Ascending aortic aneurysm and its clinical

significance: A case report

APME-305; No. of Pages 3

Case Report

Ascending aortic aneurysm and its clinicalsignificance: A case report

Saju B. Cherian a,*, Aruna Jyothi Gandhalamb, M. Bhavani c,P. Rohit Kumar d, Vaishnavi Reddy d

aAssistant Professor, Department of Anatomy, Apollo Institute of Medical Sciences and Research, Hyderabad, Indiab Professor, Department of Anatomy, Apollo Institute of Medical Sciences and Research, Hyderabad, IndiacAssociate Professor, Department of Pathology, Apollo Institute of Medical Sciences and Research, Hyderabad, Indiad First Year MBBS Student, Apollo Institute of Medical Sciences and Research, Hyderabad, India

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x

a r t i c l e i n f o

Article history:

Received 1 July 2015

Accepted 22 July 2015

Available online xxx

Keywords:

Aneurysm

Aorta

Ascending aorta

Thoracic aortic aneurysm

Ascending aortic aneurysm

a b s t r a c t

Aorta, the major conductance vessel of the body, can be affected by a variety of pathologic

processes leading to aneurysm, dissection, or ischemic syndromes. There has been a drastic

increase in the incidence of aortic aneurysm making it the 18th most common cause

for death.

When ignored, the patients' condition might worsen leading to death due to rupture and

hemorrhage. Here we report a case of ascending aortic aneurysm affecting the aortic root

and proximal part of ascending aorta. Conscious awareness of this pathological process

augments a great deal to radiologists and sonographers during various imaging techniques

and rescues the patient from aneurysm-related deaths.

# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights

reserved.

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/apme

1. Case report

During routine dissection classes held for medical under-graduates at Apollo Institute of Medical Sciences and Research,Hyderabad, we observed a distinct dilatation at the proximalpart of aorta in a 65-year-old, well-built female cadaver. Itsdiameter was almost equal to that of right atrium and wasinitially mistaken for the same (Fig. 1). Later, the bulge appearedto be a fusiform dilatation in the ascending portion of aortaextending till the aortic arch was measuring about 20 cm in itsbroadest part (Fig. 2). The circumference at the annulus and root

* Corresponding author at: Department of Anatomy, Apollo Institute oIndia. Tel.: +91 9573564627.

E-mail address: sajubinu@gmail.com (S.B. Cherian).

Please cite this article in press as: Cherian SB, et al. Ascending aortic(2015), http://dx.doi.org/10.1016/j.apme.2015.07.009

http://dx.doi.org/10.1016/j.apme.2015.07.0090976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by

of aorta measured about 13.5 cm. The brachiocephalic trunkalso appeared to have a dilated wall measuring about 6.5 cm atits root. The right and left ventricles appeared to be normal. Apart of descending aorta was opened and multiple plaques wereobserved within the lumen of the vessel (Fig. 3) and the tissuewas sent for histopathological sectioning.

2. Discussion

Aortic aneurysm is defined as the localized or diffusedilatation of more than 50% normal diameter of aorta.1

f Medical Sciences and Research, Jubilee Hills, Hyderabad 500096,

aneurysm and its clinical significance: A case report, Apollo Med.

Elsevier B.V. All rights reserved.

Fig. 1 – Sternocostal surface of heart. Note the thoracic aorticaneurysm (TAA) in the proximal part of aorta. Aortic arch(AA) with brachiocephalic trunk (BT); Left common carotidartery (LCC) can be seen. Descending aorta (DA) andpulmonary trunk (PT) are normal.

Fig. 2 – Lateral view of heart showing ascending aorticaneurysm (AAA). Note the size of the dilated vessel wall incomparison to the right atrium (RA).

Fig. 3 – Severe atherosclerosis seen in the vessel wall.

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APME-305; No. of Pages 3

Please cite this article in press as: Cherian SB, et al. Ascending aortic(2015), http://dx.doi.org/10.1016/j.apme.2015.07.009

It has been estimated that 1–2% of the population harboraneurysms in their aorta, with up to 10% prevalence in olderage groups.2 Aneurysms may be hereditary.3

Most aortic aneurysms go undetected until rupture, and themortality from ruptured aneurysms is as high as 90%2 andhence referred to as 'silent killer'.4 Aortic aneurysms areclassified based on the segment involved as thoracic,thoracoabdominal, or abdominal.5 Thoracic aortic aneurysmis much less common in occurrence when compared toabdominal aortic aneurysm with the incidence of 50%involving the ascending aorta, 10% of the arch, and 40% ofthe descending thoracic aorta.2 Although a virulent disease,thoracic aortic aneurysm grows in an indolent fashion.6 It isoften associated with a condition termed cystic medialnecrosis (CMD),6,7 a normal physiologic process of aging.CMD is characterized by accumulation of basophilic groundsubstances, composed of proteoglycans, in arteries, and inparticular the aorta. CMD is known to occur in some of thediseases associated with connective tissue degeneration anddamage, such as Marfan's syndrome (defect in synthesis offibrillin-1)8 and Ehlers–Danlos syndrome. Mutations result in amarked decrease in elastin aortic wall as well as increase inelastic properties that lead to progressive increase in stiffnessand dilation.4 Ascending aortic aneurysm may also occur inpatients who lack connective tissue disorders.4 It occurs morefrequently and at a younger age in patients with bicuspidaortic valves (BAV) than it does in patients with normaltrileaflet aortic valves (TAV).9

Histologically, when the walls of the aneurysm have allthree layers, they are called true aneurysms. If the wall of theaneurysm has only the outer layer remaining, it is called apseudoaneurysm. Pseudoaneurysms may occur as a result oftrauma when the inner layers are torn apart. Most fusiformaneurysms are true aneurysms. The weakness is often alongan extended section of the aorta and involves the entirecircumference of the aorta. The weakened portion appears as agenerally symmetrical bulge. Degenerative aneurysms are themost common types of aneurysms. They occur as the result ofbreakdown of the connective tissue and muscular layer.Histologically, the wall of the aneurysm revealed thinnedout tunica media, loss of smooth muscle cells, reduced elasticfibers, with fibro-connective tissue, and fragmentation ofelastic fibers, calcification, and atherosclerotic changes. Therewas no evidence of dissection. In the present case, it could befusiform degenerative aneurysm. The cause could be highblood pressure and/or genetic/inflammatory conditions. There

aneurysm and its clinical significance: A case report, Apollo Med.

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APME-305; No. of Pages 3

were no definitive physical characteristics to suggest that thevictim was suffering from either Ehlers–Danlos syndrome orMarfan's syndrome.

Conscious awareness of this finding is very important forradiologists while performing the various imaging technolo-gies like scan, echocardiography (echo), computed tomogra-phy (CT),3 and magnetic resonance imaging (MRI). It is of vitalimportance to extirpate the thoracic aortic aneurysm beforerupture or dissection10 occurs to prevent the patient fromneedless death.

3. Conclusion

Fusiform degenerative aneurysm, a category of ascendingaortic aneurysm, is an enlargement of both aortic annulus andproximal portion of aorta characterized by aortic regurgitation.Awareness of this vascular pathology is of crucial importanceto radiologists, cardiologists, and sonographers, and if ignoredcan lead to rupture and dissection, which can be fatal.Furthermore, the clinician should realize that first-degreerelatives of patients with thoracic aortic dilatation are also atrisk and should be evaluated for manifestations of connectivetissue disorders.

Conflicts of interest

The authors have none to declare.

Please cite this article in press as: Cherian SB, et al. Ascending aortic(2015), http://dx.doi.org/10.1016/j.apme.2015.07.009

r e f e r e n c e s

1. Coselli JS, Conklin LD, LeMaire SA. Thoracoabdominal aorticaneurysm repair: review and update of current strategies.Ann Thorac Surg. 2002;74(5):S1881–S1884.

2. Beckman JA. Aortic aneurysms: pathophysiology,epidemiology, and prognosis. In: Creager MA, Dzau VJ,Loscalzo J, eds. In: Vascular Medicine. Philadelphia, PA:Saunders Elsevier Inc; 2006.

3. Sanford RM, Bown MJ, London NJ, et al. The genetic basis ofabdominal aortic aneurysms: a review. ESVS J. 2007;33(4):381–390.

4. Elefteriades JA, Sang A, Kuzmik G, et al. Guilt by association:paradigm for detecting a silent killer (thoracic aorticaneurysm). Open Heart. 2015;2:e000169.

5. Fuster V, Walsh RA, Harrington RA. Diseases of aorta. In:Hurst's The Heart. 13th ed. McGraw-Hill; 2011.

6. Elefteriades JA, Farkas EA. Thoracic aortic aneurysm: clinicalpertinent controversies and uncertainties. JACC.2010;55:841–857.

7. Becker AE. Medionecrosis aortae. Pathol Microbiol.1975;43:124.

8. Milewicz DM, Hariyadarshi P, Avidan N, et al. The geneticbasis of thoracic aortic aneurysms and dissections. In:Elefteriades J, ed. In: Acute Aortic Conditions. New York, NY:Taylor & Francis; 2007.

9. Tardos TM, Klein MD, Shapira OM. Ascending aorticdilatation associated with bicuspid aortic valvepathophysiology, molecular biology and clinicalimplications. Circulation. 2009;119:880–890.

10. Anagnostopoulos CE. Acute Aortic Dissections. Baltimore, MD:University Park Press; 1975.

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