False echocardiographic diagnosis of aortic root dissection in case of abdominal aortic dissection.

A patient with strong clinical and radiological indications of dissection involving the ascending aorta had this "confirmed" on an echocardiogram which showed a typical pattern of double lumen. At necropsy there was dissection of the abdominal aorta but the heavily calcified thoracic aorta was free of dissection. Echocardiography may be useful but not entirely reliable in the diagnosis of dissection even in the presence of a typical clinical picture.     

Reconstruction of heavily calcified aorta and its visceral branches without extracorporeal circulation.

A 61-year-old Japanese female was referred to our hospital for surgical treatment of a localized heavily calcified abdominal aorta. Preoperative angiograms and computed tomograms revealed severe stenosis of the aorta, resembling a slit. Bypass grafting between the thoracic and abdominal aorta was successfully performed together with the reconstruction of the celiac artery, superior mesenteric artery, and bilateral renal arteries without extracorporeal circulation. Postoperative angiograms showed patency of the graft and branches. A localized heavily calcified abdominal aorta is relatively rare, and the cause of this entity might be Takayasu's aortitis.     

Ascending to descending aorta bypass for middle aortic syndrome.

Though stenoses of the descending aorta and its branches are seen with congenital anomalies or systemic inflammation, occlusion of the descending aorta is extremely rare. A patient with an occluded hypoplastic descending thoracic aorta required re-operation because of graft failure between the descending thoracic aorta and the infrarenal abdominal aorta. The etiology of the aortic occlusion in this case is unknown, but inflammation, such as Takayasu disease, is speculated.     

Surgical management of synchronous coronary artery disease and multiple aortic stenosis: a case report with brief review of the literature

One-stage surgery was successfully performed in a 44-year-old hypertensive man with uncontrolled angina, multiple coarctations of the thoracic and abdominal aorta, and a previous subtotal gastrectomy. There was a gradient of 120 mm Hg between the thoracic and abdominal aorta. A graft was placed retroperitoneally from the infrarenal aorta to the ascending aorta and was followed by a coronary artery bypass graft. Twenty-four months postoperatively, the patient was free of angina, and his hypertension was easily controlled.     

Atherosclerotic enlargement of the human abdominal aorta

Aortic aneurysms usually develop in the atherosclerosis prone infrarenal abdominal aorta. To assess the role of atherosclerosis in aortic enlargement, we studied the relation between plaque formation and aortic size in 30 pressure-fixed male cadaver aortas (age 40-95 years, mean age 67 years). Morphometric analysis of transverse sections of the mid-thoracic and the mid-abdominal aortas included measurement of intimal plaque area, lumen area, plaque and media thicknesses. The area encompassed by the internal elastic lamina area (IEL area) was taken to be an index of aortic size. IEL area increased with age at both the thoracic (r=0.77, P<0.01) and abdominal (r=0.54, P<0.01) aortic levels. The aorta also enlarged with increasing plaque area at the thoracic (r=0.73, P<0.01) and abdominal (r=0.79, P<0.01) levels. Regression analysis of IEL area on age, body weight, height and plaque area revealed that the primary predictor of thoracic aortic size was age, whereas the primary predictor of abdominal aortic size was plaque area. Plaque thickness in the abdominal aorta was greater than in the thoracic aorta (P<0.01). Increased plaque area was associated with a significant decrease in media thickness in the abdominal aorta (r=-0.75, P<0.01) but not in the thoracic aorta. Aortas with relatively enlarged abdominal segments, i.e. those with a thoracic to abdominal ratio of <1.2 (n=13), were compared to those with a normal ratio (> or =1.2, n=17). Relatively large abdominal aortas had twofold greater plaque area (P<0.001), reduced medial thickness (P<0.05), fewer medial elastic lamellae (P<0.01) and greater mural tensile stress (P<0.05) than relatively normal abdominal aortas. We conclude that plaque formation in the infrarenal abdominal aorta in humans is associated with aortic enlargement and decreased media thickness. These changes may be predisposing factors for the preferential development of subsequent aneurysmal dilation in the abdominal aorta.     

Total detachment of cardiac myxoma causing saddle embolization and mimicking aortic dissection

A 51-year-old male presented with sudden onset lower abdominal pain followed by weakness of both legs. Examination revealed blood pressure of 220/130 mmHg, with a grade 2/6 systolic murmur audible at the apex of the heart, and absence of both femoral arterial pulses. Two-dimensional and transesophageal echocardiography showed no evidence of intracardiac tumor or dissection of the ascending and thoracic aorta. Moreover, an aortogram demonstrated total occlusion of the abdominal aorta just below the renal arteries. A myxomatous-like material occupying the abdominal aorta just above the bifurcation of the common iliac arteries was discovered during surgery. Histologic examination of the embolic material confirmed the diagnosis of myxomatous embolus. One year after the embolic episode, the patient was well and two-dimensional and transesophageal echocardiography revealed no evidence of residual intracardiac tumor.     

A case report of corrected hypertension after surgical revascularization for Takayasu's disease associated with severe hypertension]

A 59 year old woman presenting with headache subsequently diagnosed as having Takayasu's disease associated with marked systemic hypertension of 290/120 was operated on. She had a 90% constriction of the right renal artery, 70 mmHg pressure gradient across coarctation of abdominal aorta and severe calcification of thoracic and abdominal aorta. In order to correct the hypertension and the coarctation, right axilla-femoral artery and renal artery revascularization were performed. Study carried out one year later showed blood pressure 160/80 and no pressure gradient between upper and lower extremities.     

Impaired endothelium-dependent relaxations in rabbits subjected to aortic coarctation hypertension

Rabbits were rendered hypertensive by suprarenal coarctation of the abdominal aorta. Seven days later, endothelium-dependent and endothelium-independent vascular relaxations were examined in vascular rings taken from hypertensive (thoracic aorta, carotid artery) and normotensive (abdominal aorta) regions. Relaxation of phenylephrine-contracted rings in response to endothelium-dependent agonists (acetylcholine, A23187) was impaired, compared with that in sham-operated and intact controls, in regions exposed to the elevated blood pressure (i.e., above the coarctation). Responses to acetylcholine and A23187 in the abdominal aorta, below the coarctation, were not altered. The diminished endothelium-dependent responses in the thoracic aorta were not affected by pretreatment with the cyclooxygenase inhibitor indomethacin. In contrast to acetylcholine and A23187, responses to the endothelium-independent agonist nitroprusside were not attenuated in vessels from hypertensive regions, indicating that the defect occurred in the endothelium. The EC50 for acetylcholine-induced relaxations of thoracic aorta correlated significantly with mean arterial pressure above the coarctation, indicating that the extent to which endothelium-dependent relaxation is impaired is in proportion to the degree of blood pressure elevation. This study suggests that the diminished relaxations by endothelium-dependent agonists is a local response to the elevation of blood pressure and is not due to a circulating factor.     

同期行降主动脉和腹主动脉腔内修复术

目的：讨论病变同时累及降主动脉和腹主动脉的主动脉疾患,同期行胸主动脉和腹主动脉腔内修复术对脊髓缺血的影响.方法：回顾性分析2009年2月至2013年1月间,本中心收住院的病变同时累及降主动脉和腹主动脉的18例患者,其中男性17例,女性1例,年龄50 ～ 78岁,平均（61.13±7.25）岁,其中胸主动脉瘤伴腹主动脉瘤10例,胸主动脉穿通溃疡伴腹主动脉瘤5例,胸主动脉及腹主动脉均为穿通溃疡2例,胸主动脉夹层伴腹主动脉瘤1例,全部采用双侧股动脉切开行主动脉腔内修复术,其中胸主动脉根据病变范围置入1枚或2枚覆膜支架（部分重叠）,腹主动脉置入分体式或一体式支架.结果：术后1例脊髓供血障碍（5.6％）,经脱水及神经营养性治疗后痊愈,随访3～24个月,无支架移位或内漏等并发症发生.结论：应用覆膜支架同时覆盖降主动脉和腹主动脉处理主动脉病变是安全、有效的.个别可引起脊髓缺血,应进行积极预防和及时处理.     

Hypoplasia of the descending thoracic and abdominal aorta: a case report and review of literature

Coarctation of the aorta has been found at necropsy in approximately 1 of every 1550 individuals. The most common location for segmental coarctation (juxtaductal) is the attachment of the ductus arteriosus to the thoracic aorta, which accounts for 98% of focal lesions. Less commonly, a relatively long segment of constriction extends beyond the left subclavian artery. When longer segments of the aorta are narrowed, the term "hypoplasia" is often used. Aortic hypoplasia, an exceedingly rare cardiovascular anomaly, has been described in all portions of the thoracic and abdominal aorta. In the current case report, we described a 21-year-old man presenting with severe hypertension in whom the diagnosis of hypoplasia of the descending thoracic and abdominal aorta was made using with magnetic resonance imaging.     

Expanding false lumen in the abdominal aorta 5 years after endovascular repair of a type B aortic dissection: successful exclusion of 3 distal re-entry sites.

PURPOSE: To report endovascular treatment of an expanding aneurysmal false lumen several years after successful stent-graft deployment in the descending thoracic aorta for type B aortic dissection. CASE REPORT: A 54-year-old woman who had a stent-graft placed at the entry site of a type B aortic dissection 5 years prior presented with abdominal discomfort and palpable abdominal mass. Successful remodeling of the thoracic aorta was demonstrated by computed tomography; however, a false lumen aneurysm in the abdominal aorta had expanded from 4.8 to 6.5 cm and caused symptoms. She was successfully treated with 3 additional stent-grafts at 3 re-entry sites. Six months after the procedure, the false lumen aneurysm was completely excluded. CONCLUSIONS: Endovascular repair of the re-entry sites can prevent further expansion of false lumen aneurysm, which occurs in some patients with type B dissection treated with stent-grafts.     

Characteristic change in local pulse wave velocity in different segments of the atherosclerotic aorta in KHC rabbits

BACKGROUND: Pulse wave velocity, conventionally determined between the carotid and femoral arteries, is a useful measure to estimate stiffness of the aorta. We investigated local pulse wave velocity (LPWV) in different segments in the aorta with relatively early-stage atherosclerosis in relation to the extent and severity of atherosclerotic lesions. METHODS: Pressure waves were recorded in eight aortic positions using two catheters with one or two micromanometers to determine LPWV in the ascending aorta, distal end of the aortic arch, proximal, middle, and distal thoracic aortas, and proximal, middle, and distal abdominal aortas in Kurosawa and Kusanagi-hypercholesterolemic (KHC) and normal rabbits aged 10 to 12 months. RESULTS: The LPWV in the KHC rabbit was greatest in the aortic arch, decreased almost to the normal level in the middle and distal thoracic aorta, increased in the proximal abdominal aorta, and showed almost identical change to that in the normal rabbit in the middle and distal abdominal aortic regions. There was significant difference in LPWV in the aortic arch, proximal thoracic, and proximal abdominal aortas between the two rabbit groups. The sclerotic lesion was prominent in the aortic arch, proximal thoracic aorta, and proximal abdominal aortas. The wall was severely thickened with abundant foam cells. The significant increase in LPWV would be mainly related to the increased wall thickness in these aortic regions. CONCLUSIONS: We can conclude that LPWV reflects well the distribution and severity of atherosclerotic lesion and the increased wall thickness in the local aortic region in which pulse waves were traveled.     

Crohn’s disease and Takayasu’s arteritis: An uncommon association

Takayasu’s arteritis(TA)and Crohn’s disease(CD)are two rare autoimmune disorders;however some reports describe the presence of both diseases in the same patient.This finding has suggested the possibility that both diseases could share some common etiologic origin.We describe a case of a 13-year-old male affected by CD characterized by fever,diarrhea,weight loss,abdominal pain and elevation of inflammatory markers.Clinical and histological features from colonic specimens were consistent with CD.Treatment with steroids and azathioprine was started,however disease flared every time steroids were tapered.One year later,while still on treatment,he came back to our attention for dyspnea at rest and at night,tiredness and weakness.At physical examination a diastolic heart murmur was found as well as a left carotid artery bruit.A transthoracic echocardiography showed mild aortic valve insufficiency,left ventricular hypertrophy and a dilated ascending aorta with same findings at the aortic arch.A computed tomography scan showed abdominal aortathickening,dilated thoracic aorta and the presence of a thoracic aortic aneurysm.TA associated with CD was diagnosed and medical treatment with cyclophosphamide,steroids and aminosalicylic acid was started,with good clinical response at 6 mo follow-up.We discuss the presence of possible common causes for the two diseases and the importance of differential diagnosis in those patients characterized for intractable disease.     

Positron emission tomography (PET): evaluation of chronic periaortitis

OBJECTIVE: To evaluate the presence and extent of large-vessel inflammation in patients with chronic periaortitis (CP) using (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET). METHODS: A consecutive case series consisting of 7 patients with CP seen over a 3-year period and a control group of 14 patients with malignancy were evaluated with FDG-PET. For every case we selected 2 age- and sex-matched controls who underwent PET imaging for malignancy. The diagnosis of CP was made by means of computed tomography. PET imaging was performed at diagnosis before therapy was started. Measurement of vascular uptake was graded using a 4-point semiquantitative scale. RESULTS: All patients had evidence of grade 2+ or 3+ vascular uptake in the abdominal aorta and/or iliac artery. No controls showed vascular uptake greater than 1+. Vascular uptake in the thoracic aorta and/or in its branches was seen in 3 (43%) of 7 patients. Vascular uptake in abdominal aorta and/or iliac artery was observed in patients with CP but not in controls (100% versus 0%). There was also a significantly more frequent FDG uptake in the large thoracic arteries in case-patients compared with controls (43% versus 0%; P = 0.03). CONCLUSION: FDG-PET scan shows in patients with CP the presence of a large-vessel vasculitis involving abdominal aorta and common iliac arteries, which in some patients is also extended to thoracic aorta and/or its branches.     

An autopsy case of aortitis resulting in a tear of the aortic valve due to a rupture of the aneurysm of Valsalva's sinus]

A 43-year-old man was admitted to a hospital because of acute dyspnea and nocturnal orthopnea. Echocardiogram and chest CT showed the dilation of thoracic aorta from the root to ascending portion. On the third hospital day, he died suddenly. At autopsy, the cause of death was indicated to be a tear of an aortic valve due to a rupture of the aneurysm of Valsalva's sinus, followed by acute aortic regurgitation and acute cardiac insufficiency. Histopathological findings of thoracic aorta revealed mesoaortitis, characterized by patchy destruction of the media with a moth-eaten appearance of the medial elastic laminae and a microgranuloma formation, a perivascular mononuclear cell infiltration of the vasa vasorum, and a fibrous thickening of the intima and adventitia. However, there were no abnormalities in main branches of aorta and abdominal aorta, and no systemic vasculitis. This case is a rare one in the clinical course, and may be important to be differentiated from other cases with aortitis, especially Takayasu arteritis and syphilitic aortitis.     

Hypoplasia of the descending thoracic and abdominal aorta in Williams-Beuren syndrome

Hypoplasia of the descending thoracic and abdominal aorta is a very rare condition and its etiology is poorly understood. Associations with congenital and acquired disorders have been reported. In this article we present the case of a 24-year-old woman with hypoplasia of the thoracic and abdominal aorta and Williams-Beurensyndrome. This rare syndrome is attributed to deletions of genes on chromosome 7, among other the elastin-gene, and is characterized by cardiovascular anomalies, dysmorph facial features and mental retardation. The patient presented with a history of severe hypertension and recurrent abdominal pain since childhood. Diagnosis was established by duplex-sonography and magnetic resonance angiography. The patient was treated by an aortoaortic bypass from the ascending to the infrarenal aorta with reinsertion of the visceral and the right renal arteries. It is essential to recognize the condition early to withhold high morbidity and mortality resulting from long standing severe hypertension.     

Surgical treatment of aneurysms of the abdominal and thoracic aorta

The danger of an arteriosclerotic abdominal aortic aneurysm is clearly related to the size of the aneurysm. From available clinical data it seems logical to recommend elective surgical excision and graft replacement of abdominal aneurysms 6 cm or greater in diameter because of the considerable danger of rupture of untreated aneurysms of this size. Although small aortic aneurysms do rupture, most patients with small abdominal aneurysms may be safely followed with examination at regular intervals. Surgery is reserved for those who demonstrate evidence of aneurysm expansion. The operative mortality rate for elective surgical excision of abdominal aortic aneurysms is by no means negligible but has probably diminished recently to levels of approximately 5% in the hands of experienced surgeons. Achievement of an operative mortality rate in this range requires sensible case selection, expeditious operative management and skillful postoperative care with particular attention to problems of hypoxemia in the early postoperative period.Patients with ruptured abdominal aortic aneurysms require immediate aneurysm resection for survival. Of those patients with ruptured abdominal aneurysms who reach the hospital alive, approximately 60% should be salvaged at present by emergency surgery.The prognosis of the patient with a thoracic aortic aneurysm depends upon the etiology of the aneurysm. Syphilitic aneurysms of the thoracic aorta are now fortunately rare but appear to have a high incidence of rupture. The prognosis of patients with arteriosclerotic aneurysms, which characteristically involve the descending thoracic aorta, appears to be considerably better than that of patients with aneurysms of the abdominal aorta for unknown reasons. Since the removal of thoracic aneurysms ordinarily requires extracorporeal bypass and is associated with an operative mortality rate in the range of 20%, considerable judgment must be exercised in case selection for elective resection of such aneurysms.The surgery of dissecting aneurysms of the thoracic aorta has recently been modified by the widespread acceptance of antihypertensive drug therapy for acute dissection. Surgery may be reserved, hopefully on an elective basis, for those patients with significant aortic valvular insufficiency, significant aneurysmal dilatation of the dissected aorta, or symptomatic involvement of a major aortic branch in the dissection.     

Diet-induced atherosclerosis in cynomolgus monkey aorta and regression by the sixth-month observation.

Pathomorphologic analysis was employed to evaluate diet-induced atherosclerosis in cynomolgus monkey aorta and regression by administration of a hypolipidemic agent for six months after the atherogenic ration. Twenty-seven male cynomolgus monkeys were divided into three groups. Group A was fed individually with a high-fat diet containing 0.3% cholesterol under identical conditions for six months. Group B was fed with normal monkey chow for six months after the same atherogenic ration. Group C was fed with normal monkey chow and administered a hypolipidemic agent 1% of 4-[2-(4-isopropylbenzamido)ethoxy] benzonic acid for six months after the same atherogenic ration. Each thoracic and abdominal aorta of animal models was separately analyzed. Lipid composition analysis and esterified cholesterol (CE) in aortic wall, ratio of free cholesterol to phospholipid, surface involvement, and atherosclerotic index after Sudan IV staining were studied for evaluation of progression and regression. The configurations of atherosclerotic involvement were histologically evaluated among each group. These observed lesions, features specific to cynomolgus lesions, mainly consisted of lipid-rich foam cells, lipid debris, and proliferated extracellular matrix. No different lesion composition was noted between the thoracic and abdominal aorta. This may suggest that some local factors play an important role for development of atherosclerosis after the initial event. Group C had remarkable reduction of foam cells and of CE accumulation in both the thoracic and abdominal aortic wall. Accelerated regression in group C as compared with group B was demonstrated both biochemically and pathohistologically. These results suggest that substantial regression of atherosclerosis in both the thoracic and abdominal aorta can be expected. This hypolipidemic agent exerts notable antiatherosclerotic activity, along with a lowering effect on plasma total cholesterol levels.     

Magnetic resonance tomography in the diagnosis of vascular lesions in hypertension patients

Fifty-six patients with arterial hypertension (AH) and various vascular disorders were investigated by magnetic resonance (MR) tomography. All patients were also subjected to radiopaque aortography. Twenty-seven normal subjects were taken as controls. They showed good visual images of thoracic and abdominal aorta and vena cava inferior in all tomographic sections, yet the frontal section proved the best for vessel visualization as it showed the vessels at length. MR tomograms were similar in patients with essential hypertension, stage I-IIA and in normal subjects, while patients with more than 5-year essential hypertension, stage IIB-III, demonstrated a convoluted aorta (sagittal and frontal sections), with an S-shaped convolution in a number of cases; their aortic diameter was increased owing to a thicker vascular wall as well as a wider lumen. Patients with renovascular hypertension showed abnormal renal arteries featuring pre-stenotic dilatation and stenosed portions. Iliac arterial occlusions were clearly seen. Patients with wide-spread atherosclerosis and nonspecific aorto-arteritis showed a variety of thoracic or abdominal aortic aneurysms.     

Hybrid thoracoabdominal aneurysm repair with simultaneous antegrade visceral revascularization and supra-aortic debranching from the ascending aorta.

PURPOSE: To describe a hybrid technique involving combined antegrade revascularization of both supra-aortic and visceral arteries and complete exclusion of a dissecting thoracoabdominal aortic aneurysm (TAAA). TECHNIQUE: A 46-year-old man had a dissecting TAAA involving the left subclavian artery (LSA) and the descending thoracic and abdominal aorta down to the left common iliac artery. The ascending aorta was the only feasible source of inflow to the cerebral and visceral vessels. Via a median thoracolaparotomy, the supra-aortic and visceral arteries were dissected, and an octopus graft was implanted using 3 bifurcated Dacron grafts. An 18-x9-mm bifurcated Dacron graft was anastomosed in an end-to-side fashion to the ascending aorta, the brachiocephalic trunk, and the left common carotid artery. A 16-x8-mm bifurcated Dacron graft was sutured end-to-side to the celiac artery and superior mesenteric artery. A third 12-x7-mm bifurcated graft was sutured to both renal arteries. In a second step, 3 tapered custom-made thoracic Zenith TX2 endografts were used to repair the thoracic and the thoracoabdominal aorta. A bifurcated Zenith AAA device was used to treat the aneurysm at the level of the infrarenal aorta and both iliac arteries. Despite covering the LSA and all intercostal and lumbar arteries, the patient developed only a temporary paresis of the left leg. Computed tomography showed complete exclusion of the aneurysm and normal flow to the supra-aortic and visceral arteries. CONCLUSION: In selected cases, this hybrid approach using the ascending aorta for antegrade revascularization of cerebral and visceral arteries is feasible, with acceptable perioperative morbidity. However, its role for the treatment of complex thoracoabdominal aortic disease must be evaluated further.