Dissecting aneurysm of the aorta due to giant cell arteritis

Incidence of Aortitis in Surgical Specimens of the Ascending Aorta Clinical Implications at Follow-Up

The objectives of this study are to evaluate the incidence of aortitis on a surgical population, establish any relationship with systemic diseases, verify early and late surgical results and provide clinical and radiological follow-up to determine factors potentially predicting progression of the disease and influencing late outcome. From 2009 to 2017, 237 patients underwent elective operations on the ascending aorta. Segments of the excised tissues were routinely sent for histologic evaluation, providing adequate data in 178 (75%) for a clinical and pathologic correlation. Patients with aortitis (Group 1) (n = 26) were compared with 152 with atherosclerotic or degenerative disease (Group 2). Incidence of aortitis was 15%, being clinically isolated in 73%. In 24 patients (92%), a giant cell aortitis was found. Actuarial survival at 3 years is 88% in Group 1 and 98% in Group 2 and 74% and 98% at 5 years, respectively (P = 0.016). A control angio-computed tomography revealed an increased descending aorta diameter in 2 out of 14 late survivors. A positron emission tomography showed presence of arteritis in other vascular segments in 3 patients. Clinically isolated aortitis is extremely frequent in patients with inflammatory aortic disease. The diagnosis is often difficult and may be supported by routine pathologic evaluation of surgical explants and by multimodality imaging. The latter should be employed to allow adequate patient follow-up and to disclose potential recurrences in untreated aortic segments.

Temporal arteritis and gangrene of the tongue

A 69-year-old woman, suspected of having polymyalgia rheumatica, was biopsied from the temporal artery to establish the diagnosis. Six hours after the biopsy, she developed progressive gangrene of the tongue and the floor of the mouth, and intensive steroid therapy was initiated. The histological examination of the biopsy revealed giant-cell arteritis. Biopsy or other manipulation of the artery is suggested to be the cause of exacerbation of the arteritis locally. Steroid treatment is proposed in all cases prior to the biopsy. Other studies have not shown that the possibility of obtaining a positive histological diagnosis is reduced during or after steroid treatment. A review of the literature on gangrene of the tongue is given.

Coronary ischaemia and occlusion in giant cell (temporal) arteritis

Reports of coronary artery involvement in giant cell (temporal) arteritis--polymyalgia rheumatica (GC(T)A--PMR) together with other large arteries arising from the aorta have been numerous over the past 40 years, but on this the specialist cardiac literature has been virtually silent. This article summarises that evidence, and records nine additional patients from a large group of cases with both GC(T)A--PMR and ischaemic heart disease (IHD) observed since a previous report in 1960. The case histories illustrate the benefit from corticosteroids and the hazards of non-diagnosis and premature cessation of such treatment. It seems that many patients with arteritic IHD (and claudication) are not being identified before or after death. Possible reasons for this oversight by clinicians and pathologists are offered, and suggestions are made with regard to points in history-taking and important physical signs which may help to alert the clinician. There is autopsy evidence from Malmö, Sweden, that the prevalence of GC(T)A--PMR is much higher than at present suspected on clinical grounds.

Ulceration and necrosis of the tongue due to giant cell arteritis

A case is reported of giant cell arteritis in a 74-year-old woman, complicated by ulceration and necrosis of the tongue. During steroid treatment recovery was observed.

Lack of association between angiotensin-converting enzyme gene polymorphism and type I aortic dissection

The relationship between angiotensin-converting enzyme (ACE) gene polymorphism and type I aortic dissection was examined in 205 unrelated hypertensives. A total of 94 patients underwent emergency repair due to type I aortic dissection, confirmed by computed tomography, and the remaining 111 were controls. Polymerase chain reaction was used to confirm that ACE gene polymorphism was due to insertion (I) or deletion (D) of a 287 base pair (bp) DNA sequence within intron 16. The genotype distribution and allele frequency of ACE I/D polymorphism between patients and controls were not statistically significant. When the frequency of at least one D allele carrier (DD or ID genotype) was compared with the II homozygous genotype, there was also no significant difference between the study groups. The findings revealed no association between ACE I/D polymorphism and aortic dissection. We conclude that I/D mutation of the ACE gene does not seem to be a risk factor for aortic dissection.

Horton's aortitis

Giant cell arteritis is the most common systemic vasculitis in people over the age of 50 years. Ischaemic manifestations are well known. 'Occult' manifestations as aortic aneurysmal disease need consideration. The incidence of aortic aneurysm and/or dissection is about 18.5 per 1000 person-years at risk (18.9 in Lugo(4) and 18.7 in Olmsted County(3)). Predictive factors are hypertension, polymyalgia rheumatica, coronaropathy, and hyperlipaemia. Another factor is the apparition of an aortic regurgitation murmur as in this case. So, these patients should be monitored by echocardiography.

Survival after aortic dissection in giant cell arteritis

Images

Aortic dissection in giant-cell arteritis

Twenty-three cases of aortic dissection in patients with giant-cell arteritis are reviewed and an additional case is reported. Forty-six percent presented catastrophically with aortic dissection and no prior history of giant cell arteritis. Eighty percent died within 2 weeks of the event; four patients had successful surgical grafts. There was diffuse involvement of the aorta with giant cells in 89%, but dissecting tears occurred primarily in the proximal aorta in 85% of cases. The majority of cases with a preceding history of giant cell arteritis were on low doses of steroid or on no treatment at the time of dissection, and the median erythrocyte sedimentation rate of these patients was 62 mm/h (range 21-98). Evidence of some form of hypertension, whether acute or chronic, mild or severe, was found in 77% of patients. Inadequate treatment of giant-cell arteritis and underlying hypertension (treated or untreated) are potential factors leading to aortic dissection in these patients.

Thoracic aortic aneurysm and rupture in giant cell arteritis. A descriptive study of 41 cases

OBJECTIVE

To determine the features and outcomes of patients with giant cell arteritis (GCA) who have aneurysms or rupture of the thoracic aorta.

METHODS

Patients with GCA seen over a 40-year period who had aneurysms and/or rupture of the thoracic aorta were identified by assistance of a computerized indexing system. The presence of thoracic aortic aneurysms (TAA), with or without aortic valve insufficiency (AI), was determined by radiographs, computed tomography scans, and ultrasound studies of the thorax, angiograms of the aorta, and postmortem examination.

RESULTS

Ten men and 31 women with GCA were found to have TAA and/or rupture. Three developed TAA before GCA was diagnosed, 5 developed aortic findings near the time of the diagnosis, and 33 after the diagnosis of GCA (median of 7 years after diagnosis). Sixteen patients developed acute aortic dissection, which caused death in 8. Nineteen patients also had AI due to aortic root dilation, 15 of whom developed congestive heart failure. Eighteen patients underwent 21 surgical procedures for TAA resection and/or aortic valve replacement or repair. Aortitis was documented histologically in 10 cases.

CONCLUSION

Thoracic aortic complications in GCA are associated with serious outcomes that have been underrecognized and may be fatal. Physicians should be alert to the development of these complications at any time in the course of GCA, even many years after usual symptoms have subsided.

The arteritides

This article reviews the histopathological, clinical and immunological features of the arteritides. Based on these criteria, a classification scheme is proposed that includes infectious and non-infectious causes. Included in the non-infectious arteritides are: hypersensitivity vasculitis including serum sickness. Henoch-Schönlein purpura, mixed cryoglobulinaemia, hypocomplementaemia, drug and malignancy-associated vasculitis; arteritides of small and medium-sized arteries including polyarteritis nodosa, Kawasaki's disease, Wegener's granulomatosis, Churg-Strauss syndrome, necrotizing sarcoid granulomatosis, thromboangiitis obliterans (Buerger's disease) and localized forms of arteritis; arteritides involving large, medium and small-sized arteries which includes giant cell (temporal) arteritis, Takayasu's disease and arteritis of collagen-vascular disease (rheumatoid arthritis, rheumatic fever, Behçet's disease, Sjörgren's syndrome, systemic lupus erythematosis and systemic sclerosis.

Necrosis of the tongue in a patient with intestinal infarction

A patient with a rare combination of bilateral lingual necrosis and intestinal infarction, caused by giant cell arteritis, is described and the literature reviewed.

Acute aortic dissection due to giant cell arteritis. Report of two autopsy cases

Two autopsy cases of giant cell arteritis with aortic dissection are reported. One patient was an 87-year-old man, and the other was an 80-year-old woman. In both cases the patient died suddenly, and fatal pericardial bleeding due to the aortic dissection was revealed at autopsy. Histologically, marked inflammation with giant cells was observed in the wall of the aorta and in other arteries including the cranial arteries. The authors therefore consider that giant cell arteritis was one of the preceding lesions that culminated in aortic dissection.

On the occurrence of necrotising lesions in arteritis temporalis: review of the literature with a note on the potential risk of a biopsy

Against the background of a steadily growing proportion of elderly individuals within the populations in the Western countries, arteritis temporalis with its wide diversity of presenting symptoms in the elderly patient, including purely psychiatric ones, has become a disease of increasing interest to the medical profession. Increasing demands may be made on the surgeon, often a plastic surgeon, responsible for carrying out the biopsy that is necessary in arteritis temporalis for both diagnostic and therapeutic reasons. Attention is called to certain elements of risk inherent in taking a biopsy of an artery under local anaesthesia, and to the fact that the administration of ergotamine tartrate may provoke serious complications in this particular disease.

Simultaneous aortic and pulmonary artery aneurysms due to giant cell arteritis

Images

Giant-cell arteritis. Signs and symptoms

Giant-cell arteritis is a polysymptomatic disease of the elderly. Systemic symptomatology includes headaches, arthralgias, myalgias, tender temporal arteries, jaw claudication, low-grade fever, anemia, anorexia, malaise, and weight loss. Visual loss from anterior ischemic optic neuropathy and diplopia resulting from ischemia of the ocular muscles represents the major ocular manifestations of giant cell arteritis. When the diagnosis is suspected, blood for a sedimentation rate should be drawn, and, if it confirms the clinical impression, high dose prednisone should be started immediately and a temporal artery biopsy performed at a later date. Only by asking the proper questions and suspecting the diagnosis will this preventable form of blindness receive the prompt attention it deserves.

Successful treatment of dissecting aortic aneurysm due to giant cell arteritis

A 72-year-old women with polymyalgia rheumatica clinically controlled on maintenance steroid therapy presented with symptoms of chest pain and numbness in the right arm. A diagnosis of dissecting aortic aneurysm was confirmed at thoracotomy and the aorta was successfully resected. Histology revealed active giant cell aortitis. We suggest that a normal erythrocyte sedimentation rate in patients with treated temporal arteritis does not preclude large vessel involvement.

Polymyalgia rheumatica and giant cell arteritis--rational diagnosis and treatment predicated and disordered prostaglandin metabolism

We suggest that polymyalgia rheumatica with giant cell arteritis (PR-GCA) is an arachidonic acid metabolites mediated disease which can be diagnosed more accurately and monitored more precisely for therapeutic benefits by the serial determinations of the major urinary prostaglandin F, serum urinary lysozymes, serum acid phosphatase, and serum angiotensin converting enzyme rather than by the erythrocyte sedimentation rate, and, when necessary by temporal artery biopsy. The pathogenetic role proposed for prostaglandins (PG) and, even more precisely perhaps, the leukotrienes in this disease is consistent with the several published clinical observations that non-steroidal anti-inflammatory drug treatment produces in some cases a therapeutic paradox of symptomatic relief with concurrent, if clinically silent, progression of the arteritis, even to blindness. Furthermore, the impressive response of PR-GCA to low maintenance dose steroid therapy, a clinical conundrum for decades, is rationally explained on the basis of depressed or obstructed PG metabolism early on in the metabolic cascade. These views warrant clinical evaluation, confirmation or correction in whole or in part, and may increase our understanding of PR-GCA.

Aortic valve replacement for severe aortic regurgitation caused by idiopathic giant cell aortitis

Giant cell aoritis occurred in a 25-year-old woman, with absent pulses in the left arm and severe aortic regurgitation from dilatation of the valvar annulus. The aortic valve was replaced by a Starr-Edwards prosthesis, and the patient was treated with steroids. Five years later, she continues asymptomatic and haemodynamically stable. The left brachial and radial pulses have returned.

Pulmonary and systemic aneurysms in a case of widespread arteritis

A patient in whom asthma preceded the development of multiple pulmonary and systemic artery aneurisms died after dissection of the aorta. At necropsy he was found to have widespread arteritis of unknown aetiology affecting many large and medium-sized pulmonary and systemic vessels as well as a few microscopic ones. Endarteritis obliterans was present in some of the vasa vasorum. The clinical and histopathological findings are discussed in relationship to other known causes of arteritis, and it is concluded that this condition has not previously been described.

Homograft replacement of aortic valve and ascending aorta in a patient with non-specific giant cell aortitis

A case of giant cell aortitis causing ascending aortic aneurysm associated with aortic regurgitation is reported. The aneurysm was excised and the aortic valve replaced using a fresh homograft. The patient has been followed up for three and a half years. There is good evidence of correction of the haemodynamic lesion and no evidence of further arteritis or aneurysmal formation. The pathological and clinical problem of this disease are discussed.

Non-specific arteritis ofhe aorta and its main branches

Four cases of non-specific arteritis involving the aorta and its main branches are described. Three of the cases were hypertensive and one of these had evidence of aortic incompetence. Cases 1, 2, and 3 had involvement of the aortic arch vessels and the descending aorta, whereas Case 4 presented as a coarctation of the abdominal aorta. There was a significant association with systemic disturbance such as polyarthritis, fever, weight loss, raised erythrocyte sedimentation rate, and hyperglobulinaemia. A detailed necropsy in Case 2 showed two large dissecting aneurysms. The nomenclature, the diagnostic criteria, and a probable pathogenesis of the disease are discussed with reference to the relevant published material.