Surgical Management of Peripheral Vascular Manifestations of Loeys-Dietz Syndrome

Familial visceral branch artery aneurysms in Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is an autosomal dominant heritable disorder due to pathogenic variants in one of several genes involved in TGF-β (transforming growth factor-beta) signalling. LDS is associated with aortic aneurysm and dissection. LDS may also lead to extra-aortic aneurysms, the majority of which occur in the head and neck vasculature. Visceral aneurysms are uncommon, and no cases of distal superior mesenteric artery (SMA) branch aneurysms in patients with LDS have been reported. Three related females with TGFBR1-related LDS developed distal SMA branch artery aneurysms involving the ileocolic and jejunal arteries. Endovascular or surgical intervention was performed in each. The presence and severity of arterial, craniofacial, and cutaneous features of LDS in these patients are variable. TGFBR1-related LDS may rarely lead to SMA branch artery aneurysms that can develop later in life. Surgical and endovascular procedures can successfully treat these aneurysms, but data to guide size thresholds and optimal treatment strategies are lacking.

Total arch replacement using frozen elephant trunk and repair of bilateral subclavian artery aneurysms in a patient with type 2 Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. Vessel tortuosity and aneurysms throughout the vasculature are unique to LDS. Aortic root enlargement is ubiquitous, with most patients undergoing root replacement at some point in their lifetime. Multiple vascular procedures are required to prolong life expectancy. We describe a staged hybrid approach to a 17-year-old patient with LDS presenting with ascending aorta, arch, and bilateral subclavian artery aneurysms and prominent tortuosity. Transposition of the left vertebral and subclavian arteries onto the common carotid artery was performed. Total aortic arch replacement with frozen elephant trunk extension into the descending thoracic aorta was performed as a second stage. Bilateral subclavian artery aneurysms were excluded with the use of a four-branched graft.

Multiple deep femoral artery aneurysms with Loeys-Dietz syndrome

A 60-year-old man with Loeys-Dietz syndrome (LDS) underwent surgery for multiple left deep femoral artery aneurysms (DFAAs). An intraoperative graft replacement was performed from the common femoral artery to the distal DFAAs; the superficial femoral artery was sutured to the graft. DFAAs in association with LDS and the occurrence of multiple DFAAs are rare. To the best of our knowledge, no studies have reported their coexistence. Graft replacement was decided as the optimal treatment for our patient. However, treatment should be considered on a patient-by-patient basis. Therefore, a lower limb arterial examination should accompany the screening of patients with LDS.

Operative repair of right intrathoracic subclavian artery aneurysms in patients with genetic arteriopathy

True intrathoracic subclavian artery aneurysms (SCAAs) are rare and have various etiologies. Right intrathoracic SCAAs pose specific anatomic challenges to repair. We present three different operative approaches, open, endovascular, and hybrid repair, for the repair of a right intrathoracic SCAA in three patients with genetic arteriopathy: Marfan syndrome, vascular Ehlers-Danlos syndrome, and unspecified Ehlers-Danlos syndrome, respectively. These cases demonstrate an individualized operative approach based on the genetic diagnosis for each patient presenting with a right intrathoracic SCAA.

Clinical features and complications of Loeys-Dietz syndrome: A systematic review

INTRODUCTION

Loeys-Dietz syndrome (LDS) is a connective tissue disorder that arises from mutations altering the transforming growth factor β signalling pathway. Due to the recent discovery of the underlying genetic mutations leading to LDS, the spectrum of characteristics and complications is not fully understood.

METHODS

Our search included five databases (Pubmed, SCOPUS, Web of Science, EMBASE and google scholar) and included variations of "Loeys-Dietz Syndrome" as search terms, using all available data until February 2021. All study types were included. Three reviewers screened 1394 abstracts, of which 418 underwent full-text review and 392 were included in the final analysis.

RESULTS

We identified 3896 reported cases of LDS with the most commonly reported features and complications being: aortic aneurysms and dissections, arterial tortuosity, high arched palate, abnormal uvula and hypertelorism. LDS Types 1 and 2 share many clinical features, LDS Type 2 appears to have a more aggressive aortic disease. LDS Type 3 demonstrated an increased prevalence of mitral valve prolapse and arthritis. LDS Type 4 and 5 demonstrated a lower prevalence of musculoskeletal and cardiovascular involvement. Amongst 222 women who underwent 522 pregnancies, 4% experienced an aortic dissection and the peripartum mortality rate was 1%.

CONCLUSION

We observed that LDS is a multisystem connective tissue disorder that is associated with a high burden of complications, requiring a multidisciplinary approach. Ongoing attempts to better characterise these features will allow clinicians to appropriately screen and manage these complications.

Extrathoracic subclavian artery aneurysm in a patient with suspected genetic arteriopathy

This is a case of a 4-cm left extrathoracic subclavian artery aneurysm (SCAA) in a 58-year-old man with an aortic root and abdominal aortic aneurysm. The patient had features suggestive of genetic arteriopathy, including vertebral artery tortuosity, pectus excavatum, tall stature, and scoliosis. The SCAA was successfully repaired with an inline prosthetic graft and anastomotic pledgets via a supraclavicular approach. Genetic testing revealed an FBN1 pathogenic variant consistent with Marfan syndrome. Repair is satisfactory 2 years later. Patients with SCAA should include consideration of genetic arteriopathy. Open repair of the extrathoracic SCAA in Marfan syndrome is recommended.

Endovascular Stenting in a Rare Case of Multiple Spontaneous Visceral Arterial Dissections

Spontaneous dissection of abdominal aortic branches is rare. Prior reports discuss incidents of isolated renal artery dissections and isolated splanchnic artery dissections; however, these types of dissections almost never occur simultaneously. Based on literature review, only one other case report has described spontaneous dissections of multiple visceral arteries. This brief report presents the successful endovascular treatment of a previously healthy man with spontaneous dissection of the proximal celiac artery and bilateral renal arteries. Due to the patient's acute presentation and renal injury, stenting of bilateral renal arteries was undertaken with successful medical outcomes on postprocedural follow up.

Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries

Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.

Loeys-Dietz syndrome pathology and aspects of cardiovascular management: A systematic review

Loeys-Dietz syndrome is an autosomal dominant genetic disorder which is associated with significant and often crucial vascular manifestations. This review is aimed to examine current evidence on pathophysiology and management of Loeys-Dietz syndrome in current era. A comprehensive electronic search was done to identify the articles that discussed all the aspects of Loeys-Dietz syndrome, combined key words and Medical Subject Headings (MeSH) terms were used. Relevant articles have been summarized in each relevant section. Loeys-Dietz syndrome is an autosomal dominant genetic disorder which has combined and multi-systemic manifestations. The increased breakdown of extracellular matrix predisposes an individual to developing aneurysms in the aortic tree which is undoubtedly the most significant complication of this disorder. Understanding the pathophysiology and natural history of Loeys-Dietz syndrome and regular surveillance is important to plan prophylactic interventions to prevent life-threatening aortic emergencies which can be fatal. Loeys-Dietz syndrome is an aggressive genetic condition that predisposes an individual to the development of life-threatening aortic aneurysms. Our understanding of Loeys-Dietz syndrome remains ever-changing and it is likely that the knowledge regarding its diagnosis and treatment will become more clearly defined in the coming years with deeper genetic studies.

The Chalice Sign : Characteristic Morphology of the Cervical Carotid Bifurcation in Patients with Loeys-Dietz Syndrome

BACKGROUND AND PURPOSE

Loeys-Dietz syndrome (LDS) is a connective tissue disorder characterized by arterial aneurysms and dissections. This study sought to assess and describe the arterial changes of the cervical arterial vasculature of such patients, with an emphasis on the carotid bifurcation.

MATERIAL AND METHODS

A retrospective review of patients with a known diagnosis of LDS was carried out. The maximum diameters of the external carotid artery (ECA) and internal carotid artery (ICA) origins, common carotid artery (CCA) terminus, maximum transverse and craniocaudal dimensions of the carotid bulb, and bifurcation angle were measured. The presence of a chalice sign was defined as a carotid bifurcation angle of ≥80°. A semi-quantified analysis of vertebral artery tortuosity was completed as well. All measurements were compared to a cohort of age-matched controls.

RESULTS

A total of 21 patients with LDS were included. Compared to normal controls, the presence of a chalice sign had 61.9% sensitivity and 100.0% specificity for LDS if present bilaterally; the sensitivity and specificity of a unilateral chalice sign were 66.7% and 82.3%, respectively. Patients with LDS also had significantly higher rates of a bilateral chalice sign compared to patients with vascular Ehlers-Danlos syndrome (vEDS) (61.9% versus 0%, P <0.0001) and patients with Marfan syndrome (61.9% versus 14.3%, P = 0.001).

CONCLUSION

Patients with LDS have characteristic findings of the cervical arterial vasculature that enables them to be distinguished from normal controls as well as patients with connective tissue diseases, such as Marfan syndrome and vEDS; most notably including marked widening of the carotid bifurcation angle in what is proposed to be named the chalice sign.

Congenital superior mesenteric artery aneurysm in a 6-week-old infant presenting with upper gastrointestinal bleeding

Visceral artery aneurysms are rare in infants and children. The majority of cases are caused by genetic syndromes, trauma, or infection. Although the majority of aneurysms are asymptomatic, visceral artery aneurysms can present with abdominal pain, nausea/vomiting, or rupture. Aneurysm rupture can manifest as hemodynamic instability and/or gastrointestinal bleeding. We present the case of a congenital idiopathic aneurysm of the superior mesenteric artery in a 6-week-old infant who presented with gastrointestinal bleeding. We report a stepwise surgical approach to achieving aneurysm exclusion and thrombosis, and highlight the robust mesenteric collateral circulation that can develop in pediatric patients.

Complications of Insufficient Dura and Blood Loss During Surgical Intervention in Shprintzen-Goldberg Syndrome: A Case Report

BACKGROUND Shprintzen-Goldberg syndrome (SGS) is an extremely rare collagenopathy, most often caused by autosomal-dominant mutations in the SKI proto-oncogene, which is a component of the transforming growth factor beta (TGF-ß) signaling pathway. Approximately 50-60 cases of SGS have been recorded in the literature worldwide since its discovery in 1982. This collagen disorder affects bone and vascular development throughout the body, resulting in craniosynostosis, scoliosis, chest deformities, and aortic root dilation. Patients may have problems in the central nervous system, including Chiari 1 malformation, hydrocephalus, and dilation of the lateral ventricles. Unfortunately, the symptoms of SGS closely parallel those of related collagenopathies involving mutations in the TGF-ß signaling pathway, which makes accurate diagnosis difficult without genetic testing, especially in cases with complex presentation. CASE REPORT In this report we present the unique and complex disease manifestations in a 9-year-old girl with SGS. The patient had severe cervical spinal instability that resolved after surgical occipital-C4 fusion with an autograft from the rib. Midface distraction surgery was used to treat the patient's craniosynostosis and related facial deformities. This surgery was complicated by loss of 750 mL of blood due to insufficient dura and prominent vasculature. CONCLUSIONS Connective tissue symptoms associated with SGS can involve dural and vascular problems, as seen in this case report. Thus, the risk of extreme blood loss should be anticipated any time midface distraction surgery is performed on an SGS patient. Continued research is needed to define how this case relates to the SGS patient population.

A Rare Case of 7 Simultaneous Arterial Dissections and Review of The Literature

Objective:

Spontaneous multiple artery dissection is a relatively rare phenomenon. Early clinical signs are often nonspecific, making it difficult to diagnose.

Case Report:

This is a case of a 51-year-old female who presented with spontaneous dissection of 4 visceral arteries, both iliac arteries, and of the right internal carotid artery. The patient underwent urgent successful endovascular repair. Later complications included acute respiratory distress syndrome and pneumonia after massive blood transfusion. She recovered gradually and was discharged after 21 days. Due to this rare presentation, genetic investigation was performed in search of a connective tissue disorder. Results revealed a new COL3A1 subtype mutation. The pathogenicity of this variant remains unclear.

Conclusion:

We recommend a high index of suspicion for visceral artery dissection in the differential diagnosis for abdominal pain with concurrent uncontrolled hypertension. Early diagnosis and intervention are crucial to reducing the mortality rate.

Carotid Artery Tortuosity Index Is Associated With the Need for Early Aortic Root Replacement in Patients With Loeys-Dietz Syndrome

OBJECTIVE

This study aimed to determine if carotid arterial tortuosity represents a marker of disease severity in Loeys-Dietz syndrome (LDS).

METHODS

Fifty-four 54 LDS patients (mean age, 17.0 years) who underwent computed tomogram angiography from January 2004 to December 2013 were retrospectively identified. Carotid artery tortuosity index (CATI) was calculated from computed tomogram angiography. Clinical variables were obtained from the medical records. Relationship between CATI and need for aortic root replacement was evaluated with Cox proportional hazard model and Kaplan-Meier analysis.

RESULTS

Higher CATI was associated with the need for aortic root replacement (P < 0.001) in the univariate Cox proportional hazard model. Patients were stratified based on both CATI and aortic root size in Kaplan-Meier analysis, and patients with higher CATI were more likely to require aortic root replacement (P < 0.001) in both aortic root size strata.

CONCLUSION

Increased carotid artery tortuosity is associated with the need for early aortic root replacement in patients with LDS.

Cardiovascular surgery in Loeys-Dietz syndrome types 1-4

OBJECTIVES

The first publication of Loeys-Dietz syndrome (LDS) described aortic rupture at young ages. Experience with new LDS types showed that the clinical course varies, and thresholds for prophylactic surgery are discussed. As this is an uncommon disease, experience needs to be shared.

METHODS

Retrospective review of patients with LDS types 1-4 undergoing cardiovascular surgery during the years 1991-2016.

RESULTS

Thirty-five patients (including 6 children with LDS2) underwent 57 operations. LDS 1, 2, 3 and 4 included 4, 17, 11 and 3 patients, respectively. Mean age at first surgery was 36 years, with a non-significant trend that LDS2 patients were younger. Of the 9 emergency surgeries, 7 were type A dissections, with 1 postoperative death. Twenty-two patients had prophylactic aortic root surgery (17 valve-sparing root replacements), with 1 postoperative death, 1 reoperation with valve replacement and 1 late death. Freedom from root reintervention and death was 92% at 13 years. Of the 11 patients with LDS3, 5 needed mitral valve surgery. Mitral valve disease was not found in the other LDS types. Ten patients needed >1 operation. Of the 57 operations, 33 were in the ascending aorta, 20 in the aorta distal to the arch including branches and 4 were isolated heart surgeries. Of the 20 vascular operations, 16 were in LDS2. Cumulative survival 20 years after first surgery (all patients) was 94.3%.

CONCLUSIONS

Clinical course seems to be more aggressive in LDS2, with index operation at a younger age, and higher risk of needing several operations. Vascular disease distal to the arch is not uncommon. LDS3 seems to be associated with mitral valve disease. Prophylactic aortic root surgery is safe and durable.

Endovascular repair of tortuous recurrent femoral-popliteal aneurysm in a patient with Loeys-Dietz syndrome

Loeys-Dietz syndrome is a rare connective tissue disorder with widespread arterial tortuosity and aneurysms. This syndrome is most notable for its aortic disease, including aortic root dilation and aortic dissection or rupture. Although not as well studied, peripheral artery aneurysms are a prevalent concurrent manifestation and have previously been repaired with both open and endovascular approaches. There are minimal data about the durability and technical considerations of endovascular repair in this disease. We report a case of a patient who developed an extremely tortuous recurrent femoral-popliteal artery aneurysm secondary to aneurysmal degeneration around previously placed stents that was treated with an endovascular approach.

Localized Aortic Root Dissection with a Superior Mesenteric Artery Aneurysm

In this study, the case of a 46-year-old female patient with localized aortic root dissection and a superior mesenteric artery (SMA) aneurysm is described. Computed tomographic angiography could not clearly delineate an intimal flap in the aortic root, but it detected SMA aneurysm, which implied the presence of a vulnerability of the aortic wall. Finally, transesophageal echocardiography (TEE) evidently showed the intimal flap localized in the aortic root. The present case suggests that TEE is of paramount importance for detecting localized aortic root dissection. In addition, a coexisting vascular lesion may be a clue to diagnose another vascular lesion.

Acute Aortic Syndromes: Update in Current Medical Management

OPINION STATEMENT

Advances in medical therapy and non-surgical percutaneous options to manage the specter of acute aortic syndromes have improved both patient morbidity and mortality. There are key features in the patient history and initial exam which physicians should be attuned to in order to diagnose acute aortic syndromes such as aortic dissection, penetrating aortic ulcer, and intramural hematoma. Once recognized, early initiation of the appropriate pharmacologic therapy is important, and further appreciating the limitations of such therapy before considering a surgical approach is critical to improve patient outcomes. For the undifferentiated patient with acute aortic dissection presenting to facilities who do not routinely manage this condition, adding pharmacologic agents in the correct sequence assures the best chance for a satisfactory outcome.