A 74-year-old man presents to the ER with upper back pain ongoing for 3 hours. The pain is described as sharp and severe occurring at rest. He has no associated symptoms of shortness of breath, chest pain, or presyncope. His past medical history is notable for a coronary artery bypass graft (CABG) 2 years previously, HTN, and ongoing tobacco use. At the time of his CABG, he was noted to have a 4.4-cm ascending aortic aneurysm that was not repaired. His medications include aspirin, an angiotensin-converting enzyme inhibitor, and a β-blocker.
Physical Examination:
A CT scan demonstrates an ascending aortic aneurysm of 4.8 cm and a descending thoracic aortic aneurysm of 6.0 cm but no evidence of dissection. There is no abdominal aortic aneurysm (AAA). The patient continues to have ongoing pain despite high doses of β-blockers, sodium nitroprusside, and opioid analgesics.
ECG and cardiac enzymes remain normal.
D-dimer level is >500 ng/mL.
What is the most appropriate next decision for management?
MRA of the chest/aorta. The patient is experiencing ongoing pain refractory to medical therapy and the clinical history remains suggestive of an acute aortic syndrome. The types of acute aortic syndromes are listed in Table below.
Types of Aortic Syndromes:
Although CT imaging is highly accurate in diagnosing aortic dissection, there are false-negative readings. In the International Registry of Aortic Dissection (IRAD) registry, many patients with suspected aortic dissection required more than one imaging test. Therefore, additional imaging should be performed in this patient especially since an alternative diagnosis for the patient’s symptoms is not available. An acute coronary syndrome is not likely in view of recent CABG and unremarkable ECG and cardiac enzymes. Biomarkers are emerging as a diagnostic aide in diagnosing acute aortic syndromes. A D-dimer level <500 ng/mL and a low C-reactive protein make aortic dissection unlikely.
A 62-year-old man presents for a routine annual examination. He has a history of HTN that is managed with monotherapy. He is active and has no symptoms.
What is the most appropriate management step?
Initiate a β-blocker and repeat ultrasound in 6 months. To determine the stability of an AAA between 4.0 and 4.9 cm (4.2 cm in this patient), it is generally recommended to do an initial follow-up ultrasound in 6 months. However, most patients with AAA size = 4.5 cm should be referred to a vascular surgeon for subsequent follow-up and risk assessment for surgical consideration and have a baseline CT of the aorta to assess for anatomic feasibility for endovascular repair. β-Blockers have been shown to delay the rate of AAA enlargement and would be indicated for this patient with suboptimal control of BP.
A 76-year-old man presents to the ER with severe sharp chest pain that began 2 hours previously. He has a history of HTN and had CABG 3 years ago after an MI. He continues to smoke. The CABG was performed off-pump because of severe atheroma in the ascending aorta seen by intraoperative TEE. The patient’s pain has not subsided with the initiation of IV heparin, nitroglycerin, and βblockers. The pain is different in character from the pain before his MI.
Despite severe atheroma in the aorta, the physician taking care of the patient is not convinced that he does not have an acute coronary syndrome and performs a cardiac catheterization. It shows that the grafts are patent and there is no culprit lesion in the native vessels. He then decides to perform aortography and a focal outpouching is seen in the aortic wall in the distal ascending aorta (Fig. below).
Contrast dye collects slowly in this region. The patient’s chest pain is intensifying. A TEE is also performed (Fig. below).
What is the correct diagnosis?
Penetrating aortic ulcer. A penetrating aortic ulcer occurs when aortic atheroma ruptures into the aortic media through the internal elastic lamina. Subsequently, an aneurysm, pseudoaneurysm, localized dissection, hematoma, or aortic rupture may develop. Penetrating ulcers can be diagnosed by aortography, CTA, MRA, or TEE. They more typically occur in the descending aorta. Typical findings include a focal outpouching or ulcer crater in the region of severe, calcified atheroma. Localized flow may be seen by contrast opacification or color Doppler. The aortogram in this patient shows multiple penetrating aortic ulcers, seen as outpouching on the greater curvature of the ascending aortic wall. Contrast aortogram (A) shows several outpouchings on the greater curvature of the ascending aorta consistent with penetrating ulcers. Transesophageal echocardiogram (B) showing a break in the lesser curvature of the aorta in the same patient in the region of diffuse calcific atheroma also consistent with a penetrating aortic ulcer (see figure in question).
What is the most appropriate next management step to take?
Transfer to the operating room immediately for replacement of the ascending aorta. The patient has an acute aortic syndrome with a symptomatic penetrating ulcer in the ascending aorta. Immediate surgery is indicated to prevent the possibility of aortic rupture. Further confirmatory imaging is not required.
A 45-year-old woman presents with discomfort in her left leg with walking, dizziness, headaches, and a cold right hand. She has no chest pain or shortness of breath. There is no significant past medical history and she does not smoke.
What test would be most useful for diagnosing the patient’s condition?
Angiography. The patient presents with pulse deficits, bruits, and symptoms consistent with arterial insufficiency in multiple distributions, including the upper and lower extremities. Angiography (either CTA/MRA or invasive) of the arterial system would define the site and extent of arterial disease. The appearance of the lesions may also help with determining the etiology of the vascular disease (i.e., atherosclerotic versus vasculitic).
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