Chronic dissection aneurysm of the aorta: clinical and pathologic study

  • Yu. I. Kuzyk Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
  • O. O. Sira Lviv Regional Pathology and Anatomy Burea, Lviv, Ukraine
  • D. M. Beshley Lviv Regional Clinical Hospital, Lviv, Ukraine
  • N. V. Fadeichuk Lviv Regional Pathology and Anatomy Burea, Lviv, Ukraine
Keywords: chronic dissection aortic aneurysms, aortic vascular remodeling, aortic pathology

Abstract

An analysis of the clinical case of chronic dissection aortic aneurysm (DAA) in a 47-year-old man was conducted. Diagnosis of chronic DAA type A for Stanford is established at CT angiography of the thoracic and abdominal aorta with proven contrast enhancement. The operation of supracoronary prosthetics of the ascending department of the aorta was performed with full root method. During surgery, a chronic RAA of the ascending aorta with a diameter of about 5.5 cm was detected. The aorta was enlarged in the area of the root, whereas at the point of transition into the arc was of ordinary diameter. The aortic valve was three-lobed with signs of slight dilation of the fibrous ring. The ascending aorta was circularly mobilized and excised 1.0 cm above the coronary artery cells. The organized thrombus from the false lumen from the lateral wall of the ascending aorta (from the side of the superior vena cava) was removed. A proximal anastomosis was applied between the vascular prosthesis and the ascending aorta with a telescopic double continuous suture. Subsequently, a distal ascending aorta 1.5 cm below the shoulder-main trunk was dissected. Therefore, a distal anastomosis was applied between the distal ascending aorta and the vascular prosthesis with a telescopic double continuous suture. The postoperative period was satisfactory. On the 8th day of the postoperative period the patient was in a satisfactory condition discharged home.

Pathomorphological examination of the operating material revealed segmental hyperplasia of the media with focal mucoid swelling, multiple cystic cavities, diffuse-focal fibrosis. The cavity of the dissection looked like a “two-stemmed” (two-channel) lumen, located on the border of adventitia and media, was filled with blood clots with the spread of hemorrhagic infiltration into the peri-adventitious fat. The new pseudocanal contained blood clots and fresh blood clots, and the old one was completely covered with endothelium with neointima formation. The aortic architecture is completely broken, the division into layers was absent. In the section of the irregular canal, the formation of a two-layer structure was observed – neointima, which differed from the intima of the true lumen of the aorta by the number of smooth muscle cells and heterogeneous accumulation of components of the extracellular matrix. In the middle layers, connective tissue remodeling of the aorta was detected in the form of chaotically located immature mesenchymal cells in combination with muscular and connective tissue hyperplasia, complete loss of elastic fibers, massive sclerosis of adventitia, and periadventitial layer. In sections of the aorta, out of stratification, its structure was preserved, there are signs of cystic medial necrosis.

The revealed pathomorphological changes in the described case point to the processes of vascular remodeling, which explain the relative stability of DAA.

References

  1. Zerbino DD, Kuzyk JuI. [Dissecting aortic aneurysm: clini-cal masks, features of differential diagnosis]. Klinicheskaja medicina. 2002;5:58–61. Russian.
  2. Sitar LL, Kravchenko IN. [Aneurysms of the thoracic aorta]. Lіkuvannia ta dіagnostyka. 1999–2000;4–1:44–6. Russian.
  3. Tyshko LO, Kuzyk YuI. [Chronic splitting aneurysm of the aorta as a consequence of medianecrosis]. Praktychna anhi-olohiia. 2012;3–4:52–3. Ukrainian.
  4. Beebeejaun M, Malec A, Gupta R, Alkhawam H. Conservative management of chronic aortic dissection with underlying aortic aneurysm. Heart International. 2013;8:e4. https://doi.org/10.4081/hi.2013.e4
  5. Carnevale D, Lembo G, Frati G. Chronic type A aortic dissection: Could surgical intervention be guided by molecular markers? J. Cell. Mol. Med. 2011;15:1615–9. https://doi.org/10.1111/j.1582-4934.2011.01314
  6. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J. Am. Coll. Cardiol. 2010;55(14):e27–e129. https://doi.org/10.1016/j.jacc.2010.02.015
  7. Hynes CF, Greenberg MD, Sarin S, Trachiotis GD. Chronic Type A Aortic Dissection: Two Cases and a Review of Current Management Strategies. Aorta (Stamford). 2016;4(1):16–21. https://doi.org/10.19161/etd.418028
  8. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwцger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Von Allmen RS, Vrints CJM, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol З, Fagard R, Ferrari R, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Czerny M, Deanfield J, Di Mario C, Pepi M, Taboada MJS, Van Sambeek MR, Vlachopoulos C. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Eur Heart J. 2014;1:35(41):2873–926. https://doi.org/10.1093/eurheartj/ehu281
  9. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, Rakowski H, Struyven J, Radegran K, Sechtem U, Taylor J, Zollikofer Ch, Klein WW, Mulder B, Providencia LA. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22:1641–81. https://doi.org/10.1053/euhj.2001.2782
  10. Frederick JR, Woo YJ. Thoracoabdominal aortic aneurysm. Ann Cardiothorac Surg. 2012;1:277–85. https://doi.org/10.3978/j.issn.2225-319x.2012.09.01
  11. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca RN, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos J, Robles Y, Llovet A, Gilon D, Sugata K, Armstrong WF, Deeb GM, Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease. JAMA. 2000;283(7):897–903. https://doi.org/10.1001/JAMA.283.7.897
  12. Oda T, Minatoya K, Sasaki H, Tanaka H, Seike Y, Itonaga T, Inoue Y, Higashi M, Nishimura K, Kobayashi J. Surgical Indication for Chronic Aortic Dissection in Descending Thoracic and Thoracoabdominal Aorta. Circ Cardiovasc Interv. 2017;10:1–7. https://doi.org/10.1161/CIRCINTERVENTIONS.116.004292
  13. Palma J, Gaia D, Guilhen JS, Buffolo E. Endovascular treatment of chronic type A dissection. Interact Cardiovasc Thorac Surg. 2008;7:164–6. https://doi.org/10.1510/icvts.2007.165027
  14. Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O’Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria JE, Blackstone EH, David TE, Desai ND, Dewey TM, D’Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reardon M, Reece TB, Reiss GR, Roselli EE, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic valve and ascending aorta guidelines for management and quality measures: executive summary. Ann Thorac Surg. 2013;95:1491–505. https://doi.org/10.1016/j.athoracsur.2012.12.027
  15. Wu D, Shen YH, Russell L, Coselli JS, LeMaire SA. Molecular Mechanisms of Thoracic Aortic Dissection. J Surg Res. 2013;184(2):907–24. https://doi.org/10.1016/j.jss.2013.06.007
  16. Suzuki T, Bossone E, Sawaki D, Janosi RA, Erbel R, Eagle K, Nagai R. Biomarkers of aortic diseases. Am Heart J. 2013;165:15–25. https://doi.org/10.1016/j.ahj.2012.10.006
  17. Steuer J, Bjorck M, Mayer D, Wanhainen A, Pfammatter T, Lachat M. Distinction between Acute and Chronic Type B Aortic Dissection: Is there a Sub-acute Phase? European Journal of Vascular and Endovascular Surgery. 2013;45(6):627–31. https://doi.org/10.1016/j.ejvs.2013.03.013
Published
2020-01-07
How to Cite
Kuzyk, Y. I., Sira, O. O., Beshley, D. M., & Fadeichuk, N. V. (2019). Chronic dissection aneurysm of the aorta: clinical and pathologic study. Ukrainian Journal of Cardiovascular Surgery, (4 (37), 72-76. https://doi.org/10.30702/ujcvs/19.3712/075072-076