Interrupted aortic arch with post-interruption aneurysm and bicuspid aortic valve in an adult: a case report and literature review. Radiol Case Rep. 2015;10:5-8. [PMID: 26649108 PMCID: PMC4633978 DOI: 10.1016/j.radcr.2015.06.001]

Interrupted aortic arch with severe aortic stenosis in an adult bicuspid aortic valve patient

Interrupted aortic arch (IAA) is a rare congenital anomaly with a high mortality rate if left unoperated in infancy. Very few cases have been reported in adults so far. In this article, we are describing a case of IAA in a 28-year-old male patient. It was associated with bicuspid aortic valve (BAV) leading to severe aortic stenosis (AS). To our knowledge, very few complex cases involving trio of IAA with BAV and AS have been reported so far.

Rare case series of adult interrupted aortic arch

Interrupted aortic arch (IAA) is a rare congenital heart condition where there is a complete discontinuation between the ascending and descending aorta. The association with a patent ductus arteriosus or developed arterial collateral allows survival until adulthood in extremely rare cases. We report a case series of adult forms of IAA. Even if the incidence is very rare, IAA should be could excluded in the setting of resistant asymmetrical hypertension. The first case is singular regarding its association with a bicuspid aortic valve and aortic aneurysm, while the second case is characterized by massive left ventricular hypertrophy. The diagnosis was suspected on echocardiographic findings and confirmed by computed tomography angiography. Both patients refused surgical repair given the high operative risk.

Learning objectives

-The evaluation of severe resistant high blood pressure should include complementary investigation for adult form interrupted aortic arch.-To understand the major impact of multimodality imaging for the recognition, localization, and stratification of interrupted aortic arch.

SMAD4: A Critical Regulator of Cardiac Neural Crest Cell Fate and Vascular Smooth Muscle Differentiation

Background

The pharyngeal arch arteries (PAAs) are precursor vessels which remodel into the aortic arch arteries (AAAs) during embryonic cardiovascular development. Cardiac neural crest cells (NCs) populate the PAAs and differentiate into vascular smooth muscle cells (vSMCs), which is critical for successful PAA-to-AAA remodeling. SMAD4, the central mediator of canonical TGFβ signaling, has been implicated in NC-to-vSMC differentiation; however, its distinct roles in vSMC differentiation and NC survival are unclear.

Results

Here, we investigated the role of SMAD4 in cardiac NC differentiation to vSMCs using lineage-specific inducible mouse strains in an attempt to avoid early embryonic lethality and NC cell death. We found that with global SMAD4 loss, its role in smooth muscle differentiation could be uncoupled from its role in the survival of the cardiac NC in vivo . Moreover, we found that SMAD4 may regulate the induction of fibronectin, a known mediator of NC-to-vSMC differentiation. Finally, we found that SMAD4 is required in NCs cell-autonomously for NC-to-vSMC differentiation and for NC contribution to and persistence in the pharyngeal arch mesenchyme.

Conclusions

Overall, this study demonstrates the critical role of SMAD4 in the survival of cardiac NCs, their differentiation to vSMCs, and their contribution to the developing pharyngeal arches.

Interrupted aortic arch associated with aortic coarctation, bicuspid aortic valve and moderate to severe mitral valve regurgitation in an adult patient: a case report

Interrupted aortic arch is a rare congenital abnormality with a high mortality rate in infancy conditioning only a few cases reported in adult patients. The principal finding is a complete loss of continuity between the ascending and descending portions of aorta, and is usually associated with other cardiac defects. In this case report, we present a 22-year-old male patient with refractory hypertension and diagnosis of interrupted aortic arch associated with aortic coarctation, bicuspid aortic valve and moderate to severe mitral valve regurgitation. We decided to perform a surgical correction and the patient underwent to bypass grafting of the ascending-to-descending aorta, and mitral valve repair. Interrupted aortic arch must be considered in the differential diagnosis of adult patient with refractory hypertension and a careful physical examination is crucial for ensuring the correct diagnosis of rare congenital abnormality non made until adulthood.

Difference and similarity between type A interrupted aortic arch and aortic coarctation in adults: Two case reports

BACKGROUND

Aortic coarctation (CoA) is usually confused with interrupted aortic arch (IAA), especially adult type A interrupted aortic arch, due to their similar anatomical location. Although the main difference between them is whether arterial lumen exhibits continuity or not, the clinical manifestations are similar and connection exists between them. Adult type A IAA is considered as an extreme form of CoA, which is complete discontinuity of aortic function and lumen caused by degenerative arterial coarctation. This paper reports two cases (interrupted aortic arch and severe aortic coarctation) to analyze the difference and similarity between them.

CASE SUMMARY

The two cases of patients presented with hypertension for many years. Computed tomography angiography showed that the aortic arch and descending aorta were discontinuous or significantly narrowed with extensive collateral flow. The IAA patient refused surgical treatment and blood pressure could be controlled with drugs. While the CoA patient underwent stent implantation because of uncontrollable hypertension, the blood flow recovered smoothly and the blood pressures at both ends of the stenosis returned to normal after surgery.

CONCLUSION

Adult type A IAA and CoA have difference and similarity, and type A IAA is associated with CoA to a certain extent. The treatment method should be chosen based on the patient's clinical symptoms rather than the severity of the lesion.

Type B Interrupted Aortic Arch With a Very Large Right Subclavian Artery Aneurysm in an Adult

Interruption of the aortic arch and right subclavian artery aneurysm is a rare congenital malformation. Survival in adults depends on the formation of collaterals to supply the descending aorta. The interruption of the aortic arch must be taken into account, particularly in patients with hypertension and weak pulses in the lower extremities. We present a case of aortic arch interruption and a right subclavian artery aneurysm in a woman who survived to adulthood.

Aortic Arch Variants and Anomalies: Embryology, Imaging Findings, and Clinical Considerations

There is a wide spectrum of congenital anomalies or variations of the aortic arch, ranging from non-symptomatic variations that are mostly detected incidentally to clinically symptomatic variations that cause severe respiratory distress or esophageal compression. Some of these may be accompanied by other congenital heart diseases or chromosomal anomalies. The widespread use of multidetector computed tomography (CT) in clinical practice has resulted in incidental detection of several variations of the aortic arch in adults. Thus, radiologists and clinicians should be aware of the classification of aortic arch anomalies and carefully look for imaging features associated with a high risk of clinical symptoms. Understanding the embryological development of the aortic arch aids in the classification of various subtypes of aortic arch anomalies and variants. For accurate diagnosis and precise evaluation of aortic arch anomalies, cross-sectional imaging modalities, such as multidetector CT or magnetic resonance imaging, play an important role by providing three-dimensional reconstructed images. In this review, we describe the embryological development of the thoracic aorta and discuss variations and anomalies of the aortic arch along with their clinical implications.

Interventional treatment for acute cerebral infarction with large vessel occlusion combined with aortic arch interruption: A case report

RATIONALE

Aortic arch interruption is a type of congenital vascular malformation that is often observed in childhood. Most children die of congestive heart failure due to rapid deterioration. Children can only survive to adulthood if they have extremely rich collateral circulation. Cases of acute cerebral infarction with large vessel occlusion receiving interventional treatment in adult patients with interrupted aortic arch have not been reported.

PATIENT CONCERNS

A 55-year-old man with a history of atrial fibrillation and smoking but without a family history of stroke was admitted to our hospital with a 5-hour history of left limb weakness and speech difficulties.

DIAGNOSES

Emergency brain computed tomography showed a large cerebral infarction in the right frontal temporal parietal lobe. He was suspected to have aortic arch interruption in the early stage of endovascular interventional therapy through the femoral artery approach, and was converted to the transradial artery pathway. The aortic arch was disconnected, and the right internal carotid artery was occluded.

INTERVENTIONS

Considering the possibility of cardiogenic embolism, a middle catheter was used for thrombus aspiration of the right internal carotid artery. After removal of the dark red thrombus was removed, the right internal carotid artery was successfully recanalized.

OUTCOMES

The patient recovered well after the operation. However, the patient and his family refused further treatment for aortic arch interruption. The modified Rankin Scale score was 0 at 3 months and 1 year of follow-up which meant that he recovered quite well.

LESSONS

Adult patients with acute cerebral infarction with large vessel occlusion are rarely complicated with aortic arch interruption, and emergency thrombectomy via the radial artery approach is feasible.

Is surgery necessary for adults with isolated interrupted aortic arch?: Case series with literature review

BACKGROUND AND AIM

Interrupted aortic arch (IAA) is defined as a complete interruption of aortic lumen between the ascending and descending aorta. It is an uncommon and complicated congenital heart disease. It is rare for patients with isolated IAA to survive to adulthood without operation. Here we present three rare cases with isolated IAA together with a review of the literature of IAA. Besides, we reviewed reported adult cases with isolated IAA in the last 20 years and summarized the relevant data of the isolated type.

METHODS

We retrospectively searched the hospital databases for adult patients with isolated IAA diagnosed at the Wuhan Union Hospital over the past 10 years. Cases related to adult isolated IAA published in last 20 years were identified by searching Pubmed.

RESULTS

Three adult patients with isolated IAA were identified. Two were referred to us for hypertension management and were diagnosed with IAA. They declined surgical treatments and took antihypertensive medications. One patient was referred to our hospital for further treatment options after diagnosed with IAA at another hospital. He received an extra-anatomic bypass surgery. But his hypertension did not well resolve after surgery, and was subsequently managed by anti-hypertensives medications. 25 published adult patients with isolated IAA were identified in Pubmed and relevant details were summarized.

CONCLUSIONS

Adult patients with isolated IAA usually have extensive collateral vessels joining the descending aorta. Anti-hypertensives medical management with long-term follow-up appears to be a reasonable treatment option for these patients, although surgical intervention is a good choice.

Isolated interrupted aortic arch in an adult: A case report

BACKGROUND

Interrupted aortic arch (IAA) is a rare congenital heart disease defined by an interruption of the lumen and anatomical continuity between the ascending and descending major arteries. It is usually found within a few hours or days of birth. Without surgery, the chances of survival are low. If IAA patients have an effective collateral circulation established, they can survive into adulthood. However, IAA in adults is extremely rare, with few reported cases.

CASE SUMMARY

A 27-year-old woman presented with a 6-year history of progressively worsening shortness of breath and chest tightness on exertion. She had cyanotic lips and clubbing of the fingers. A transthoracic echocardiogram revealed an enlarged heart and dilation of the main pulmonary artery. There was an abnormal 9 mm passage between the descending aorta and pulmonary artery. The ventricular septal outflow tract had a 14 mm defect. Doppler ultrasound suggested a patent ductus arteriosus and computed tomographic angiography showed the absence of the aortic arch. The diagnoses were ventricular septal defect, patent ductus arteriosus, and definite interruption of the aortic arch. Although surgical correction was recommended, the patient declined due to the surgical risks and was treated with medications to reduce pulmonary artery pressure and treat heart failure. Her condition has been stable for 12 mo of follow-up.

CONCLUSION

Although rare, IAA should be considered in adults with refractory hypertension or unexplained congestive heart failure.

Study on the views and methods of ultrasonic screening and diagnosis for abnormal aortic arch in infants

BACKGROUND

The purpose of this study was to explore echocardiographic views and methods of aortic arch anomalies in infants, so as to improve the screening sensitivity and diagnostic accuracy.

METHODS

140 children with abnormal aortic arch diagnosed by ultrasound in Children's Hospital of Hebei Province from January 2014 to December 2019 were selected for retrospective analysis. All were confirmed by surgery or/and computerized tomography angiography. Series of views for aortic arch (the three-vessel and tracheal view, aortic arch short axis view, left aortic arch long axis view, aortic arch long axis continuous scan views) were performed in all cases on the basis of the routine views of echocardiography. The screening sensitivity and diagnostic coincidence rate of different echocardiographic views for aortic arch anomalies were analyzed.

RESULTS

Among the 140 infants, right aortic arch were 21 cases (6/21 were accompanied by mirror branch and 15/21 were with aberrant left subclavian artery). Left aortic arch with aberrant right subclavian artery were 2 cases, and double aortic arch with both arches open were 20 cases. Double aortic arch with left arch atresia were 2 cases, and atresia of the proximal aorta with aortic arch dysplasia was 1 case. Coarctation of the aorta were 67 cases, and interruption of aortic arch were 27 cases. All the patients were correctly diagnosed except that 2 infants with interruption of aortic arch were incorrectly diagnosed as coarctation of the aorta, and 1 infant with coarctation of the aorta was misdiagnosed as interruption of aortic arch by echocardiography. The screening sensitivities of four views and four-view combination for abnormal aortic arch were 99.3, 73.6, 87.1, 99.3, and 100%; the diagnostic coincidence rates were 85.7, 27.1,66.4, 95.0%, and 97.9% respectively. On the basis of traditional left aortic long axis view, other three views had their own advantages. The screening sensitivity and diagnostic coincidence rate of four-view combination were significantly improved.

CONCLUSIONS

The three-vessel trachea view is simple and feasible, which is suitable for screening abnormal aortic arch. The combination of four views conduces to improving screening sensitivity and diagnostic accuracy of aortic arch abnormalities.

Interrupted aortic arch: A case report

Interrupted aortic arch diagnosed in adult age is a rare entity, with only a few cases published in the literature. Most of them are classified as type A interrupted aortic arch and differential diagnosis is associated with severe chronic coarctation. We present a case of a 52-year-old woman accessed to the emergency department for chest and right upper limb pain that increased in the last days. She underwent a computed tomography angiogram showing interruption of the aortic arch, distal to left subclavian artery origin, large bilateral collateral vessels connecting subclavian arteries to descending aorta with multiple voluminous aneurysms, a bicuspid aortic valve, dilatated tubular segment of ascending thoracic aorta, and a suspected atrial septal defect. A nonsystematic literature review regarding these conditions has been performed.

Patient-specific Computational Hemodynamic Analysis for Interrupted Aortic Arch in an Adult: Implications for Aortic Dissection Initiation

The guideline for the treatment of interrupted aortic arch (IAA) in adults has not been established although most centers tend to propose surgery. There is no clear evidence for the preferred selection of surgical repair versus conservatively medical treatment for the uncertain effects of both treatments. However, reports of sporadic aortic dissection (AD) of descending aorta (DAo) in IAA in adults before surgery drew our attention. It is quite perplexing because there seems to be no risk factors for the development of AD at DAo such as long-term uncontrolled hypertension, atherosclerosis, aortic aneurysm or genetic disorder. In this paper, we carried out the numerical investigation on the hemodynamics in a patient-specific IAA model, which was reconstructed from computed tomography images. Hemodynamic parameters including the flow pattern, pressure distribution, and wall shear stress (WSS) indicators were obtained. The simulation revealed that the jet flows from the collateral arteries (CAs) induced risk hemodynamic forces on the lumen wall including high time-averaged wall shear stress (TAWSS), high pressure and rapid change of WSS direction throughout the cardiac cycle. Moreover, it is found that only a jet flow which circumferentially washes out the aortic wall might cause tears on the wall. It is concluded that the specific geometrical features of the extensive major CAs might result in the risky hemodynamics leading to the initiation and development of AD in this particular IAA patient. CFD analysis in IAA can provide a clinical reference, and the results should be further studied in depth in the future.

Congenital abnormalities of the aortic arch: revisiting the 1964 Stewart classification

The traditional classification of congenital aortic arch abnormalities was described by James Stewart and colleagues in 1964. Since that time, advances in diagnostic imaging technology have led to better delineation of the vasculature anatomy and the identification of previously unrecognized and unclassified anomalies. In this manuscript, we review the existing literature and propose a series of modifications to the original Stewart classification of congenital aortic arch abnormalities to incorporate this new knowledge. In brief, we propose the following modifications: (1) In Group I, we further divide subgroup B into left arch atretic and right arch atretic; (2) In Group II, we add three more subgroups, including aberrant right innominate artery, "isolated" right innominate artery (RIA), "isolated" right carotid artery with aberrant right subclavian artery; (3) In Groups I, II, and III, we add a subgroup of absence of both ductus arteriosus; and (4) In Group IV, we add three subgroups, including circumflex retro-esophageal aorta arch, persistent V aortic arch, and anomalous origin of pulmonary artery from ascending aorta.

Isolated interrupted of aortic arch diagnosed using CT angiography: A case report and literature review

RATIONALE

Interrupted aortic arch (IAA) is defined as a complete luminal and anatomical interruption between the ascending and descending aortas. The majority of patients with IAA rarely reach adulthood. In most cases, IAA is associated with an intracardiac malformation, such as ventricular septal defect, bicuspidaortic valve, and patent ductus arteriosus. We reported a 70-year-old man with isolated IAA diagnosed using computed tomography angiography (CTA) without previous intervention.

PATIENT CONCERNS

The patient presented with edema of the lower extremities and productive cough.

DIAGNOSES

CTA displayed an interruption of the aortic arch distal to the left common carotid artery (type B) and extensive collateralization.

INTERVENTIONS

The patient refused surgery and underwent conservative therapy with follow-up examinations because of the extensive collateral vascularization.

OUTCOMES

The patient is still currently undergoing conservative therapy with follow-up examinations.

LESSONS

IAA can present in adulthood with different clinical symptoms. Careful physical examination of the lower and upper peripheral pulses in adults with a chief complaint of hypertension is of outmost importance. CTA is a useful noninvasive imaging modality for the morphologic evaluation of aortic interruption and collateral circulation.

Preoperative Physiology, Imaging, and Management of Interrupted Aortic Arch

Interrupted aortic arch (IAA) is a rare form of critical neonatal heart disease in which there is lack of continuity between the ascending aorta and the descending thoracic aorta. In the absence of prenatal diagnosis, patients with IAA present in shock when the patent ductus arteriosus closes. Diagnosis can generally be made by echocardiography, and initiation of prostaglandin E1 infusion allows for adequate lower body perfusion prior to surgical repair. Full neonatal repair can be achieved with good outcomes in most cases. However, there is often underdevelopment of the left ventricular outflow tract and risk for later surgical re-intervention. Many patients with IAA, particularly those with type B, have DiGeorge syndrome, which has important development implications.

Congenital anomalies of the aortic arch

Congenital anomalies of the aortic arch include diverse subgroups of malformations that may be clinically silent or may present with severe respiratory or esophageal symptoms especially when associated with complete vascular rings. These anomalies may be isolated or may be associated with other congenital heart diseases. Volume rendered computed tomography (CT) and magnetic resonance angiography (MRA) help in preoperative surgical planning by providing information about the complex relationship of aortic arch and its branches to the trachea and esophagus. Three dimensional capabilities of both computed tomography angiography (CTA) and MRA are helpful in determining evidence of tracheal or esophageal compression or other high-risk features in patients with a complete vascular ring.

Interrupted Aortic Arch in an Adult

Interrupted aortic arch (IAA) is a rare congenital abnormality with only a few cases reported in adults. It is defined as complete loss of continuity between the ascending and descending portions of the aorta, and is usually associated with other cardiac defects. The diagnosis in adults should be suspected in the presence of refractory hypertension, a careful physical examination being crucial to early diagnosis. Magnetic resonance angiography (MRA) techniques can accurately characterize cardiovascular anatomy, and also provide information regarding heart chamber and valve function.

LEARNING POINTS

Although rare, interrupted aortic arch (IAA) must be considered in the differential diagnosis of adults with refractory hypertension. A careful physical examination, with evaluation of femoral pulses and blood pressure in the four limbs, is essential for the diagnosis and for ensuring that the correct diagnosis is made promptly.This case highlights the value of magnetic resonance angiography (MRA) in radiation-free non-invasive evaluation of adults with congenital aortic abnormalities, as it may provide clinically important haemodynamic information.Only a few cases have been reported in adults. We present an unusual case in which the diagnosis was not made until adulthood.