Repair of thoracic aortic aneurysm due to noninfectious aortitis

Abstract 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.     

Rupture of ascending aorta secondary to tuberculous aortitis

Tuberculous aortitis generally develops at the distal aortic arch and the descending aorta that are close to specific groups of mediastinal lymph nodes, but exceptionally it develops in the ascending aorta. We report a case of rupture of the ascending aorta after tuberculous aortitis in a 53-year-old man without a history of tuberculosis or evidence of a primary foci who underwent cardiopulmonary resuscitation due to severe hemoptysis with subsequent cardiac arrest. The tuberculous aortitis associated with rupture of the ascending aorta was treated with surgical resection and in situ graft placement.     

Ascending aortic aneurysm following aortic valve replacement due to aortitis syndrome; report of a case

A 60-year-old woman had previously undergone aortic valve replacement for aortic regurgitation. As the aortic wall was elastic hard, inflammatory change was suspected; therefore, we undertook a partial biopsy of the ascending aortic wall and the intraoperative pathological specimens were compatible with aortitis syndrome. As there was no active inflammatory change, she was diagnosed as inactive aortitis syndrome and steroid therapy was not applied. Seven years later, a follow-up computed tomography (CT) showed an ascending aortic aneurysm of 65 mm in diameter. Aortic root replacement was planned based on a clinical diagnosis of an aneurysm of the ascending aorta. The patient was discharged without complication 21 days after surgery. It is possible that an inactive stage of aortitis may lead to late dilatation of the ascending aorta; therefore, careful postoperative follow-up is necessary in such cases.     

Aortic involvement in giant cell arteritis: current data

Aortitis due to giant cell arteritis (GCA) is rare but probably underestimated given the frequent paucity of symptoms. Thus, early studies relied on the occurrence of complications to estimate the prevalence of GCA aortitis. With this method, aortitis was a feature in 3 to 18% of GCA patients. Since then, the introduction of modern imaging techniques has established that aortitis is more common than previously thought. Aortitis should be considered in patients with atypical clinical presentations of GCA consisting, for instance, in isolated laboratory evidence of systemic inflammation or a relapse during treatment. Aortitis may be difficult to diagnose, as temporal artery biopsy has limited sensitivity in patients with predominant large-vessel involvement. Positron emission tomography (PET) and magnetic resonance imaging (MRI) are both highly effective for the early diagnosis of aortitis. Case-series evaluating PET in patients with GCA found evidence of aortitis in over half the cases, with predominant involvement of the thoracic aorta. To date, no evidence is available about the potential usefulness of PET or MRI in monitoring patients with GCA aortitis over time. Involvement of the aorta and other large arteries does not change the treatment strategy, which rests on corticosteroid therapy. Administration of a corticosteroid-sparing drug should be considered, most notably when a relapse occurs. Aortitis is associated with an increased risk of aneurysm of the thoracic aorta. Consequently, all GCA patients should be monitored for aneurysm at regular intervals, even after treatment discontinuation. The recommended strategy is an annual evaluation including a chest radiograph, echocardiogram, and abdominal Doppler sonogram; these imaging studies can be replaced by contrast-enhanced computed tomography of the chest and abdomen.     

A case of atypical aortic coarctation with mitral and aortic regurgitation and ascending aortic dilatation

A 67-year-old female presented with dyspnea on exertion as a chief complaint. Diagnosed as having severe mitral regurgitation, aortic regurgitation, dilatation of the ascending aorta and atypical coarctation due to aortitis syndrome, she underwent mitral valve replacement, aortic valve replacement, ascending aorta and hemiarch replacement and ascending aorta-abdominal aorta extraanatomical bypass in one stage. Pathologically, typical findings of aortitis syndrome were not observed in the wall of the ascending aorta and aortic valve, but cystic medionecrosis was noted in the wall of the ascending aorta. Follow-up observations are needed for the remaining aortic wall.     

Mediastinal mass caused by syphilitic aortitis.

A 47 year old man presented with hoarseness and chest pain found to be due to proliferative syphilitic aortitis. The case is unusual as the syphilitic aortitis caused a mediastinal mass without affecting the lumen of the aorta.     

Prevotella intermedia infection causing acute and complicated aortitis—A case report

INTRODUCTIONAortitis is a general term that refers to all conditions involving an inflammation of the aortic wall. This case report describes the surgical approach of a patient with infectious and symptomatic aortitis caused by the rare vector Prevotella intermedia.PRESENTATION OF CASEA 44-year old male patient was admitted with fever and general discomfort after a period of sore throat in a non-teaching hospital. After two weeks he developed acute abdominal and back pain accompanied by sweating and elevated infection parameters. Computed tomography angiography revealed atherosclerotic changes of the infrarenal aorta with a locally contained rupture of the aorta alongside peri-aortal signs of inflammation (and aortitis aspects). An urgent aortic reconstruction was performed according to Nevelsteen. The blood cultures turned out positive for Prevotella intermedia. Postoperatively the patient received antibiotics for six weeks. The patient recovered uneventful from this infection and surgical procedure.DISCUSSIONA complicated and acute aortitis is a rare but potentially life-threatening disease. The aetiology can be ordered into two main groups; inflammatory and infectious. Diagnosis is based upon symptoms, biochemical values, microbiological results and imaging modalities. Treatment depends on aetiology and should be discussed in an experienced multidisciplinary setting. Infectious aortitis should be treated with antibiotics for at least six weeks with close monitoring of the patient’s clinic and biochemical values, even after surgery.CONCLUSIONPrevotella intermedia is a rare causative agent for aortitis. Acute aortitis is a challenging clinical entity which should be managed in an equipped medical center by an experienced multidisciplinary team.     

Application of a large occlusion balloon catheter to re-do open heart surgery

A very rare case having re-do open heart surgery four times during two years was reported. The case was 30 year-old-male complicated with aortitis syndrome and underwent mitral valve replacement because of infective endocarditis. But the prosthetic valve repeated detachment over and over again after first MVR in spite of complete treatment of steroid for aortitis syndrome. When fourth re-operation, it was easily expected that median sternotomy, cannulation and clamping would be difficult because of tough adhesion. So large occlusion balloon catheter was used to clamp the ascending aorta and operative field was exposed by left thoracotomy under femoro-femoral bypass. We could accomplish the operative procedure safely under "instrument free" operative field. Large occlusion balloon catheter is very useful for aortic clamping in case of not only reoperation but calcified aorta and so on.     

Surgical pathology of noninfectious ascending aortitis: a study of 45 cases with emphasis on an isolated variant

BACKGROUND: Aortitis is emerging as an important cause of ascending aortic aneurysm in the elderly. Its features have not been described in a surgical population. DESIGN: Retrospective clinicopathologic review of 45 cases of active noninfectious aortitis among 513 consecutive ascending aortic resections (1985 to 1999). METHODS: Clinical data were collected from medical records. Histopathologic features were recorded during review of slides stained with hematoxylin-eosin and Verhoeff-van Gieson. Cases were categorized by predefined clinical criteria. Clinicopathologic features were compared among groups, with emphasis on unsuspected aortitis without systemic arteritis. RESULTS: The 2 largest groups were isolated aortitis (47%) and giant cell arteritis (31%). Other aortitis groups included Takayasu (14%), rheumatoid (4%), and unclassified (4%). Patients with isolated aortitis and giant cell arteritis were generally women (80%; mean age 73 y). All 6 with Takayasu arteritis were women (mean age 26). Although giant cell arteritis and isolated aortitis were histologically indistinguishable, their clinical courses differed substantially. Among 21 patients with isolated aortitis (2 treated with corticosteroids), only 10% later developed aortic aneurysms. In contrast, of 14 patients with giant cell arteritis (11 treated with corticosteroids), 21% subsequently developed aneurysms (P=0.09). CONCLUSIONS: Aortitis primarily affected women. Patients with isolated aortitis and giant cell arteritis were generally older than 50 years and, by definition, those with Takayasu arteritis were younger. In patients with isolated aortitis, outcomes were generally good, despite the absence of anti-inflammatory therapy. Accordingly, a conservative approach may be warranted for managing this subset of patients with aortitis.     

Custom-made endograft with left subclavian artery branch in a patient with Takayasu aortitis complicated by type-B dissection and inflammatory involvement of the epiaortic vessels

Type-B aortic dissection in a patient affected by Takayasu disease is a rarely described condition and its management can be challenging. A 47-year-old woman with Takayasu aortitis and previous aortic valve and ascending aorta replacement was admitted to hospital for type-B aortic dissection. The recent instabilization of aortic disease, the persistence of episodes of transient chest pain and the largest size of the aneurismatic tract of thoracic descending aorta rendered an invasive approach mandatory. Since the patient presented a complete bilateral occlusion of the subclavian artery just after the origin of the vertebral artery and a subcritical, smooth, bilateral stenosis of the common carotid artery, a custom-made endograft with left subclavian artery branch was successfully positioned, thus allowing the preservation of antegrade left vertebral circulation. This is the first case reporting an entirely endovascular exclusion of type-B dissection in a patient affected by Takayasu aortitis using a custom-made endograft with a subclavian branch allowing the preservation of the antegrade flow to left vertebral artery.     

A case of coexisting descending thoracic aortic aneurysm and atypical aortic coarctation treated successfully by surgery using the thromboexclusion method

The thromboexclusion method was successfully applied to a 43-year-old male with aortitis syndrome. Preoperative aortogram showed a fusiform aneurysm of the descending aorta just below the left subclavian artery and atypical coarctation of the descending aorta distal to this aneurysm. Pressure gradient across the stenosis was about 70 mmHg. The technique of flow reversal and thromboexclusion was performed in this patient because of severe calcification in the aortic arch and the entire descending aorta. A long extra-anatomical bypass between the ascending aorta and the infrarenal abdominal aorta was made, and a permanent aortic clamp was placed across the aorta at the left subclavian artery. Hypertension in the arm disappeared immediately after the operation, and postoperative catheterization revealed no pressure gradient between the ascending and the abdominal aorta. Computed tomogram performed 18 days after the operation and aortogram done 44 days postoperatively disclosed thrombi formation in the aneurysm.     

Left coronary ostial stenosis in aortitis syndrome--patch mounted graft technique for proximal anastomosis

Late restenosis or total occlusion of proximal aortic anastomosis frequently occurs due to intimal proliferation in aortitis CABG patients although successful early postoperatively. A Gore-Tex patch (diameter 20 mm) mounted grafts to LAD and CX with a single ostium was sutured in the inflammatory aorta to prevent late occlusion in a 40-year-old female patient. Postoperative CAG a month after showed a patent graft to LAD and improved exercise treadmill test. Graft to Cx occluded due to competed flow from LAD. No aneurysm was found in the proximal anastomosis. Tissue nonpermeable Gore-Tex mounted graft is considered to be suitable for CABG in aortitis patients with the high incidence of late occlusion.     

Cryptococcal aortitis presenting as a ruptured mycotic abdominal aortic aneurysm.

Mycotic processes occasionally complicate atherosclerotic aortic disease and usually require aggressive surgical therapy to control sepsis and prevent arterial rupture. Rarely, fungal organisms are responsible for primary infection of the abdominal aorta. We report the first case of Cryptococcal aortitis presenting as a ruptured abdominal aortic aneurysm. The surgical, pathologic, and microbiologic aspects of fungal aortitis are discussed.     

A case of surgery for annuloaortic ectasia and aortic regurgitation complicated by ulcerative colitis and aortitis syndrome]

We performed an operation for AAE and AR complicated by ulcerative colitis and aortitis syndrome. The patient was a 20-year-old male who had been treated for ulcerative colitis in our hospital since 1983, when he was 18 years old. In 1985, he was admitted to our hospital for treatment and evaluation of left heart failure. He was diagnosed as having AAE and AR due to aortitis syndrome, and steroid therapy was started. He developed heart failure, and surgery was indicated. At operation, before clamping the aorta we made a composite graft. The ascending aorta and aortic valve were replaced by the composite graft, and button-shaped coronary ostia were sutured directly into the graft. His postoperative course was uneventful and he was discharged. He is now maintained on steroid therapy for his aortitis syndrome.     

A case of coronary artery bypass for bilateral coronary ostial stenosis in aortitis syndrome with occlusion of bilateral subclavian arteries]

A 52-year-old female with bilateral coronary ostial stenosis in aortitis syndrome underwent CABG. Vein grafts were used instead of arterial grafts, because of the occlusion of bilateral subclavian arteries. Proximal anastomosis of the grafts was performed after oval stomas larger than usual were created on the aortic wall to prevent late graft occlusion due to intimal proliferation of the aorta. On postoperative CAG, all grafts to RCA, LAD and Cx were patent. The patient left the hospital 3 weeks after surgery. We believe that CABG is preferable to the transaortic endarterectomy in the surgical treatment for coronary ostial stenosis associated with aortitis syndrome, because of the prevalence of technical difficulty and postoperative morbidity in the latter.     

Abdominal infectious aortitis caused by Streptococcus pneumoniae: a case report and literature review

We report a case of a 75-year-old man who had been complaining of fever and pelvic pain for 3 weeks. First angio-computed tomography (CT) characteristics and blood culture led to suspicion of a pneumococcal-infected aortic aneurysm, which however was not confirmed by the surgeon. The abdominal infectious aortitis caused by Streptococcus pneumoniae was affirmed by a second angio-CT performed 7 days later. Without further delay, the patient underwent surgery for resection of mycotic aneurysm and in situ reconstruction with aortobiiliac homograft, in association with antibiotics. He died 10 days after the surgery as a result of severe sepsis in a polyvalent intensive care unit. This case report highlights the severity of this pathology. We reviewed the relevant literature related to Streptococcal pneumoniae mycotic aneurysm located in the abdominal aorta, including 29 more cases. Various microorganisms have already been associated with mycotic aneurysms, including S pneumoniae. Infectious aortitis remains a rare disease. It is extremely important to establish an early diagnosis but it may be delayed because clinical manifestations are usually nonspecific. However, if left untreated it is always lethal. Antibiotic in combination with complete surgical excision of the infected aorta is the treatment of reference. This therapeutic association dramatically improved patient survival.     

Open stent implantation for ascending aorta aneurysm with severe calcification

A 77-year-old woman had an ascending aortic aneurysm and aortic regurgitation due to aortitis syndrome. Computed tomography showed that ascending aorta was 55 mm in diameter and had severe calcification between the ascending aorta and distal aortic arch involves neck vessels. We performed open stent implantation and aortic valve replacement with bioprostheses valve. No adverse event occurred after the operation and the patient was discharged on the 28th postoperative day. The open stent implantation was useful for the treatment of the aneurysm in high risk patients.     

How to mimic a type A intramural hematoma: A case of IgG4-related aortitis associated with cerebral hemorrhage

IgG4-related aortitis is an inflammatory condition of the aorta, characterized by aortic wall thickening and periaortic soft-tissue involvement. Therefore, this condition can mimic an aortic intramural hematoma (IMH), due to similar radiological findings. We hereby report the case of an IgG4-related aortitis misdiagnosed as an IMH, associated with cerebral hemorrhage, possibly due to cerebral vascular system involvement.     

Aortitis and bacterial endocarditis

Aortitis is an inflammatory condition that can be due to numerous causes. It is a diagnostic quandary because it commonly shows similar clinical, pathologic, and aortographic features independently of the etiology. A case of aortitis, possibly secondary to bacterial endocarditis, initially misdiagnosed as an atherosclerotic aortic ulcer and managed with an endoprosthesis is presented. On the fourth postoperative day, the patient presented with fever and worsening abdominal pain, which was later diagnosed as infectious aortitis. It required débridement and replacement of the infrarenal aorta with a cadaveric cryopreserved allograft. This case emphasizes the need for early diagnosis and aggressive therapy to avoid life-threatening sequelae.     

Aortitis – ein seltenes Krankheitsbild

Rupture of the aorta is a life threatening situations. The genesis of the alteration of the aortic wall is not very important for the prognosis, but it well influence the outcome. One of the rare causes of aortic rupture is aortitis. At the time of beginning of the illness the symptoms are not characteristic and are difficult to diagnose. In this article a case of aortic rupture secondary to aortitis is reported. The operative methods are discussed.