Noninfectious Ascending Aortitis: A Case Series of 64 Patients

CMR in inflammatory vasculitis

Vasculitis, the inflammation of blood vessels, can produce devastating complications such as blindness, renal failure, aortic rupture and heart failure through a variety of end-organ effects. Noninvasive imaging with cardiovascular magnetic resonance (CMR) has contributed to improved and earlier diagnosis. CMR may also be used in serial evaluation of such patients as a marker of treatment response and as an indicator of subsequent complications. Unique strengths of CMR favoring its use in such conditions are its abilities to noninvasively visualize both lumen and vessel wall with high resolution. This case-based review focuses on the large- and medium-vessel vasculitides where MR angiography has the greatest utility. Because of increasing recognition of cardiac involvement in small-vessel vasculitides, this review also presents evidence supporting greater consideration of CMR to detect and quantify myocardial microvascular disease. CMR's complementary role amidst traditional clinical, serological and other diagnostic techniques in personalized care for patients with vasculitis is emphasized. Specifically, the CMR laboratory can address questions related to extent and severity of vascular involvement. As ongoing basic and translational studies better elucidate poorly-defined underlying molecular mechanisms, this review concludes with a discussion of potential directions for the development of more targeted imaging approaches.

Insights into imaging of aortitis

BACKGROUND

Aortitis is a subtype of the more general term "vasculitis", an inflammatory condition of infectious or noninfectious origin involving the vessel wall. The term "vasculitis" refers to a broad spectrum of diseases with different aetiologies, pathophysiologies, clinical presentations and prognoses. The clinical manifestations are nonspecific, as are the laboratory findings such as pain, fever, weight loss, vascular insufficiency and elevated levels of acute phase reactants, as well as other systemic manifestations, and sometimes may mimic other entities. Thus, if not suspected as part of the initial differential diagnosis, aortitis can be overlooked during the workup of patients with constitutional symptoms and systemic disorders.

METHODS

Imaging is rarely used for the primary diagnosis, but imaging findings, although nonspecific, can help in the assessment of these patients and is often required for making the final diagnosis. Imaging can be critical in the initiation of appropriate management and therapy.

RESULTS

Noninvasive cross-sectional imaging modalities such as contrast-enhanced CT, magnetic resonance (MR) imaging, nuclear medicine and in particular positron emission tomography (PET) are the leading modalities in modern diagnostic imaging of aortitis for both the initial diagnosis and follow-up.

CONCLUSION

This review focusses on the most common manifestations of aortitis with which radiologists should be familiar. TEACHING POINTS : • Aortitis is an inflammatory condition of infectious/noninfectious origin involving the vessel wall. • Imaging findings can help in the assessment of aortitis and are often crucial for the final diagnosis. • Contrast-enhanced CT, MRI and PET-CT are used for both the initial diagnosis and follow-up of aortitis.

Repair of thoracic aortic aneurysm due to noninfectious aortitis

BACKGROUND AND AIM

Isolated thoracic aortitis (ITA) is a newly-defined pathological entity with a still-unknown etiopathology and with some potential relationship to IgG4-related systemic disease. We investigated patients on whom the ascending aorta was operated to identify the clinical and histopathological features of ITA and its relationship to IgG4-related systemic disease.

METHODS

Two hundred fifty-one patients underwent replacement of the ascending aorta. Retrospective review of all histological reports was done to identify noninfectious aortitis. Immunohistochemical analysis of resected specimens was performed in all cases.

RESULTS

We found 11 (4.4%) patients with noninfectious aortitis aged 52 to 79 years; nine of the patients were female. All patients underwent ascending aorta replacement. The 30-day mortality was 0. During the follow-up period (median 12 months) four patients died (two of them because of progression of aortic disease). None of the seven living patients developed any IgG4-related diseases, and all had normal serum levels of IgG and IgG4.

CONCLUSIONS

Surgical treatment of ITA has acceptable short- and mid-term results. Because follow-up serum levels of IgG and IgG4 were normal in survivors, postoperative corticosteroid therapy may not be indicated in patients in the absence of active vasculitis.

Idiopathic aortitis: an underrecognized vasculitis

Aortitis is a general term denoting inflammation of the aortic wall. Various infectious and non-infectious diseases can be complicated by aortitis; in addition, isolated idiopathic aortitis has also been described. In a 12-year nationwide Danish population-based study, the prevalence of aortitis among 1,210 resected thoracic aorta samples was 6.1%, with nearly three-quarters of cases being idiopathic. Identified risk factors for aortitis included advanced age, a history of connective tissue disease, diabetes mellitus, and heart valve pathology. As in virtually all pathological studies, this study has a bias toward reporting the most severe cases of aortitis requiring surgical repair.