Development of Mega-Aorta Following Incompletely Treated Giant Cell Arteritis

Abstract

An 82-year-old male presented with a 9.3 cm ascending aorta and arch aneurysm with additional aneurysms of the innominate, right subclavian, and left common carotid arteries. The patient had a history of temporal arteritis that was only briefly treated in 1989 and a 6 cm ascending aortic aneurysm that was repaired in 1993. Our operative strategy was to construct a temporary parallel cerebrovascular circuit for cerebral protection during the redo-sternotomy and aortic arch reconstruction, with the added benefit of permanently excluding the branch arch vessel aneurysms. Pathological analysis of the aortic specimen at the first operation may have identified giant cell arteritis, prompting medical therapy against further disease progression.Copyright © 2014 Science International Corp. Key WordsAortic aneurysm · Inflammation · Subclavian artery · Carotid artery Case PresentationAn 82-year-old male of Hungarian descent presented with dilated neck veins and pulsatility in his neck. Preoperative imaging (Fig. 1) identified a 9.3 cm ascending aortic (AscAo) and aortic arch aneurysm, as well as a 4.0 cm innominate artery (InomA), a 2.5 cm right subclavian artery (RScA), and a 2.6 cm left common carotid artery (LCCA). The RScA was at risk of rupturing. Both common carotid arteries were redundant proximally. The maximal diameters of the descending and visceral aorta were 5.8 and 5.0 cm, respectively.In 1989 the patient presented with malaise, extremity joint pain, and fatigue. A biopsy conducted at that time indicated temporal arteritis. The patient selfreported a 1-to 2-month course of prednisone after that admission. In 1993 a 6 cm proximal AscAo aneurysm was resected. The AscAo aneurysm diameter distal to the repair grew to 7.4 cm in 2004, 8.2 cm in 2007, and 9.3 cm in 2011. The patient did not have a history of tobacco abuse, hypertension, or emphysema. He had no family history of aneurysms, although his aunt had temporal arteritis. Three weeks prior to surgery, a percutaneous transluminal coronary angioplasty was performed and a bare metal stent was placed in the left anterior descending artery.Preoperative imaging showed extremely torturous left and right carotid arteries (Fig. 2), as well as apposition of the aneurysm to the previous sternotomy with compression of the vena cava and innominate vein (Fig. 3). Our operative strategy was to (1) maintain continuous cerebrovascular perfusion during initial exclusion of the InomA, RScA, and left common carotid artery, (2) conduct a redo-sternotomy to replace the AscAo and arch aneurysms, and (3) replace the aortic valve. To these ends, a temporary extra-anatomic circuit was constructed. The first step was to perfuse the right and left common carotid arteries, and the right axillary Fax ϩ1 203 785 3346 E-Mail: aorta@scienceinternational.org

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Giant Cell Arteritis with Intracranial and Extracranial Aneurysms: A Case Report and Brief Review of the Literature

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