Penetrating aortic ulcers after absorption of intramural hematoma

We report a case of a type B aortic intramural hematoma, which rapidly expanded, with ulcer-like projections, after complete absorption of the hematoma. One month after the initial presentation, a new computed tomographic scan showed the appearance of a thin ulcer-like projection in the aortic wall. Three months later, after the patient reported a new episode of chest pain, a computed tomographic scan revealed 2 penetrating ulcers and rapid aortic dilation; the aortic hematoma had been completely absorbed. Urgent thoracic aortic replacement was undertaken. Three years postoperatively, the patient was asymptomatic, with no lesion or dilation of the aorta upon computed tomography. After an acute hematoma, the strength and structure of the aortic wall can alter rapidly. Damage and weakening of the aortic wall are caused mainly by infiltration of inflammatory cells, which have pronounced proteolytic and elastolytic activity. Due to the unstable nature of the lesion, optimal management remains controversial. In our patient, the inflammatory process led to the development of 2 aortic ulcers and aortic dilation within 3 months of the acute lesion, requiring urgent surgical intervention.     

主动脉壁内血肿的诊疗现状

主动脉壁内血肿(IMH)是一种急性、致命性的主动脉病变,与主动脉夹层、主动脉穿透性溃疡并称为急性主动脉综合征。目前,IMH的定义、病因和治疗等方面仍存在争议,故本文就IMH的诊疗现状做一综述。     

Magnetic resonance imaging of thoracic aortic dissections

Magnetic resonance imaging is an excellent noninvasive method for evaluating thoracic aortic dissections. A variety of magnetic resonance scans of aortic dissections are shown, documenting the ability of magnetic resonance to image the true lumen, the false channel, and the intimal septum. Detail is provided on magnetic resonance imaging techniques and findings.     

带膜血管内支架置入治疗胸主动脉夹层

目的　总结带膜血管内支架置入治疗DebakeyⅢ型主动脉夹层临床经验。方法　胸主动脉夹层 4 9例 ,男 4 4例 ,女 5例 ,平均年龄 (5 1 6± 1 8)岁。经CT增强扫描或磁共振成像确诊。切开右或左侧股动脉置入带膜血管内支架 ,封堵原发破口。置入后重复造影检查。随访行胸部X线平片与电子束CT检查。结果　支架置入全部成功 ,术后即刻造影 4 0例无内漏 ,9例见少量内漏。降主动脉及腹主动脉真腔均明显扩大 ,远端降主动脉及分支供血均有不同程度的改善。 1例因支架置入位置过高 ,行外科升主动脉 左颈总动脉 左锁骨下动脉旁路移植术。 1例术后死于中毒性休克。术后随访 :降主动脉及腹主动脉真腔扩大 ,术后造影 9例有内漏者 ,无加重 ,4例患者近端夹层动脉瘤消失 ,余者夹层近端假腔内均有血栓形成。结论　带膜血管内支架置入治疗胸主动脉夹层近期疗效满意 ,远期疗效有待于进一步观察。     

Genetic basis of thoracic aortic aneurysms and dissections

The major diseases affecting the aorta are aortic aneurysms and dissections, which are classified based on anatomic location. Diseases affecting the ascending aorta, such as thoracic aortic aneurysms and type I and II dissections, are primarily associated with medial necrosis on pathologic examination. Medial necrosis is characterized by fragmentation and loss of elastic fibers, loss of smooth muscle cells, and interstitial collections of collagenous tissue and basophilic ground substance. Medial necrosis occurs as part of the normal aging of the aorta but is accelerated by other conditions, including hypertension and genetic alterations that predispose persons to these aortic diseases. The etiologies of many of the genetic syndromes, such as Marfan syndrome, that predispose persons to thoracic aortic aneurysms and dissections are understood. Studies are just beginning to elucidate the genes that predispose persons without known syndromes to these aortic diseases, and a major locus for this condition, termed the TAAD1 locus, has been mapped to 5q13-14. Future characterization of this gene and others will enhance the ability to determine persons at risk for aortic aneurysms and dissections and will define molecular mechanisms involved in the pathogenesis of this disorder.     

Penetrating atherosclerotic ulcer of the thoracic aorta descendens

Penetrating atherosclerotic ulcer of the thoracic aorta descendens. HISTORY AND CLINICAL FINDINGS: A 75-year-old man with a history of generalised atherosclerosis was admitted to hospital for invasive assessment of progredient typical angina pectoris. Apart from diminished peripheral pulses, physical examination was normal. INVESTIGATIONS: Coronary angiography revealed a three vessel coronary artery disease. The chest X-ray showed elongation and dilatation of the distal aortic arch and the proximal descending aorta thoracalis. Computed tomography and magnetic resonance imaging of the thorax as well as magnetic resonance angiography of the thoracic aorta, demonstrated a penetrating atherosclerotic ulcer of the descending aorta thoracalis, with extensive intramural hematoma. TREATMENT AND COURSE: After percutaneous ballon-dilatation of the right coronary artery and the circumflex artery, the patient was asymptomatic. Considering all aspects of the patients condition, medical treatment of the penetrating atherosclerotic ulcer was decided for the patient. The findings of the thoracic computed tomography after 6 months were unchanged. CONCLUSION: The penetrating atherosclerotic ulcer of the thoracic aorta is a less known clinical entity. Our case report demonstrates that even extensive forms can be clinical asymptomatic and discovered by routine radiologic examinations.     

腔内血管支架植入治疗胸主动脉夹层

目的：总结腔内血管支架植入治疗主动脉夹层临床经验。方法：胸主动脉夹层5例,男3例,女2例,平均年龄(53.5±4.5)岁。经多排 CT 增强扫描或磁共振成像确诊。切开右侧股动脉,植入腔内血管带膜支架,封堵原发破口。植入后重复造影检查。随访行胸部 X 线平片与多排螺旋 CT 检查。结果：支架植入均成功,术后即刻造影5例均无内漏。降主动脉及腹主动脉真腔均明显扩大,远端降主动脉及分支供血均有明显改善。术后3月随访,降主动脉及腹主动脉真腔扩大,近端夹层动脉瘤消失。结论：腔内血管带膜支架植入治疗胸主动脉夹层近期疗效满意。     

Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography

Objectives. This study sought to describe the ability of transesophageal echocardiography (TEE) to document the presence of penetrating atherosclerotic aortic ulcers and their complications.Background. TEE has greatly enhanced our ability to assess patients with suspected aortic disease. However, the utility of this technique in the diagnosis of penetrating atherosclerotic aortic ulcers is still undefined.Methods. TEE was performed prospectively in 194 patients to evaluate aortic disease. Twelve patients with the diagnosis of aortic ulcers or their complications were specifically studied. The diagnosis was confirmed by pathologic studies in six patients and by an additional diagnostic technique (angiography, computed tomography or magnetic resonance imaging) in the other six. All 12 patients were hypertensive and presented with chest or back pain; the mean age was 65 years (range 56 to 79). The initial working diagnosis was acute aortic dissection in nine patients. Aortic ulcers were located in the descending thoracic aorta in eight patients, the aortic arch in two and the ascending aorta in two.Results. TEE could detect aortic ulcers or their complications in 10 patients but failed to detect these lesions in the remaining 2 (1 with aortic ulcers in the distal ascending aorta and 1 with aortic ulcers in the aortic arch). In four patients, aortic ulcers were detected as a calcified focal outpouching of the aortic wall and were associated with concomitant aneurysmal dilation of the aorta in two patients and with a small localized intramural hematoma in one. TEE visualized a partially thrombosed pseudoaneurysm complicating an aortic ulcer in the descending thoracic aorta of two patients. Four patients had an aortic ulcer complicated by a “limited aortic dissection” in the descending aorta that could be detected by TEE. Five patients underwent operation, two because of aneurysmal dilation of the aorta and three because of aortic dissection; two patients died of aortic rupture; the remaining five did well (11-month follow-up) without operation.Conclusions. Aortic ulcers should be included in the differential diagnosis of chest or back pain, especially in elderly hypertensive patients. These ulcers and their complications may be recognized by TEE.     

Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections

The natural history of thoracic aortic aneurysms and dissections is diverse, reflecting a broad spectrum of etiologies which include increasing aortic size, hypertension, and genetic factors. The pathogenesis is related to defects or degeneration in structural integrity of the adventitia, not the media, which is required for aneurysm formation. The ascending and descending aorta appear to have separate underlying disease processor that lead to a weakened vessel wall and an increased susceptibility for dissection. Etiologic factors for aortic aneurysms and dissections are multifactorial, reflecting genetic, environmental, and physiologic influences.     

Elective stent-graft treatment of aortic dissections.

PURPOSE: To retrospectively review 8 years' experience with stent-graft treatment of aortic dissections at a single institution. METHODS: Forty-six patients (31 men; mean age 59 years, range 38-88) underwent stent-graft treatment for 9 Stanford type A and 37 type B aortic dissections (9 acute phase, 13 subacute, 24 chronic). Custom-designed self-expanding stainless steel Z stents covered with polytetrafluoroethylene were used (n=20) until low-profile modular stent-grafts became available for percutaneous delivery (n=26). RESULTS: Endovascular stent-graft deployment was technically successful in 44 (96%) patients; the 2 failed cases owing to intraprocedural migration and graft torsion were converted to surgery. There were 5 type I endoleaks for a clinical success (entry tear exclusion) of 85% (39/46). Complications included 3 cases of transient renal failure, 2 puncture site pseudoaneurysms, 1 guidewire-induced new intimal tear (converted), and 2 cases of stent-induced saccular aneurysms (1 converted). Follow-up at a mean 34 months (range 12-96) showed complete resolution of the thoracic false lumen in 14 (74%) of 19 acute/subacute patients treated successfully; 3 (16%) showed a reduced thoracic false lumen diameter. In the 23 chronic-phase patients treated successfully, 8 (35%) had complete resolution of the thoracic false lumen, and 11 (48%) showed size reduction. Enlargement of the abdominal aortic false lumen due to persistent flow into re-entry tear(s) occurred in 3 (13%). CONCLUSIONS: Stent-graft treatment is a feasible and effective treatment modality in aortic dissection. However, close follow-up is mandatory to monitor new intimal tear, saccular aneurysms, or enlargement of the abdominal aortic false lumen.     

Different remodeling of descending thoracic aorta after acute event in aortic intramural hemorrhage versus aortic dissection

The natural healing process of medically treated aortic dissection (AD) and aortic intramural hemorrhage (AIH) developed in the descending thoracic aorta was compared to test the hypothesis that absence of intimal tear and flow communication in AIH may have different impact on the remodeling of the affected aorta after the acute event. In 25 patients with AD and 20 with AIH involving distal descending thoracic aorta stabilized with medical treatment, follow-up (mean 9 months) transesophageal echocardiography was performed to measure the maximal dimensions of aorta, true lumen, false lumen in AD, and abnormal wall thickening in AIH. The sex ratio, prevalence of hypertension, baseline maximal dimension, and longitudinal extent of the affected aorta did not show any significant difference in both groups. Patients with AIH were older than those with AD (63 +/- 10 vs 50 +/- 9, p <0.01). Disappearance of abnormal wall thickening with complete restoration of the aorta occurred in 70% (14 of 20) patients with AIH, which was significantly more frequent than in AD (8%, p <0.01). In AD, progressive dilatation of the aorta with continuous flow communication in the false lumen resulted in larger dimension of the aorta than in AIH (44 +/- 13 vs 35 +/- 7 mm, p <0.01). Absence of persistent flow communication resulted in a favorable remodeling process in AIH affecting distal descending aorta. This finding, along with different mean age in AIH and AD, may suggest that AIH is not just a precursor of overt AD but a distinct disease entity with different pathophysiology.