John W. Joyce

Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations

Clinically, penetrating atheromatous ulceration of the aortic wall may be confused with either symptomatic thoracic aneurysm or classic spontaneous aortic dissection. Aortography and computed tomographic (CT) scanning of the thoracic aorta provide specific diagnostic information which permits one to distinguish this lesion from atherosclerotic aneurysm and classic dissection. Hallmarks of findings on aortography and CT scan include the presence of the ulcer and an intramural hematoma. Since the findings may be disarmingly subtle, the potentially progressive and serious nature of this condition may remain unappreciated. Recognition of the penetrating atheromatous ulcer and distinguishing it from aortic dissection arising just distal to the origin of the left subclavian artery is mandatory. Resection of only a conservative segment of the proximal descending aorta suffices for classic dissection in the upper descending thoracic aorta, but the penetrating aortic ulcer requires graft replacement in the area of the ulcer and intramural hematoma.

Clinical Features and Differential Diagnosis of Aortic Dissection: Experience With 236 Cases (1980 Through 1990)

Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.

Inflammatory abdominal aortic aneurysms: A thirty-year review

The operative records of 2816 patients undergoing repair for abdominal aortic aneurysm (AAA) from 1955 to 1985 were reviewed. Inflammatory aortic or iliac aneurysms were present in 127 patients (4.5%), 123 men and four women. Most patients were heavy smokers (92.1%). Clinical evidence of peripheral arterial occlusive disease and coronary artery disease was found in 26.6% and 39.4%, respectively. Additional aneurysms occurred in half of the patients; iliac aneurysms were the most common (55 patients), followed by thoracic or thoracoabdominal (17 patients), femoral (16 patients), and popliteal aneurysms (10 patients). Ultrasound and computed tomography suggested the diagnosis in 13.5% and 50%, respectively; angiography was not helpful. Excretory urographic findings of medial ureteral displacement or obstruction suggested the diagnosis in 31.4%. The aneurysm was repaired in 126 patients. Only one patient experienced acute aneurysm rupture, but eight patients had chronic contained leakage. When compared with patients who have ordinary atherosclerotic aneurysms, patients with inflammatory aneurysms are significantly more likely to have an elevated erythrocyte sedimentation rate (ESR, 73% vs. 33%, p less than 0.0001); weight loss (20.5% vs. 10%, p less than 0.05); symptoms (66% vs. 20%, p less than 0.0001); and an increased operative mortality rate (7.9% vs. 2.4%, p less than 0.002). The triad of chronic abdominal pain, weight loss, and elevated ESR in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm and may be beneficial in the preoperative preparation of the patient for aneurysm repair.

Aneurysms of the Thoracic Aorta A Clinical Study with Special Reference to Prognosis

The clinical features and follow-up data on107 patients who had a clinical diagnosis of aneurysm of the thoracic aorta made at the Mayo Clinic in the period 1945 through 1955 were reviewed. The ratio of male to female was 2.8 to 1, and the average age at the time of diagnosis was 59.3 years. Fusiform aneurysms were four times as frequent as saccular aneurysms; the most common location of the former was the descending thoracic aorta and of the latter the ascending thoracic aorta. Most of the aneurysms (73 per cent) were probably arteriosclerotic in origin. Symptoms, usually pain, and physical signs were present in a minority of patients and indicated a large aneurysm with a poor prognosis.Diastolic hypertension was present in almost half of the patients at the time of diagnosis and had an adverse effect on the patients survival. Associated arteriosclerotic cardiovascular disease was present in 40 (37 per cent) of the patients at the time of diagnosis; some of these patients had multiple associatedcardiovascular lesions. The presence of associated coronary, cerebral, or other peripheral arterial occlusive or aneurysmal disease had the most deleterious effect on survival. The prognosis for patients with large aneurysms was poorer than for those with small aneurysms.Information as to the cause of death was available in 59 (83 per cent) of the 71 patients known to be dead at the time of follow-up. Approximately a third of the deaths were due to rupture of the thoracic aortic aneurysm, and approximately a half, to associated cardiovascular disease, particularly that due to arteriosclerosis.It is believed that this study of patients with untreated aneurysms of the thoracic aorta may be used as a guide to the selection of patients with aneurysm for surgical treatment and may serve as a basis for evaluating the long-term results of such treatment.

Lower limb ischemia in young adults: Prognostic implications *

Fifty patients (41 men and nine women) less than 36 years of age were evaluated for lower limb ischemia. Claudication was the presenting symptom in 30 patients (60%) and distal ulceration in 20 (40%). The mean age was 28.3 years. Premature atherosclerosis was present in 24 patients (48%) and thromboangiitis obliterans in 12 (24%). Other causes included a variety of unusual etiologies. Risk factors were analyzed. Twenty-two patients with claudication underwent arterial reconstruction; three had sympathectomy. Arterial reconstruction was possible in only three patients with ulceration; 17 had sympathectomy. No operative deaths or early amputations occurred. Follow-up averaged 13.5 years. Twenty-four patients with claudication were improved, three were unchanged, one developed ulceration, one required late amputation, and one was lost to follow-up. Four patients with ulceration were improved, one was unchanged, 14 required late amputation, and one was lost to follow-up. Ten patients, all with atherosclerosis obliterans, developed coronary artery disease; five died of myocardial infarction. No patient developed cerebrovascular disease. We conclude that reconstructive arterial surgery for claudication can be performed with low risk and a strong likelihood of long-term improvement. Most patients presenting with ulceration, however, will ultimately require amputation. Patients with atherosclerosis obliterans are at risk for coronary artery disease and death of myocardial infarction.

Selection and Preparation of High-Risk Patients for Repair of Abdominal Aortic Aneurysms

OBJECTIVE To discuss the most important risk factors in patients who undergo surgical repair of an abdominal aortic aneurysm (AAA). DESIGN This update in vascular surgical repair highlights the criteria that identify high-risk patients, the useful preoperative tests, and the perioperative measures that can aid surgical recovery. MATERIAL AND METHODS In elective repair of AAAs, high-risk patients are those with severe coronary or valvular heart disease, decompensated chronic obstructive pulmonary disease, severe cerebrovascular disease, chronic renal failure, hepatic cirrhosis with portal hypertension, and chronic hematologic disorders associated with bleeding dysfunction. Patients with unstable or severely symptomatic heart disease should undergo preoperative coronary angiography and ventriculography. Pharmacologic stress testing is recommended for patients with clinical markers of serious coronary artery disease and other medical or physical factors that prevent any type of standard exercise stress testing. RESULTS Our experience with high-risk patients supports conventional repair of AAAs. Our preference for the midline abdominal incision in high-risk patients is substantiated by an operative mortality rate of 5.7% in comparison with a reported 7% mortality rate for nonresective therapy. Approximately one in three high-risk patients will have a serious postoperative complication, the most common of which is a cardiac event. Most patients recover after a slightly prolonged hospital stay. CONCLUSION Despite an increased operative risk, patients with a stable medical condition and an AAA larger than 6 cm in diameter should be considered for elective repair. High-risk patients with smaller aneurysms (5 to 6 cm in diameter) should undergo efforts to stabilize or to improve their general medical condition before elective operation.

Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations@@@Ulceras arteriosclerosas aorticas perforantes: historia natural y correlacion clinico-patologica

Clinically, penetrating atheromatous ulceration of the aortic wall may be confused with either symptomatic thoracic aneurysm or classic spontaneous aortic dissection. Aortography and computed tomographic (CT) scanning of the thoracic aorta provide specific diagnostic information which permits one to distinguish this lesion from atherosclerotic aneurysm and classic dissection. Hallmarks of findings on aortography and CT scan include the presence of the ulcer and an intramural hematoma. Since the finding may be disarmingly subtle, the potentially progressive and serious nature of this condition may remain unappreciated. Recognition of the penetrating atheromatous ulcer and distinguishing it from aortic dissection arising just distal to the origin of the left subclavian artery is mandatory. Resection of only a conservative segment of the proximal descending aorta suffices for classic dissection in the upper descending thoracic aorta, but the penetrating aortic ulcer requires graft replacement in the area of the ulcer and intramural hematoma.ResumenLa úlcera arteriosclerosa aórtica perforante (UAAP) puede producir exactamente el mismo cuadro clínico que la disección aórtica aguda. Radiológicamente la imágen de la UAAP es semejante a la de un ulcus duodenal y claramente diferenciado de lo que aparecía hasta ahora como disección espontánea aórtica. Se han estudiado 16 enfermos, 8 hombres y 8 mujeres siendo 13 de ellos hipertensos. Otros antecedentes significativos fueron lipidemias e insuficiencia cerebro vascular. En todos se visualizó lesiones importantes de la pared aórtica torácica. En 13 la presentación clínica fue de dolor retroesternal. La aortografía se indicó principalmente por dolor y los hallazgos arteriográficos mostraron ulceraciones de 5 a 20 mm de diámetro y de 5 a 30 mm. de profundidad. En 15 pacientes se consiguió demostrar un hematoma adyacente. El TAC torácico fue el método idóneo para el diagnóstico de esta entidad morfológica. En 3 casos el TAC demostró el lugar de la perforación. En cuanto al tratamiento efectuado en 14 enfermos fue quirúrgico, y en 10 de ellos con hallazgos peroperatorios de hematoma intramural y ruptura controlada por la adventicia. La técnica quirúrgica utilizada fue la sustitución protésica del segmento de aorta torácica afectada. Hubo sólo 1 exitus en el postoperatorio inmediato y 4 paraparesias. La anatomía patológica mostraba una afectación arteriosclerosa difusa en 9 casos, demostrándose que el hematoma comenzaba en la zona de perforación ulcerosa, siendo contenido en su ruptura externa por la adventicia, formándose así un falso aneurisma. En la discusión los autores especifican los carácteres radiológicos diferenciadores entre la UAAP y entidades clásicas como el falso aneurisma y la disección aguda de la aorta torácica. Siendo el paciente típico el individuo de edad avanzada arterioscleroso e hipertenso que presenta un cuadro de dolor retroesternal y alteración hemodinámica con o sin signos concomitantes. La aortografía no muestra dos luces del aneurisma disecante y en su lugar se aprecia una ulceración ateromatosa perforante, siendo el hematoma intramural diagnosticado por TAC. Algunos autores mantienen que este fenómeno de la UAAP es el fenómeno inicial de la disección aórtica. Sin embargo, en la UAAP se encuentra un nicho profundo que penetra hasta la capa media produciendo un hematoma sin que necesariamente haya una disección de la pared. Desde el punto de vista de la historia natural la mayoría de ulceraciones ateromatosas son asintomáticas. Sin embargo, la historia natural de las UAAP no es benigna como lo demuestran los casos que tratados médicamente produjeron una recidiva de la sintomatología precisando cirugía. La mortalidad de 7.7% es aceptable para este tipo de cirugía. Sin embargo, la incidencia de paraparesia (28%), es muy elevada, explicándose por la sustitución de la aorta torácica distal. A pesar, de todo creen los autores que el tratamiento quirúrgico es superior al médico a largo plazo.