Aneurysm of the ascending aorta in systemic lupus erythematosus: Case report and review of the literature

Fatal ascending aortic aneurysm in a patient with systemic lupus erythematosus: A case report

Aortic aneurysm is a potentially life-threatening condition with higher incidence in patients with systemic lupus erythematosus(SLE). Patients usually present with nonspecific symptoms and diagnosis is typically made incidentally through imaging studies. Management strategies include medical therapy to control inflammation and hypertension, surgical intervention for large or symptomatic aneursyms, and close monitoring for early detection of complications. We present a case of a 49-year female with multiple joint pain and other nonspecific symptoms for 7 years. Anti-ds DNA and ANA titre were significantly high and CT angiogram showed ascending aortic aneurysm measuring 5.5 cm. Conservative management was started with steroids, hydroxychloroquine, and antihypertensives, while awaiting surgery. However she suddenly collapsed, probably due to aneurysm rupture and could not be revived. Our case report therefore emphasizes the importance of close surveillance and timely intervention to minimize the morbidity and mortality in these patients.

Individualized prediction of risk of ascending aortic syndromes

Objectives

Although ascending aortic diameter changes acutely after dissection, recommendation for prophylactic surgery of thoracic aortic aneurysms rely on data from dissected aortas. In this case-control study we aim to identify risk markers for acute and chronic aortic syndromes of the ascending aorta (ACAS-AA). Furthermore, to develop a predictive model for ACAS-AA.

Methods

We collected data of 188 cases of ACAS-AA and 376 controls standardized to age- and sex of the background population. Medical history and CT-derived aortic morphology were collected. For the dependent outcome ACAS-AA, potential independent risk factors were identified by univariate logistic regression and confirmed in multivariate logistic regression. As post-dissection tubular ascending aortic diameter is prone to expand, this factor was not included in the first model. The individual calculated adjusted odds ratios were then used in ROC-curve analysis to evaluate the diagnostic accuracy of the model. To test the influence of post-ACAS-AA tubular ascending aortic diameter, this was added to the model.

Results

The following risk factors were identified as independent risk factors for ACAS-AA in multivariate analysis: bicuspid aortic valve (OR 20.41, p = 0.03), renal insufficiency (OR 2.9, p<0.01), infrarenal abdominal aortic diameter (OR 1.08, p<0.01), left common carotid artery diameter (OR 1.40, p<0.01) and aortic width (OR 1.07, p<0.01). Area under the curve was 0.88 (p<0.01). Adding post-ACAS-AA tubular ascending aortic diameter to the model, negated the association of bicuspid aortic valve, renal insufficiency, and left common carotid artery diameter. Area under the curve changed to 0.98 (p<0.01).

Conclusions

A high performing predictive model for ACAS-AA, free of ascending aortic diameter, can be achieved. Furthermore, we have identified abdominal aortic ectasia as an independent risk factor of ACAS-AA. Integration of potential biomarkers and morphologic variables, derived from undissected aortas, would probably improve the model.

Endovascular Aneurysm Repair (EVAR) of an Infrarenal Abdominal Aortic Aneurysm (AAA) in a Young Patient with Systemic Lupus Erythematosus (SLE)

Introduction

While hypertension, pericardial, myocardial, and coronary artery disease are common cardiovascular manifestations of systemic lupus erythematosus (SLE), aortic aneurysms (AA) are rare but increasingly diagnosed, with the true incidence unknown.

Case report

A 40 year old female suffering from SLE with a 5.3 cm saccular eccentric infrarenal abdominal aortic aneurysm (AAA) was treated successfully with endovascular aneurysm repair (EVAR) using the Medtronic Endurant II bifurcated stent graft and followed up 2 years post-operatively. Pre-operatively, open and EVAR options were offered and the latter was chosen by the patient.

Discussion

Proposed mechanisms for AA formation in SLE including accelerated atherosclerosis brought about by chronic steroid use and SLE associated vasculitis and cystic medial degeneration (CMD) have been discussed in other case reports and series. To the authors' knowledge, the use of EVAR for AAA in SLE patients has not been reported in available literature. The need for earlier repair, screening, and detection as well as the long-term suitability, durability, and surveillance of EVAR remain unknown. The benefit of using the Ovation device in minimising late neck dilatation is also discussed.

Conclusion

EVAR was demonstrated to be a suitable form of repair in a young female patient with SLE and AAA, followed up 2 years post-surgery. The ideal repair and the natural history of these aneurysms remains to be studied.