overview of the statistical methods most commonly used to analyze clinical outcomes with a special focus on research related to aortic disease.

Gonococcal ascending aortic aneurysm with penetrating ulcer and bovine arch

We describe a patient with ascending aorta aneurysm and bovine aortic arch who initially presented with fever. A 65-year-old man with a 2-month history of intermittent fever was referred to our hospital and diagnosed as having a gonococcal ascending aorta aneurysm with penetrating ulcers. He was successfully treated by resection of the ascending aorta and ulcers, replacement of the aortic valve, and prolonged postoperative antibiotic therapy.

Truncus bicaroticus with aberrant right subclavian artery and origin of right vertebral from right common carotid artery

We describe a rare constellation of variant anatomy of the aortic arch branches, seen on a magnetic resonance angiographic examination during the course of investigation for recent onset memory loss in a 52-year-old patient. There was a common origin of both the common carotid arteries (CCA), the common trunk being the first major branch of the aortic arch, the right vertebral artery arising from the right CCA and the right subclavian artery arising as the last branch of the arch. In isolation, the three components of this constellation have been reported with different frequencies, but as per the authors' knowledge, this entire constellation has been rarely reported. We review the literature and propose an embryological mechanism for this variant anatomy.

Spontaneous innominate and left common carotid artery dissection with bovine aortic arch

We describe a case of a 63-year-old woman who presented with spontaneous dissection of the innominate and left common carotid arteries arising from a common trunk, so-called "bovine aortic arch." The entry tear was seen in the common trunk at the origin of the innominate artery with no dissection extending into the aortic arch or the ascending aorta. The dissection was resected and total arch replacement was performed considering the aortic wall fragility complicated by the dissection.