Acute aortic syndrome: a case presentation and review of the literature

Abstract

Aortic disease can present as an acute chest pain syndrome. Although aortic dissection is the most common etiology, other processes such as intramural hematoma (IMH) and penetrating atherosclerotic ulcers are being increasingly recognized. They can all be accurately identi ed by computed tomography (CT) imaging or transesophageal echocardiography. The overlap between these processes regarding de nition and mechanism is controversial. Treatment for all three conditions has thus far been dictated by location, wherein ascending or arch involvement (Stanford type A) necessitates surgery and descending disease (type B) is treated medically. Small studies suggest that subgroups of type A IMH may be treated medically with good outcomes.Key words: acute aortic syndrome; aortic intramural hematoma; penetrating atherosclerotic ulcer Case presentationA 75-year-old woman presented with acute aortic syndrome.Twenty-four hours after arriving on a ight from London, England to San Francisco, California, our patient experienced the sudden onset of severe pleuritic chest and upper abdominal pain which radiated to her left arm and back. The pain was not affected by exertion, but decreased upon leaning forward. After 36 hours of pain, she developed severe dyspnea and presented to the emergency room. Nitroglycerin relieved her pain. She received one injection of low molecular weight heparin.The patient reported a recent low-grade temperature and non-productive cough. Her cardiovascular risk factors included hypertension and post-menopausal status. There was no history of diabetes mellitus, hypercholesterolemia, smoking, angina, myocardial infarction, congestive heart failure, deep venous thrombosis, anemia, hepatitis or tuberculosis. She had irritable bowel syndrome, managed with omeprazole, anti-spasmodics, and pancreatic enzyme supplements. Other medications were aspirin and nifedipine.On physical examination, the patient was a thin, anxious, Indian woman in moderate distress. The blood pressure was 116/75 mmHg in both upper extremities. The pulse was 98 and regular. The oxygen saturation level was 94% on 2 l of oxygen.Jugular venous pulsation was seen at 6 cm. There were no carotid bruits. The cardiac exam had a normal S1 and S2 without rubs, gallops, or murmurs. The lungs were clear bilaterally. The abdomen was soft and non-tender, without organomegaly, masses, or bruits. The extremities were normal with palpable pulses and without edema, tenderness, or cyanosis. Admission laboratory evaluation was signi cant for a CPK of 90 mg/dl with an MB relative index of 3.1 (normal ,3). The cardiac troponin T was slightly elevated at 0.07 ng/ml (normal ,0.01), WBC 13 000, Hct 33%, sodium 125 mmol/l, BUN 12 mg/dl (4.3 mmol/l), Cr 0.9 mg/dl (80 mmol/l), glucose 233 mg/dl (12.9 mmol/l), AST 146 IU/l, ALT 100 IU/l, total bilirubin 1.5 mg/dl (26 mmol/l) and alkaline phosphatase 74 IU/l. The initial electrocardiogram showed sinus rhythm with mild diffuse ST elevation and PR depression (Figure 1) and the chest X-ray revealed a tortuous ...

Atherosclerotic Vascular Disease Conference

“…Intramural hematomas may result from rupture of vasa vasorum or hemorrhage into an atherosclerotic plaque. 52 Patients tend to be older and present in ways that are indistinguishable from those with classic aortic dissection. 53 The imaging tests used to diagnose aortic intramural hematoma are the same as those used for suspected aortic dissection.…”

Endovascular Management of Acute Aortic Syndromes

“…16 The false lumen is created by rupture of the vasa vasorum that lies in the media or from hemorrhage within an atherosclerotic plaque. 17 It is important to note that IMH may not only be attributed to spontaneous rupture of a ''sick'' vasa vasorum, but may also be the result of traumatic rupture of ''healthy'' vasa vasorum during blunt aortic trauma. 5 Additionally, the hematoma, while often intramedial in nature, may extend through the outer medial layer into the subadventitial space representing a contained aortic rupture.…”

Acute aortic syndrome: pathology and therapeutic strategies

“…It occurs most commonly in the descending aorta, which may reflect more atheromatous disease here. 11 Progressive intimal erosion can lead to pulsatile blood entering the media resulting in haemorrhage. Formation of IMH (because of erosion of aortic vasa vasorum by the ulcer) or dissection can both occur.…”

“…1 4 This occurs because of rupture of the nutrient vasa vasorum that lies in the media or from haemorrhage within an atherosclerotic plaque. 11 It may therefore be related to hypertension or blunt trauma or may arise from a PAU. 2 IMH may resolve spontaneously or progress and increase in size.…”

“…It is widely available, permits assessment of other thoracic structures, and provides 3D reconstructed images that are essential in planning surgery or interventional procedures. 11 Its sensitivity for dissection and IMH approaches 100%. 15 Other imaging modalities include magnetic resonance imaging (MRI) and transoesophageal echocardiography.…”