Sequential ruptures of penetrating atherosclerotic ulcers of ascending aorta, aortic arch and descending thoracic aorta

Background

Penetrating ulcers of aorta, aortic dissections and intramural hematomas all come under acute aortic syndromes and have important similarities and differences.

Case report

We report a 67 year old man with rupture of a large penetrating ulcer of the distal ascending aorta with hemopericardium and left hemothorax. He underwent interposition graft replacement of ascending aorta and hemi-arch with a 30 mm Gelweave Vascutek graft but represented 6 months later with development of a penetrating ulcer which ruptured into a huge 14 cm pseudoaneurysm. This was repaired with a 28 mm Vascutek Gelseal graft replacement of arch and interposition graft reconstruction of innominate and left common carotid arteries. 6 weeks later, however, he ruptured his proximal descending aorta and underwent TEVAR satisfactorily. Unfortunately, 2 days later, he developed a pathological fracture of left proximal tibia with metastasis from a primary renal cell carcinoma. He died 3 weeks later from respiratory failure.

We shall briefly outline the similarities and differences in presentation and management of penetrating aortic ulcers, aortic dissections and intramural haematomas. We shall discuss, in greater detail, penetrating ulcers of thoracic aorta, their natural history, location, complications and management.

Conclusion

This case report is unique on account of initial successful surgical redressal following rupture of penetrating ulcer of distal ascending aorta into left pleural and pericardial cavities, normally associated with instant death. The haemodynamic effects of the rupture were staggered due to initial contained rupture into a smaller pseudoaneurysm, followed by a further rupture into a false aneurysmal sac followed eventually by generalised rupture into the pleural and pericardial cavities - a unique way of aortic rupture. Further development of another penetrating ulcer and a small pseudoaneurysm in the distal arch 6 months later which further ruptured into a larger 14 cm false aneurysmal sac, which again did not result in exsanguination, is again extraordinarily rare. Thereafter he underwent emergency thoracic endovascular aortic repair (TEVAR) for a further rupture of descending thoracic aorta. All three ruptures were managed successfully and would usually be associated with near-certain death, only for the patient to succumb eventually to the complications of metastatic renal cell carcinoma.

Bovine aortic arch: Prevalence in human fetuses

OBJECTIVE

"Bovine aortic arch" is the second most common variant of aortic arch branching, in which only two branches originate directly from the aorta. The prevalence of this condition has been reported in different studies to be around 6% in human fetuses and 11-27% in the adult population. In this study, we describe the prevalence of bovine aortic arch in fetuses, and assess the prevalence of concomitant fetal anomalies.

METHODS

A retrospective analysis of 417 fetuses between 15-40 weeks of gestation. Data regarding branching of the fetal aortic arch and other fetal anomalies were collected by fetal echocardiography and/or fetal ultrasonography.

RESULTS

A bovine arch was found in 20/413 fetuses (4.8%, 95CI 3.1-7.3%), of whom 14/310 (4.5%) had no fetal anomalies, and 6/77 (7.8%) exhibited minor changes (P = .241). None of the 26 fetuses with major anomalies had a bovine arch.

CONCLUSION

Fetuses in this study had a lower prevalence of bovine aortic arch than that previously reported in adults, most probably due to differences in the population examined. This study was underpowered to determine that bovine arch is a common anatomic variant, and is not associated with fetal anomalies.

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.

Innominate truncal and arch blowout with left hemiparesis and right hemothorax followed by delayed cheese-wire perforation of innominate graft

We present the case of a 68 year old Caucasian woman, in extremis, with left hemiparesis and right hemothorax, in hypovolemic shock, secondary to a blow-out of a large penetrating ulcer at the junction of innominate trunk and aortic arch. She underwent interposition graft replacement of innominate trunk and repair of aortic arch, on cardiopulmonary bypass, employing total circulatory arrest and selective antegrade cerebral perfusion and had total resolution of hemiparesis. She, however, represented, 6 months later, with threatened exsanguination after a sternal wire cheese-wired through the sternum and perforated the anteriorly lying innominate graft. Following successful repair, she was found to have an old intramural hematoma of distal arch and descending thoracic aorta and changes suggestive of chronic dissection of the whole of abdominal aorta. This was managed conservatively.

We believe this patient’s presentation initially with a spontaneous innominate blow-out, cardiogenic shock, hemothorax and hemiparesis, and later with cheese-wire perforation of the innominate graft is unique. Her surgical rescue at both presentations was equally unusual, and without surgical precedent to the best of our knowledge. Was the initial innominate blow-out the result of localised innominate dissection, or more unusually, part of retrograde descending thoracic dissection with skip penetration of innominate artery and sparing of the intervening arch? Was it secondary to the minor fall she had sustained 1 week prior to the event, resulting in a false aneurysm or a contained hematoma next to the innominate artery? More intriguingly, did diffuse aortopathy underpin these diverse etiologies and result in penetrating intimal ulcer with blow out in the innominate artery, intramural hematoma in the arch and descending thoracic aorta and dissection in abdominal aorta at different points in time?

We review the current literature for these unusual afflictions of innominate trunk and its origin from the arch of aorta.

How I do it--sole innominate cannulation for acute type A aortic dissection

We describe sole direct innominate cannulation for arterial return for establishing both cardiopulmonary bypass and selective antegrade cerebral perfusion in the repair of acute type A dissection and compare it with femoral, axillary, direct aortic and apical cannulations. We believe innominate cannulation has all the advantages of right axillary cannulation and none of its disadvantages. It can be used in all patients in whom innominate artery is not dissected, obstructed, calcified or otherwise diseased.

Innominate truncal dissection and rupture into right pleural cavity following acute type A dissection of the aorta with right coronary ostial avulsion and inferior STEMI

An innominate truncal dissection and rupture into the right pleural cavity with massive hemothorax is the initial presentation in this 66-year-old lady with type A dissection of the aorta complicated by right coronary ostial avulsion and inferior STEMI. She underwent supracoronary interposition graft replacement of the ascending aorta and hemiarch, interposition graft replacement of the innominate trunk and saphenous vein bypass grafting of the right coronary artery successfully. Innominate truncal rupture following aortic dissection is practically unknown and has not been described before in the absence of aortic rupture. Innominate truncal rupture secondary to other pathologies presents with supraaortic and mediastinal hematomas, but almost never with right hemothorax. On the backdrop of this unusual presentation with no neurological injury, we review the literature for innominate truncal dissection and rupture, other etiologies for innominate truncal rupture, the complex interplay of factors determining neurological injury and discuss the changes in the strategies and conduct of arterial return during cardiopulmonary bypass and selective antegrade perfusion imposed by this previously undescribed instance of innominate truncal rupture due to dissection.

Hybrid endovascular pseudoaneurysm and pulmonary stenosis repair in bovine arch

This case report details the endovascular management of a large aortic pseudoaneurysm in a high-risk patient with a complicated history using a multi-disciplinary, hybrid approach. The pseudoaneurysm compressed the main pulmonary artery to 5 mm with near complete obstruction of the left main pulmonary artery, while also compromising the lumens of the left superior pulmonary vein and left main bronchus. Furthermore, the patient's left upper extremity arteriovenous dialysis fistula and bovine arch anatomy required a hybrid approach of repair that preserved the fistula while treating the aortic, pulmonary, and bronchial pathology.

Open aortic arch surgery: how to reduce air embolism risk during antegrade cerebral perfusion

Antegrade cerebral perfusion (ACP) is used widely, with the aim of obtaining cerebral protection during open aortic arch surgery. ACP is considered by many to be the reason for improvements in the clinical outcome of this type of surgery. However, perioperative cerebral complications may still occur. Cerebral complications during ACP are considered to be due mainly to embolic events rather than hypoperfusion. We believe that many of the embolic events during ACP may be due to air embolism rather than to vessel manipulation only. To reduce the risk of air embolism during ACP, we propose an easy technique, with the suggested steps to be followed in an exact sequence.