Ann Thorac Surg 2006;81:750
© 2006 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Multiple Penetrating Aortic Ulcers
Akihiko Usui, MD
*
,
Hiroshi Masumoto, MD,
Toshiaki Akita, MD,
Masaharu Yoshikawa, MD,
Hiroomi Murayama, MD,
Yuichi Ueda, MD
Nagoya University, Nagoya, Japan
* Address correspondence to Dr Usui, Nagoya University, 65 Tsurumai, Showa-ku, Nagoya 466-8550, Japan (Email: ausui{at}med.nagoya-u.ac.jp).
A 72-year-old Japanese man experienced left hemothorax and mediastinal hematoma while in Switzerland. He was admitted to a local hospital and was treated by left pleural drainage and antihypertensive therapy for 1 month. He then returned to Japan and was admitted to our institute. Enhanced computed tomography of his chest and 3-dimensional reconstruction revealed an old mediastinal hematoma and slight left pleural effusion. The aortic arch had a small aneurysmal formation on the anterior wall, and the whole descending aorta showed wall irregularities and several small extrusions of less than 1 cm in diameter (Fig 1). Slices through these indicated an intima defect associated with thin aortic adventitia. We diagnosed these as multiple penetrating aortic ulcers [1]. This represents a diffusely diseased aorta and might be a cause of sealed aortic rupture. Antihypertensive medication was applied cautiously for 6 months, but the aortic arch aneurysm grew, and some aortic ulcers increased in depth. We decided on surgery. Deep hypothermic circulatory arrest with retrograde cerebral perfusion was applied after core cooling to less than 20°C with ascending aortic perfusion and bicaval drainage to avoid embolization. The aortic arch was replaced with a 4-branched woven Dacron graft (Hemashield Gold; Boston Science, Boston, MA), and an endovascular stent graft was inserted into the upper half of the descending aorta through the aortic arch in a frozen elephant trunk procedure by median sternotomy [2]. The interior of the whole descending aorta was observed with an endoscope. The intima was extensively rough, with linear wrinkles, irregular erosion, and elevated atheromatous plaques (Fig 2). The patient was discharged from the hospital without problems 32 days after surgery. He was followed up with 3-dimensional computed tomography every 6 months. It revealed wall irregularities but no apparent changes in the remaining descending aorta (Fig 3). He has had no episode or symptom in the 2 years since the operation.
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References
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- Tittle LS, Lynch JR, Cole EP, et al. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta J Thorac Cardiovasc Surg 2002;123:1051-1059.[Abstract/Free Full Text]
- Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via median-sternotomy (frozen elephant trunk procedure) Ann Thorac Surg 2002;74:S1821-S1824.[Abstract/Free Full Text]
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