A 79-year-old man with HTN underwent a routine CXR and is found to have a thoracic aneurysm. He is asymptomatic with well-controlled BP on a β-blocker. A CT angiogram of the chest is performed showing a descending thoracic aortic aneurysm of 5.4 cm distal to the left subclavian artery with a chronic dissection. The aneurysmal segment does not extend into the abdomen. The ascending aorta is 4.5 cm in the mid-portion and 4.0 cm in the mid-arch. The patient has no other comorbid conditions.
What recommendation is most appropriate for this patient based on current guidelines?
Medical therapy is recommended. Medical therapy should be recommended for this patient. The timing of surgery for descending thoracic aneurysms is addressed by the 2010 guidelines for thoracic aortic diseases. Most descending thoracic aneurysms or chronic dissections (not including thoracoabdominal aneurysms) that are of degenerative, traumatic, or connective tissue etiologies should be repaired when the size is >5.5 cm if comorbidity-related risks are acceptable.
Which statement is correct comparing TEVAR with open repair for thoracic aortic aneurysms?
TEVAR is associated with a 30-day risk of endoleaks of 10%. There are no randomized trials comparing TEVAR with open aortic repair. However, nonrandomized comparisons show a lower rate of hospital complications including paraplegia and death relative to open repair. Despite TEVAR patients generally being older with more comorbid conditions, long-term mortality seems similar. The estimated rate of type I endoleaks with TEVAR is approximately 10% due to difficulties achieving an adequate proximal anastomosis.
A 45-year-old woman with a history of fibromuscular dysplasia presents to the ER with an acute ST-elevation inferior MI. She is taken immediately to the cardiac catheterization laboratory for primary percutaneous intervention of the right coronary artery (RCA). The first injection of the RCA shows a dissection extending from the ostium to the posterior descending artery. A subsequent aortogram after stenting of the RCA is performed (figure below).
What does the aortogram show?
Aortic root localized dissection. Localized staining of contrast dye is seen in the region of the right sinus of Valsalva. This finding is consistent with an iatrogenic localized dissection. In this patient, it is likely due to either catheter trauma or retrograde propagation of the RCA dissection into the corresponding sinus of Valsalva. Coronary dissection is commonly associated with fibromuscular dysplasia. Contrast aortogram with staining of contrast seen in the right sinus of Valsalva that occurred post MI and following percutaneous coronary stenting in a young woman with fibromuscular dysplasia and RCA dissection. Contrast aortogram with staining of contrast seen in the right sinus of Valsalva that occurred post MI and following percutaneous coronary stenting in a young woman with fibromuscular dysplasia and RCA dissection (see figure in question).
What further evaluation or management do you recommend for this patient?
Observation and medical therapy. Most localized iatrogenic intramural hematomas or dissections occurring in the cardiac catheterization laboratory can be observed and managed medically even when involving the ascending aorta. In general, the site of tear seals and propagation or expansion does not occur. However, repeat aortic imaging should be performed to confirm stability.
A 35-year-old woman at 24 weeks of pregnancy is found to have several blood pressure readings in the range of 145 to 158 mmHg systolic, 80 to 92 mmHg diastolic. This is her first pregnancy and she has no prior history of hypertension. She reports bilateral mild ankle swelling and nausea, but no right upper quadrant pain, visual changes, headaches, or dyspnea. A 24-hour urine collection shows 360 g protein. The hemoglobin is 8.0 g/dL and the platelet count is 43,000 cells/mm3 .
Which of the following is the correct diagnosis?
Preeclampsia. Chronic hypertension is characterized by blood pressure ≤140/90 mmHg present before pregnancy, before the 20th week of gestation, or persisting beyond the 42nd postpartum day. Conversely, gestational hypertension develops beyond 20 weeks of gestation and usually resolves within 42 days postpartum. Preeclampsia is characterized by hypertension presenting beyond 20 weeks of gestation with >300 mg protein in a 24-hour urine collection or >30 mg/mmol in a spot urine sample, although in rare cases hypertension or proteinuria can be absent. Thrombocytopenia in this patient is very concerning for HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), a life-threatening condition showing significant overlap with preeclampsia. Eclampsia is the occurrence of seizures in a pregnant woman with preeclampsia. Edema is no longer considered to be part of the diagnostic criteria for preeclampsia because it occurs in more than half of normal pregnancies.
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