Takayasu arteritis mimicking intramural hematoma of the ascending aorta

Abstract

Takayasu arteritis (TA) is an inflammatory vascular disease which may present as aortic pseudoaneurysms, 1 intramural hematomas (IMH), 2,3 and coronary ostial stenoses. 4 We present images of a patient with TA who presented with syncope and what appeared to be an IMH of the ascending aorta.A 62-year-old female presented with a syncopal episode, and was noted on echocardiography to have moderate aortic regurgitation, a moderate pericardial effusion, and thickening of the ascending aorta without a dissection flap suggestive of an IMH. A computed tomography (CT) angiogram showed what appeared to be hematoma in the ascending aorta consistent with an IMH (Figure 1).At the time of surgery, cardiopulmonary bypass (CPB) was established with aortic and bicaval cannulation. Following cardioplegic arrest with antegrade, crystalloid cardioplegia, the ascending aorta was transected. No hematoma was found but the aorta appeared thickened and fibrotic (Figure 2A, B, and D). The right coronary aortic valve leaflet was thickened and retracted. An ascending aorta and hemi-arch replacement with a #30 Hemashield Dacron graft was performed, during a 33-minute period of circulatory arrest at 20°C. The aortic valve was replaced with a #19 ATS mechanical heart valve prosthesis (Medtronic, Minneapolis, MN). The total crossclamp time was 66 min and the CPB time was 160 min. The patient tolerated the procedure well and had an uncomplicated postoperative course. The gross pathology revealed a thickened, fibrotic aorta (Figure 2D). Microscopic sections showed both acute inflammation with polymorphonuclear neutrophils and chronic inflammation with lymphocytes and multinucleated giant cells. The aortic valve had changes consistent with myxomatous degeneration.A follow-up CT angiogram 6 years following the surgery showed no further progression of TA in the arch or descending aorta (Figure 3).During the follow-up, the patient was placed on steroid therapy. ORCIDEduardo Gabriel Danduch http://orcid.org/0000-0002-5295-408X REFERENCES 1. Nishida H, Etsuro S, Manabu S, Koga S. Repair of a pseudoaneurysm compressing the right coronary artery in a patient with Takayasu's arteritis. J Card Surg. 2018;33:748-750. 2. Torre S, Caramaschi P, Faggian G, Battista LG. Takayasu arteritis mimicking type A intramural hematoma. Ann Thorac Surg. 2017;104: e35-e37.FIGURE 1 A and B, Computed tomography image mimicking aortic hematoma. C, The aortic root; right coronary ostium stenosis is shown (white arrow) 862 |

Case Report of Ascending Aortitis Mimicking Type A Intramural Hematoma by Multiple Imaging Modalities

“…Several case reports describe patients who were thought to have type A IMH on initial imaging and were taken to the operating room for aortic surgery. [7][8][9][10][11][12] The patients in these case repots presented with chest pain, back pain, or syncope and were subsequently incorrectly diagnosed with an IMH by CT scan and TEE imaging. It was only after surgical intervention and histopathologic evaluation that aortitis was diagnosed.…”