Idiopathic medial aortopathy and arteriopathy

Inflammatory and thrombotic valvulopathies in autoimmune disease

Rheumatologic diseases are characterised by loss of immune tolerance, resulting in systemic inflammation. Inflammation and scarring of the endocardium, which lines the inner surface of the heart chambers and valves, can result in valvular thickening and dysfunction. Estimates of prevalence vary depending on the sensitivity of the screening methodology used and range from 30%-50% in systemic lupus and rheumatoid arthritis to 10%-30% in ankylosing spondylitis. Progression of valve disease is a slow process but can result in haemodynamically significant complications. Thromboembolic complications such as cerebrovascular occlusions pose a serious risk of morbidity. The presence of antiphospholipid antibodies increases the risk of valvular disease and thrombotic complications. Anticoagulation is recommended in the presence of antiphospholipid antibodies, but the guidance on the role of immunosuppressive therapy to treat valvular disease is lacking. Surgical valve therapy may be considered in severe disease, but there is increased risk in patients with an autoimmune disease which includes a higher risk of infection, thromboembolic and bleeding complications, as well as cardiovascular events in the setting of premature atherosclerotic heart disease. Therefore, management should be provided in a multidisciplinary team that includes a rheumatologist, a cardiologist and a cardiothoracic surgeon; medical therapy should be optimised before considering a high-risk valve surgery.

Takayasu's arteritis

The frequency of Takayasu's arteritis (TA) has been estimated to be 2.9 cases per 1 million people, with a female preponderance, although female-to-male ratio varies from different geographic areas. A high frequency of haplotype A24-B52-DR2 has been found in Japanese patients, without this association in other populations. TA has a striking predilection for the aortic arch and its branches. Evidence favors an autoimmune pathogenesis. Segmental inflammation (active and inactive lesions) may coexist. Due to its enhanced resolution, magnetic resonance imaging and magnetic resonance angiography eventually will replace catheterization angiography. Mortality reduction with glucocorticoid treatment has not been firmly established.

Nonneoplastic diseases of aorta and pulmonary trunk--Part III

The five-part review focuses on selected nonneoplastic diseases of the aorta and pulmonary trunk. Because many more disease affect the aorta compared with the pulmonary trunk and right and left main pulmonary arteries, most of this review will be devoted to disorders of the aorta. Part III of this five-part series discusses the etiology of aortic aneurysms and aortitis.

Incidence of aneurysms in Takayasu's arteritis

The angiographic findings of Takayasu's arteritis in a series of 113 patients were reviewed. Predominant findings were stenotic or occlusive changes, but fusiform or saccular aneurysms were also found in 36 patients (31.9%) in the various sites of aorta and its major branches. Multiple aneurysms were found in 15 patients. The most common site of aneurysms was the ascending aorta (16 patients); in 7 of the patients these were complicated by aortic regurgitation. Aneurysms developed in the aortic arch in 3 patients, in the descending aorta in 11, in the abdominal aorta in 7, and in the major branches of the aortic arch in 9 patients. In 2 patients, follow-up angiograms showed enlargement of the aneurysms, and rupture of the aneurysm occurred in 1 patient. Aneurysms were found even in young patients. A fifteen-year-old female showed a huge aneurysm in the ascending aorta as the initial manifestation of this disease. Thickening of the walls of aneurysms was common and characteristic. This study revealed the moderately high incidence of aneurysms of various sites of arteries in patients with Takayasu's arteritis. The authors conclude that aneurysm, as well as occlusive changes, can be a primary lesion.

Mucoid vasculopathy of unknown etiology

A new vascular disorder with generalized deposition of abnormal amounts of acid mucopolysaccharide (AMPS) material in arteries, veins, and vasanervorum has been observed in a large number of autopsies at the author's institution. It is unlike any of the known vascular diseases and has emerged as a distinct disorder of vascular connective tissue. This has been named "mucoid vasculopathy of unknown etiology." This hitherto unreported entity is described here.

Cardiac alterations in ankylosing spondylitis

Forty patients, 30 men and 10 women with an average age of 38.47 +/- 11.07 years, suffering from ankylosing spondylitis and attending a Rheumatology Outpatient Clinic, were evaluated for cardiovascular involvement. The evaluation was based on patients' clinical observation, electrocardiography, echocardiography, and chest x-ray. More than a simple review, this study was undertaken with the aim of arriving at a better clinical definition of the cardiovascular manifestations found in ankylosing spondylitis. In fact, of the 40 patients, 8 (20%) had systemic hypertension for which an explanation could not be found, 4 of whom were less than forty-five years old; the echocardiogram showed mitral valve prolapse in 4 patients (10%), 2 of them with a systolic murmur and other 2 with a protosystolic click on auscultation. More significant than the changes in conduction was the finding of a sinus bradycardia in 9 patients (22.5%), and a PR interval below 120 msec in 3 patients (7.5%). The authors conclude that the extension of cardiovascular changes in ankylosing spondylitis is more vast than usually acknowledged.

Aortitis and large vessel arteritis in a newborn

Disseminated arteritis with extensive involvement of the aorta, as well as involvement of the arch vessels, coronary arteries, and pulmonary arteries, but not of the arteries within the liver, spleen, kidneys, or other organs, is unusual in a newborn. The presence of both acute and chronic inflammation with fibrosis, as well as calcification and focal ossification in the aorta, would suggest that the process had been present for some time before birth. This lesion should be described rather than designated by an eponym or included with such entities as Takayasu's disease. An additional finding of interest was widespread calcification in Bowman's capsules of numerous glomeruli.

Simultaneous aortic and pulmonary artery aneurysms due to giant cell arteritis

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Dissecting aortic aneurysm in childhood and adolescence. Case report and literature review

A 15-year-old adolescent male with dissecting aortic aneurysm is presented. His young age, lack of predisposing factors, and fulminant course with rapid progression to death precluded a correct antemortem diagnosis. Review of the literature reveals that most instances of dissecting aortic aneurysm in childhood and adolescence are associated with predisposing conditions, especially congenital cardiovascular anomalies. The clinical picture is generally characteristic. Prompt evaluation and therapy may be lifesaving.

Morphological findings in idiopathic calcification of the ascending aorta and aortic valve affecting a young woman

The pathology of a case of idiopathic calcification affecting the ascending aorta in a young woman is presented. A varying width of media throughout the aorta and extending into its proximaques of calcium, found in the acellular media, were confined to the ascending aorta. No inflammatory or reparative reaction was seen in the vessel wall. Electron microscopically, the calcium seemed to have an affinity for elastic tissue elements of all sizes and the mode of deposition appeared to be by 'avenues' of the microfibrillar component. Possible pathogenetic mechanisms are discussed.

Pulmonary and systemic aneurysms in a case of widespread arteritis

A patient in whom asthma preceded the development of multiple pulmonary and systemic artery aneurisms died after dissection of the aorta. At necropsy he was found to have widespread arteritis of unknown aetiology affecting many large and medium-sized pulmonary and systemic vessels as well as a few microscopic ones. Endarteritis obliterans was present in some of the vasa vasorum. The clinical and histopathological findings are discussed in relationship to other known causes of arteritis, and it is concluded that this condition has not previously been described.

The surgical pathology of thoracic aortic aneurysms

In 63 resected thoracic aortic aneurysms, the commonest histological finding (45 cases, 71.4%) was cystic medionecrosis. These cases formed two groups, 29 with widespread fragmentation and loss of elastic tissue (elastopathy) and 16 cases without elastopathy who were older and included most of the 18 cases of dissecting aneurysms. Thirteen patients had the Marfan syndrome, 10 showing cystic medionecrosis with elastopathy, indistinguishable from the cases with no Marfan stigmata although partial 'dissections' were mainly found in the Marfan patients, Histological appearances ranged from normal to complete loss of media. Cystic changes in muscle fibres apparently preceded elastic fragmentation. Fourteen cases (22%) had aortitis: 4 were syphilitic and 3 of other known aetiology. In 7 patients the aetiology of the inflammatory process was unknown and appearances included granulomatous infarct-like lesions and necrotizing aortitis or changes indistinguishable histologically from syphilis.

Homograft replacement of aortic valve and ascending aorta in a patient with non-specific giant cell aortitis

A case of giant cell aortitis causing ascending aortic aneurysm associated with aortic regurgitation is reported. The aneurysm was excised and the aortic valve replaced using a fresh homograft. The patient has been followed up for three and a half years. There is good evidence of correction of the haemodynamic lesion and no evidence of further arteritis or aneurysmal formation. The pathological and clinical problem of this disease are discussed.

Aortic medial calcification in progeria-like syndrome

Aortic medial calcification was investigated in rats in which the progeria-like syndrome (PLS) was evoked by administering dihydrotachysterol. In 35 experimental rats and 15 controls, calcification was studied morphologically by light and electron microscopy, and by enzyme histochemistry. Body weight, food intake and serum calcium levels were also determined. Calcification occurred along and on the elastic lamellae in association with the accumulation of ground substance. In the smooth-muscle cells surrounding the calcified foci, the activities of various lysosomal enzymes increased concomitantly with a tendency toward transformation of smooth-muscle cells to a modified form. From these observations, the role of ground-substance formation by smooth-muscle cells is postulated, and participation in the catabolism of ground substance by the lysosomal enzymes of these cells is suggested. It appears the increased activity of adenosine monophosphatase should be linked to the calcification. The etiology of weight loss, skin manifestations and aortic calcification in PLS rats seems to be different from that in human progeric diseases. Therefore, the PLS rat should not be readily accepted as an animal model for the study of progeric diseases.

Takayasu's arteritis. Clinical study of 107 cases

The clinical experience derived from the retrospective study of 107 cases of TA over a 19 year period is presented. The disease predominated in females (8.5:1), with age of onset usually less than 20 years. In half of the cases an acute inflammatory phase was observed, characterized mainly by systemic and cardiovascular symptoms. Subsequently the natural course of TA was toward chronicity with gradual deterioration. The most frequent variety of TA (65 per cent of the patients) was Type III, in which the supra-aortic trunks and the abdominal aorta were involved. The predominant clinical features were reduction of amplitude of peripheral arterial pulses (96 per cent), vascular bruits (94 per cent), and raised blood pressure (72 per cent), mainly resulting from renal arterial involvement (62 per cent). Heart failure (28 per cent) is rarely the result of direct coronary arteritis. TA is most often confused with aortic coarctation, but usually the aortogram distinguishes these. The etiology of TA is discussed. The high incidence of previous and present active tuberculous (48 per cent) in the present series and previous experimental work suggest that tuberculosis may play an important role in the etiology of TA. Treatment for antihypertension and heart failure should be employed when indicated. Treatment with corticosteroids requires further evaluation. Treatment for tuberculosis is not justified in all cases until the exact role of tuberculosis is well established.

Multiple aortic aneurysms in relapsing polychondritis

A patient with relapsing polychondritis and thoracic and abdominal aortic aneurysms is described. The aortic changes were due to aortitis, which primarily involved the media, with increased vascularization, perviascular infiltration of mononuclear cells, increased amounts of collagen and decreased amounts of elastic tissue and sulfated acid mucopolysaccharides. Aortic aneurysms frequently occur in relapsing polychondritis; they are usually in the ascending aorta but may be multiple and involve the abdominal aorta; involvement of the ascending aorta results in aortic regurgitation and left ventricular failure, and involvement of the abdominal aorta may be clinically silent and result in fatal rupture.

An unusual case of reno-vascular hypertension with multiple arterial stenosis

A case of juvenile reno-vascular hypertension is presented. Extensive involvement of aorta and its branches was found. The possible inflammatory or congenital origin of the arterial lesion is discussed.

Dissection and rupture of the ascending aorta. Unusual complications of aortocoronary bypass surgery

This is a report concerning two cases of unusual complications, dissection and rupture of the ascending aorta, secondary to saphenous vein bypass surgery. We recommend that evaluation of patients undergoing saphenous vein bypass surgery include careful image-intensifier fluoroscopic examination during coronary arteriography. If aneurysmal dilatation of the aorta or calcification is observed, ascending aortography should be performed to better evaluate the aorta, and surgeons should be alerted to use appropriate maneuvers and techniques to minimize the risk of complications in the aortic site of the vein anastomosis. Internal mammary coronary-artery bypass should be the procedure of choice in such conditions.

Relapsing polychondritis: review of current status and case report,

This communication has attempted to review the present state of published knowledge on the syndrome of relapsing polychondritis. Basic anatomic, physiologic, and biochemical changes in this disorder are summarized and the role of metabolic and immunologic alterations in the pathogenesis discussed. An additional case of relapsing polychondritis is reported, and the clinical features of this case, plus those of 131 previously reported, are reviewed with discussion of present day therapeutic experience and prognosis.

Idiopathic calcification of the ascending aorta and aortic valve in two young women

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Congenital aneurysm of the extracranial carotid arteries

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Perforated hepatic artery aneurysm and multiple aneurysms in incomplete Marfan syndrome

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Inflammatory aneurysms of the abdominal aorta

Two hundred and seventeen patients presenting with abdominal aneurysms in the Department of Surgery at the Manchester Royal Infirmary between the years 1958–69 were surveyed retrospectively.

One hundred and eighty-seven of the patients underwent operation for resection of their aneurysms; of these, 19 (10 per cent) showed excessive thickening of the aneurysm walls and perianeurysmal adhesions at operation.

Subsequent histological examination of the walls of these unusual aaneurysms showed extensive active chronic inflammatory changes, including plasma-cell infiltration.

This group of patients whose aneurysms we describe as ‘inflammatory’ presented with different clinical features in comparison with the atherosclerotic group.

Retrospective investigation has not yet revealed any aetiological factors. We feel that ‘inflammatory’ aneurysms are a discrete entity with significant differences from atherosclerotic aneurysms and previously described arteritis.

Absence of elastica from inner half of aorta. Multiple dissecting aneurysms

Multiple dissecting aneurysms were found in the course of an autopsy on a 52-year-old male patient who had expired suddenly as a result of a massive pericardial tamponade. Two of these aneurysms involved the aorta. The others involved muscular arteries, namely, the superior mesenteric and the splenic. In the case of the aorta, there was an absence of elastica from the entire inner half of the media, leaving the fabric of the outer half intact. The course of dissection in the case of each aneurysm lay along the line of demarcation separating the inner from the outer half of the media. This very unusual pattern, showing an absence of elastic lamina in the inner half of the media, differs remarkably from the changes that are commonly seen in dissecting aneurysms of this large elastic artery. Neither the etiology nor pathogenesis of this defect is known. The recognition that such a disease exists is only the first step toward its solution.

Endocardial lesion in a case of Takayasu's arteriopathy

The clinical findings and the necropsy report of a 14-year-old girl suffering from Takayasu's arteriopathy have been presented. In addition to the typical arterial changes, thickening and puckering of the aortic valve and a patch of thickening in the left atrial endocardium were shown at necropsy. The histology of this lesion was found to be identical with the arterial intimal changes. It has been postulated that Takayasu's arteriopathy may rarely extend to the valvular and mural endocardium of the heart, producing cardiac murmurs. Similar cases with cardiac murmurs reported earlier and attributed to associated rheumatic endocarditis were probably due to the same pathological process extending to the endocarditis.

Scleritis and aortic incompetence. Two manifestations of connective tissue disease

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