PMC8759583_01
Preoperative computed tomography angiography (CTA) showing rapid growth of the syphilitic aortic arch aneurysm 55 days after the first visit to the outpatient's clinic (A, B, C) and the urgent setting. (D, E, F) Sagittal (A/D), axial (B/E), and coronal (C/F) views of the two preoperative CTAs, almost two months apart.
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An 82-year-old male patient with a past medical history of hypertension, mild chronic kidney injury, and chronic hepatitis C infection with liver cirrhosis was referred to our aortic outpatient clinic due to an arch aneurysm with a maximum diameter of 68mm (Figure 1) and a recent diagnosis of syphilis infection. Cardiac complications were ruled out with a normal electrocardiogram (ECG) and no increase in troponin levels. Computed tomography angiography (CTA) showed the aortic arch aneurysm diameter had increased to 95mm from the origin of the brachiocephalic trunk to the upper descending aorta. (Figure 1) Signs of contained hemorrhage into the aortic wall from the vasa vasorum, aortic wall thickening, and multiple ulcer-like projections of the aortic lumen were identified (Figure 2).
Preoperative CTA of the syphilitic aortic arch aneurysm characterized by focal and crescentic intramural hematomas (white *) - small regions of contrast accumulation with invisible or small communication with the true lumen, often with a peripheral connection with an intercostal or lumbar artery -, areas of eccentrically thickened aortic wall (white +), and ulcer-like projections with a wide neck (black arrows).
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Cardiac complications were ruled out with a normal electrocardiogram (ECG) and no increase in troponin levels. Computed tomography angiography (CTA) showed the aortic arch aneurysm diameter had increased to 95mm from the origin of the brachiocephalic trunk to the upper descending aorta. (Figure 1) Signs of contained hemorrhage into the aortic wall from the vasa vasorum, aortic wall thickening, and multiple ulcer-like projections of the aortic lumen were identified (Figure 2).
Intraoperative images. (A) exposure of the ascending aorta and the supra-aortic vessels (in this case: brachiocephalic trunk and left common carotid artery) through median sternotomy; (B) ascending aorta to the brachiocephalic trunk and left common carotid artery bypasses. Anastomoses to both vessels are highlighted. Note the ligature of the third branch of the trifurcated graft.
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A median sternotomy was performed under general anesthesia and transesophageal echocardiography (TEE) monitoring, exposing the ascending aorta and arch vessels (Figure 3A). Both BCT and LCCA were then ligated at their respective origins (Figure 3B).
Endovascular component of the hybrid aortic arch repair. (A) pre-operative angiography showing patency of the supra-aortic vessels debranching's and aneurysm perfusion; (B) after thoracic endovascular stent-graft repair, complete aneurysm exclusion was observed.
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Control intraoperative angiography showed complete exclusion of the aneurysm (Figure 4).
6-month follow-up computed tomography angiography 3D reconstruction showing complete exclusion of the aneurysm without any signs of endoleak, patency of the supra-aortic vessels, and no further aneurysm formation in the remnant aorta. (A) Sagittal view; (B) axial view; (C) coronal view.
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Six-month follow-up CTA showed complete exclusion of the aneurysm and no other aneurysm formation was observed in the remnant aorta (Figure 5).