Diagnosis Of Thoracic Aortic Aneurysm Research Articles

Conservative Management of mild symptomatic descending thoracic aneurysm – A case report with 1year follow-up

Background: The thoracic aorta is made up of the ascending, descending, aortic arch, and aortic root. An aneurysm forms when the artery's usual diameter increases by fifty percent. Thoracic aneurysms affect 10 of every 100,000 elderly adults and are less common than their abdominal counterparts. Patients with thoracic aortic aneurysms (TAAs) rarely experience symptoms, and 95% of TAA patients are asymptomatic. Case history: A 47-year-old male patient who had a medical history of hypertension, dyslipidemia, and smoking. During the first visit, the patient presented with two months of dull back pain. The patient's blood pressure was 180/110 mm of Hg. Our initial assessment involved taking an X-ray and an echocardiography of the patient's chest. The data from his echocardiography and chest reveals that he has a thoracic aneurysm. After a confirmatory CT scan, the diagnosis of thoracic aortic aneurysm was made. Conclusion: In our case report, conservative method was successful in the management of a mild symptomatic descending thoracic aorta aneurysm. However, the size, growth pace, and underlying cause of an aortic aneurysm might all affect whether doctors recommend surgery to repair it. If an aneurysm ruptures or dissects, immediate surgery may be required. J Shaheed Suhrawardy Med Coll 2023; 15(1): 87-90

Difference in risk factor profile for abdominal aortic aneurysm and thoracic aortic aneurysm

ObjectivePrevious studies suggest partly different risk factor profiles of thoracic aortic aneurysms (TAAs) and abdominal aortic aneurysms (AAAs), but prospective data are scarce. The purpose of this prospective population-based case-control study was to investigate differences in risk factor profile between TAAs and AAAs. MethodsParticipants in two prospective population-based studies, the Västerbotten Intervention Project (VIP) and the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, between 1986 and 2010, underwent cardiovascular risk assessments, including blood samples, oral glucose tolerance test, blood pressure readings, and a self-reported health questionnaire. All individuals who were later diagnosed with TAAs or AAAs were identified. Age, sex, and time-matched controls were selected from the same cohorts, aiming at four controls/case. Adjusted odds ratios (aORs) for potential risk factors for later diagnosis of TAAs and AAAs, respectively, were estimated by multivariate conditional logistic regression analyses. ResultsFrom a total of 96,196 individuals with prospectively collected data in the VIP/MONICA cohort, a total of 236 individuals with AAAs (181 men and 55 women) and 935 matched controls, and 168 individuals with TAAs (115 men and 53 women) and 662 controls were included. The average age at baseline examination was 57.0 ± 5.7 years for AAA cases and controls, and 52.1 ± 8.8 years for TAA cases and controls. Mean time between baseline examination and diagnosis of AAAs/TAAs was 12.1 and 11.7 years, respectively. There was a clear difference in risk factor profile between AAAs and TAAs. Smoking, hypertension, and coronary artery disease were significantly associated with later diagnosis of AAAs, with highest aORs for a history of smoking (aOR, 10.3; 95% confidence interval [CI], 6.3-16.8). For TAAs, hypertension was the only positive risk factor (aOR, 1.7; 95% CI, 1.1-2.7), whereas smoking was not associated. Diabetes was not associated with either AAAs or TAAs; neither was self-reported physical activity. ConclusionsIn this prospective, population-based, case-control study, risk factor profile differed between AAAs and TAAs. This suggests a partially different etiology for TAAs and AAAs.

Primary Aortic Malignant Peripheral Nerve Sheath Tumor.

A 74year-old woman suffering 1month persisting lumbago was referred with diagnosis of thoracic aortic aneurysm. Blood examinations indicated slightly or moderately elevated noradrenaline, dopamine, and homovanillic acid with normal-range vanillylmandelic acid. Contrast-enhanced CT scans revealed a tumor, protruding both intra- and extra-luminally, in the wall of the distal descending thoracic aorta without any primary focuses in the whole body. Primary aortic sarcoma or periaortic catecholamine-producing paraganglioma infiltrating the aorta was suspected. The tumor with the normal proximal and distal aorta 2-3cm apart from it was completely resected under femoro-femoral partial cardiopulmonary bypass. Macroscopically, the tumor was originated from the aortic wall and protruded both intra- and extra-luminally. Immunohistochemically, positive S-100 and vimentin; Ki67 levels of 40%; and negative CD34, CK AE1/AE3, and SMA were identified. The aforementioned findings definitively diagnosed primary aortic malignant peripheral nerve sheath tumor, which has been never reported in the literature.

Artificial intelligence in the diagnosis of thoracic aortic aneurysms in a retrospective chest computed tomography scan analysis

BACKGROUND: Aortic aneurysms, known as silent killers, are frequently asymptomatic, leading to vessel rupture and death. Annual rates for ruptures, stratifications, and sudden deaths are up to 3.6%, 3.7%, and 10.8%, respectively. Timely diagnosis and early treatment save a patients life. The use of artificial intelligence (AI) technologies helps to detect aortic aneurysms, which significantly improves the quality of diagnosis and saves patients lives.
 AIM: To assess the efficiency of using AI technologies to detect thoracic aortic aneurysms on chest computed tomography (CT) and determining the possibility of using AI technologies as an assistant to the radiologist during the primary description of radiological images.
 METHODS: The study retrospectively assessed the results of AI technologies aimed at detecting thoracic aortic aneurysms on chest CT scans. No contrast enhancement was performed primarily. The sample consisted of 84,405 observations of patients over the age of 18 years; of these, 86 scans with thoracic aortic aneurysms were selected according to AI data. The selected examinations were retrospectively assessed by radiologists and vascular surgeons for the probable presence of a thoracic aortic aneurysm. In 44 cases, an aortic aneurysm was initially detected by the radiologist. In 31 cases, an aneurysm was not initially described by the radiologist, 6 were excluded from the sample (due to the absence of the radiologists report in the Unified Radiological Information Service), and 5 scans had false-positive results according to AI findings.
 RESULTS: The use of AI technologies allows detection and labeling of pathological changes in the aorta on the images. AI technologies increase the detectability of thoracic aortic aneurysms in the description of chest CT scans by 38.8%. The incidence of ascending aortic aneurysm was 0.3%, which corresponded to the literature data of 0.16%1.6%. According to the results, 22 surgical interventions for aortic stenting were performed.
 CONCLUSIONS: The use of AI in the primary chest CT description may help increase the detectability of clinically significant pathological conditions, such as thoracic aortic aneurysm. Further development of routing for this category of patients in the cito mode for surgical treatment is relevant. Expansion of retrospective screening by chest CT scans using AI systems will improve the quality of diagnosis of concomitant pathologies and prevent adverse outcomes for patients.

Abstract 564: Genetic Basis Of Thoracic Aortic Aneurysms In A Large Unselected Clinical Population

Objectives: Thoracic aortic aneurysms (TAAs) are associated with protein coding variants in genes associated with Loeys-Dietz Syndrome (LDS), vascular Ehlers-Danlos Syndrome (VEDS) and ACTA2 . The purpose of this study was to estimate the prevalence of these variants, along with potential novel variants, in a large unselected clinical population. Methods: We analyzed exome sequence data from 174,452 participants. Rare variants (frequency <0.001) were annotated by functional consequence and classification as pathogenic or likely pathogenic (P/LP) in the ClinVar database. TAA diagnoses were determined by ICD-10 codes. Results: 2,670 (1.5%) individuals had a TAA diagnosis; mean age was 66.1 years, compared to 56.7 for the study population (p=0.014). 69% of TAA cases were male and 71% were smokers. There were 20 carriers of ClinVar P/LP variants in LDS genes (8 variants in 10 carriers for SMAD3 , 3 variants in 3 carriers for TGFB2 , 2 variants in 2 carriers for TGFBR1 , 3 variants in 5 carriers for TGFBR2); 5 had a diagnosis of TAA (2 for SMAD 3, 1 each for the others; ORs =16-65); the age of diagnosis was significantly lower than for non-carriers (p<0.0001). 11 P/LP carriers without a TAA diagnosis were <55 years old and could be at risk for TAA. There was 1 TAA case in 21 COL3A1 P/LP carriers and 0 cases in 10 COL1A1 P/LP carriers. We also identified LDS and VEDS variants that are classified as uncertain significance that could be reclassified as P/LP based on their association with early TAA (Table 1). ACTA2 P/LP variants were also strongly associated with TAA (OR=26; p<0.001). The prevalence of P/LP variants in these genes is 1/3,300 (1/1,350 if potential novel pathogenic variants are included). Conclusions: Our results provide estimates of the prevalence and penetrance of variants associated with TAA in a large unselected clinical population, reveal potential novel pathogenic variants, and support the use of genetic data to identify individuals with high disease risk.

Diagnosis of Thoracic Aortic Aneurysms by Computed Tomography Without Allometric Scaling

This diagnostic study of computed tomography scans at a single tertiary care center compares radiologist descriptions of abnormal size ascending aortas with definitions of aorta diameters defined by nomograms.

Hemoptisis como manifestación inusual de aneurisma de aorta torácica

Los aneurismas aórticos corresponden a una dilatación focal de la pared de la arteria que supera el 50% de su diámetro normal. La mayoría de los casos corresponden a la localización abdominal, siendo una pequeña proporción descritos a nivel de la aorta torácica. En este segmento, menos del 10% de los pacientes experimentan síntomas e incluso, la ruptura puede constituir la primera manifestación. Se presenta el caso de una mujer octogenaria con hemoptisis e inestabilidad hemodinámica en la que se realizó el diagnóstico de aneurisma de aorta torácica a través angiotomografía contrastada para luego recibir manejo endovascular de manera exitosa. Dado el pronóstico de esta patología, es vital un adecuado uso de los estudios de imagen para un acertado diagnóstico radiológico que permita un enfoque terapéutico oportuno.

Point-of-care ultrasound diagnosis of thoracic aortic aneurysm in a patient presenting with hemoptysis

IntroductionHemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions.Case ReportA 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day.DiscussionThe vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Hemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions. A 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day. The vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Figure 1. POC-US of suprasternal notch view showed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma (arrow). Figure 2. CTA of the aorta revealed proximal ruptured thoracic aortic aneurysm with adjacent hematoma.•Sun D, Mehta S. Hemoptysis caused by erosion of thoracic aortic aneurysm. CMAJ. 2010; 182:186.•Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg 1985; 89:50.•Nair G, Jindal S, Chandra A, Swami S, Garg P. Haemoptysis - a rare presentation of aortic aneurysm. Lung India. 2008;25:20.

The role of genetic testing in the prevention of acute aortic dissection.

Although much has been learned about disease of the thoracic aorta, most diagnosis of thoracic aortic aneurysm (TAA) is still incidental. The importance of the genetic aspects in thoracic aortic disease is overwhelming, and today different mutations which cause TAA or alter its natural history have been discovered. Technological advance has made available testing which detects genetic mutations linked to TAA. This article analyses the genetic aspects of TAA and describes the possible role of genetic tests in the clinical setting in preventing devastating complications of TAA.

Achados incidentais de aneurismas torácicos e abdominais

ResumoContextoOs aneurismas de aorta abdominal (AAAs) são os mais comuns. A incidência anual de ruptura do AAA é de oito casos por 100.000 habitantes. A detecção incidental pode beneficiar o paciente, desde que o diâmetro seja monitorado e o paciente receba o tratamento adequado.ObjetivosEstimar a prevalência do diagnóstico incidental de aneurisma de aorta torácica (AAT) e de AAA em tomografias computadorizadas (TCs); avaliar a prevalência de sexo e idade dos pacientes e determinar quais as artérias acometidas e as características morfológicas dos aneurismas; determinar quais as indicações de TC mais associadas ao diagnóstico incidental de aneurismas.MétodosEstudo descritivo, retrospectivo e randomizado. Critérios de inclusão: pacientes com 50 anos ou mais submetidos a TC de tórax, abdome ou pelve. Critérios de exclusão: acompanhamento ou suspeita diagnóstica de aneurismas. Foram utilizados protocolos com questões sobre dados demográficos e anatômicos.ResultadosForam analisados 1.202 laudos radiológicos. Detectados 27 aneurismas (prevalência de 2,2%). Pacientes: 60% do sexo masculino e 40% do sexo feminino (p < 0,05). Localização: 13 casos (48,2%) na aorta ascendente (AAT); 7 (25,9%) na aorta infrarrenal (AAA); 2 (7,4%) aorta na transição toracoabdominal (ATA); 2 (7,4%) na ilíaca comum; 1 (3,7%) na ilíaca interna; 1 (3,7%) na artéria esplênica; e 1 (3,7%) na artéria renal.ConclusõesA maioria dos pacientes foi do sexo masculino (60%); houve maior frequência de AAT (diâmetro médio de 4,1 cm), seguido de AAA (diâmetro médio de 4,0 cm) e ATA (diâmetro médio de 3,9 cm). A principal indicação para a realização de TC associada ao diagnóstico incidental de aneurismas foi em função de sintomas respiratórios.

Next-generation sequencing for diagnosis of thoracic aortic aneurysms and dissections: diagnostic yield, novel mutations and genotype phenotype correlations.

BackgroundThoracic aortic aneurysms and dissections (TAAD) are silent but possibly lethal condition with up to 40 % of cases being hereditary. Genetic background is heterogeneous. Recently next-generation sequencing enabled efficient and cost-effective examination of gene panels. Aim of the study was to define the diagnostic yield of NGS in the 51 TAAD patients and to look for genotype–phenotype correlations within families of the patients with TAAD.Methods51 unrelated TAAD patients were examined by either whole exome sequencing or TruSight One sequencing panel. We analyzed rare variants in 10 established thoracic aortic aneurysms-associated genes. Whenever possible, we looked for co-segregation in the families. Kaplan–Meier survival curve was constructed to compare the event-free survival depending on genotype. Aortic events were defined as acute aortic dissection or first planned aortic surgery.Results and discussionIn 21 TAAD patients we found 22 rare variants, 6 (27.3 %) of these were previously reported, and 16 (73.7 %) were novel. Based on segregation data, functional analysis and software estimations we assumed that three of novel variants were causative, nine likely causative. Remaining four were classified as of unknown significance (2) and likely benign (2). In all, 9 (17.6 %) of 51 probands had a positive result when considering variants classified as causative only and 18 (35.3 %) if likely causative were also included. Genotype-positive probands (n = 18) showed shorter mean event free survival (41 years, CI 35–46) than reference group, i.e. those (n = 29) without any plausible variant identified (51 years, CI 45–57, p = 0.0083). This effect was also found when the ‘genotype-positive’ group was restricted to probands with ‘likely causative’ variants (p = 0.0092) which further supports pathogenicity of these variants. The mean event free survival was particularly low (37 years, CI 27–47) among the probands with defects in the TGF beta signaling (p = 0.0033 vs. the reference group).ConclusionsThis study broadens the spectrum of genetic background of thoracic aneurysms and dissections and supports its potential role as a prognostic factor in the patients with the disease.Electronic supplementary materialThe online version of this article (doi:10.1186/s12967-016-0870-4) contains supplementary material, which is available to authorized users.

Increased Metabolic Activity Highlighted by Positron Emission Tomography/Computed Tomography in the Wall of the Dissected Ascending Aorta in a Patient With Horton Disease

Horton disease or giant-cell arteritis (GCA) is a chronic systemic vasculitis involving typically medium and large arteries. Giant-cell arteritis is a panarteritis characterized by a granulomatous inflammation, with lymphocytes, macrophages, and multinucleated giant cells related to autoimmune T-cell reactivity.1 Compared with conventional imaging tools (ultrasound, computed tomography (CT), MRI, and contrast angiography) that provide anatomic and morphological information, recent available imaging techniques such as positron emission tomography (PET)/CT provide metabolic assessment of the arterial wall. During the early 2000s, Sakalihasan et al2 observed a close correlation between clinically unstable abdominal aortic aneurysms and increased uptake of 18F-fluoro-2-deoxy-d-glucose (FDG) in the aneurysmal wall. A few years later, Hautzel et al3 studied the assessment of giant-cell arteritis with PET/CT. We describe a case of Horton disease involving the thoracic aorta and complicated with acute aortic dissection in a woman with a previous diagnosis of thoracic aortic aneurysm. In July 2011, a 66-year-old woman was referred to a cardiology center for evaluation of a recent mild hypertension related to use of high doses of corticosteroids. In December 2010, she had developed severe headache, rapid loss of weight, and elevation of sedimentation rate as high as 120 mm. Horton disease was diagnosed in April 2011 on temporal artery biopsy. During the first cardiologic examination, …

Extensive dissecting aneurysm of the ascending aorta

We present the case of a 69-year-old female surviving an extensive dissecting thoracic aortic aneurysm. Due to the initial presentation with angina and epigastric pain the first working diagnosis was acute coronary syndrome. However, on transthoracic and transesophageal echocardiography (TEE), the dissecting aneurysm (type Stanford A) could be detected. Our article stresses the importance of imaging for the rapid and accurate diagnosis of thoracic aortic aneurysms with dissection. In our case, TEE detected the intimal flap separating true and false lumen, and the consecutive hemodynamically relevant aortic valve regurgitation, in addition to the aneurysm extent. The patient underwent surgical repair with aortic arch replacement and recovered without sequelae.<Learning objective: In patients with severe hypertension and coronary artery disease presenting with atypical chest pain, ECG and troponin T assessment should be complemented by imaging of the heart and the ascending aorta to rule out aortic dissection.>

A shifting approach to management of the thoracic aorta in bicuspid aortic valve

The scientific understanding of aortic dilation associated with bicuspid aortic valve (BAV) has evolved during the past 2 decades, along with improvements in diagnostic technology and surgical management. We aimed to evaluate secular trends and predictors of thoracic aortic surgery among patients with BAV in the United States. We used the 1998-2009 Nationwide Inpatient Sample, an administrative dataset representative of US hospital admissions, to identify hospitalizations for adults aged 18 years or more with BAV and aortic valve or thoracic aortic surgery. Covariates included age, gender, year, aortic dissection, endocarditis, thoracic aortic aneurysm, number of comorbidities, hospital teaching status and region, primary insurance, and concomitant coronary artery bypass surgery. Between 1998 and 2009, 48,736 ± 3555 patients with BAV underwent aortic valve repair or replacement and 1679 ± 120 patients with BAV underwent isolated thoracic aortic surgery. The overall number of surgeries increased more than 3-fold, from 4556 ± 571 in 1998/1999 to 14,960 ± 2107 in 2008/2009 (P < .0001). The proportion of aortic valve repair or replacement including concomitant thoracic aortic surgery increased from 12.8% ± 1.4% in 1998/1999 to 28.5% ± 1.6% in 2008/2009, which mirrored an increasing proportion of patients with a diagnosis of thoracic aortic aneurysm. Mortality was equivalent for patients undergoing aortic valve repair or replacement with thoracic aortic surgery and those undergoing isolated aortic valve repair or replacement (1.8% ± 0.3% vs 1.5% ± 0.2%; multivariable odds ratio, 1.02; 95% confidence interval, 0.67-1.57), with decreasing mortality over the study period (from 2.5% ± 0.6% in 1998/1999 to 1.5% ± 0.2% in 2008/2009; multivariable odds ratio per 2-year increment, 0.89; 95% confidence interval, 0.81-0.99; P = .03). Total charges for BAV surgical hospitalizations increased more than 7.5-fold from approximately $156 million in 1998 to $1.2 billion in 2009 (inflation-adjusted 2009 dollars). There was a marked increase in the use of thoracic aortic surgery among patients with BAV.

Circulating interferon-γ–inducible Cys-X-Cys chemokine receptor 3 ligands are elevated in humans with aortic aneurysms and Cys-X-Cys chemokine receptor 3 is necessary for aneurysm formation in mice

Inflammation is associated with the formation of aortic aneurysm. This study investigates the role of inducible Cys-X-Cys chemokine receptor 3 and its ligands in the pathogenesis of arterial aneurysms. Plasma samples from patients with or without a diagnosis of thoracic aortic aneurysms were analyzed by enzyme-linked immunosorbent assay for the T-helper 1 cytokine interferon-γ and the interferon-γ-inducible chemokine receptor 3 ligands: interferon-inducible protein-10, interferon-inducible T-cell alpha chemoattractant, and monokine induced by interferon gamma. Patient charts were reviewed for demographics, initial aortic diameter, and growth rates. Aneurysm diameter and growth rates were correlated with plasma cytokine and chemokine levels using linear regression analysis. We used an animal model of aneurysm formation, where calcium chloride is applied topically to the carotid arteries of wild-type and Cys-X-Cys chemokine receptor 3(-/-) mice. After 10 weeks, the arteries were harvested and analyzed by histology and immunohistochemistry. Patients with thoracic aortic aneurysms had significant elevations in circulating interferon-γ, interferon-inducible protein-10, interferon-inducible T-cell alpha chemoattractant, and monokine induced by interferon gamma compared with referent patients (P<.001). Cytokine and chemokine plasma levels did not correlate with aneurysm size or growth rates. Cys-X-Cys chemokine receptor 3(-/-) mice were protected from aneurysm formation and showed decreased vascular infiltration by CD45(+) leukocytes. Elevated plasma levels of interferon-γ and Cys-X-Cys chemokine receptor 3-binding chemokines are present in patients with thoracic aortic aneurysms. The Cys-X-Cys chemokine receptor 3 receptor is necessary for vascular inflammation and the formation of arterial aneurysms in mice.

Total Arch Replacement with Open Stent-Grafting for Aneurysm of Ductus Arteriosus After Surgery for Patent Ductus Arteriosus

A 73-year-old woman who had undergone ligation of patent ductus arteriosus (PDA) via a left thoracotomy 19 years earlier was admitted to our hospital under the diagnosis of thoracic aortic aneurysm. An enhanced computed tomography of the chest revealed a saccular aneurysm measuring a maximum diameter of 28 mm in the lesser curvature of the distal aortic arch; she was diagnosed with an aneurysm of ductus arteriosus after surgery for PDA. We performed total aortic arch replacement with open stent-grafting through median sternotomy. This approach enabled us to avoid the risk of dissecting adhesions around the aneurysm and clamping the aorta distal to the aneurysm.

RESPONDING TO MEDICAL ERROR: FACTORS THAT INFLUENCE THE LIKELIHOOD OF DISCLOSURE BY MEDICAL RESIDENTS.

Background When a medical error occurs, studies indicate that patients prefer to be informed, be given an explanation of what happened and why, be informed of the measures that will be taken to prevent recurrences, and offered an apology from the responsible parties. Most patients endorse a preference for full disclosure, even when no harm is done. Data suggest that as few as one-third of harmful errors are disclosed to patients and that although physicians are supportive in principle, they are hesitant to actually disclose error. Resident physicians, by virtue of their inexperience, may be involved in medical errors at a rate higher than more experienced physicians, yet their responses to error, including their attitudes toward disclosure, have not been well studied. We sought to examine resident attitudes toward disclosure by asking them to predict their actions after being involved in a medical error in the hospital setting. Methods We anonymously surveyed 44 internal medicine residents attending a resident retreat. Two clinical cases were presented. In the first case, a diabetic patient is given insulin and kept NPO with resultant hypoglycemia. In the second case, a misread chest radiograph delays the diagnosis of thoracic aortic aneurysm. For each case, the outcomes ranged from no harm to serious harm. The resident was given four possible responses: (1) no explanation, (2) an explanation of the medical facts of the case, (3) an explanation and an admission of error, and (4) an explanation, admission of error, and an apology. The residents were directed to choose the response that most closely resembled what they would say and do. Results Surveys were completed by 34 (77%) residents, including 14 (34%) women, with all levels of training equally represented. In every instance, the most likely response was to explain (54%) rather than to admit error (22%) or to apologize (22%). In the case of the diabetic patient with hypoglycemia, responses did not differ regardless of whether the error caused harm. In the case of the misread chest radiograph, however, if the patient was harmed, residents were significantly more likely to include an admission of error and an apology than if no harm was done. Neither gender nor level of training affected results. Conclusions Our findings suggest that, with respect to disclosure of medical error, the actions of residents are at odds with the stated preferences of patients. When presented with hypothetical cases of medical error, residents were significantly more likely to limit their response to an explanation of medical facts rather than an admission of error or an apology. Results also suggest that the type of error may influence the response. Although both cases involved error, the first case may be viewed as a “system” error in which responsibility is shared by other members of the health care team. In the case of the thoracic aortic aneurysm, the error more clearly rests with the physician, and this sense of personal responsibility for the error may be influencing the response toward full disclosure when the patient suffered greater harm. Factors influencing the response to error by residents should be considered as educational interventions are developed to bridge the gap between patient preferences for disclosure and physician practice.

Problems and prospects of managing thoracic aortic aneurysm at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.

The objective of this report is to highlight the problems encountered in managing thoracic aortic aneurysm in a third-generation teaching hospital serving a purely rural community in the heartland of Anambra State, in the southeastern part of Nigeria. This report also proffers solutions aimed at assisting in providing better care for patients afflicted with this condition. From time to time, patients present with vascular diseases, including aneurysm, but the condition is only occasionally suspected and sparingly investigated. This is a report of two cases within the setting of the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi Nigeria. After the death of these two patients, one of whom was a member of the staff of the hospital, post mortem examinations revealed that they had died of ruptured thoracic aortic aneurysm. Their medical records were retrieved from the Medical Records Department and reviewed with the aim of analyzing their clinical features and management in the light of the unexpected post-mortem examination results. The survey of the patient records revealed that the diagnosis of thoracic aortic aneurysm was not suspected in either patient even though both had symptoms pointing to this condition. The staff member was a 55-year old man and the other patient was a 31-year old woman in her 30th week of pregnancy. We conclude by drawing the attention of medical practitioners in our community to the fact that thoracic aortic aneurysms are probably more common than we thought. Only a high index of suspicion will lead to clinical diagnosis and treatment.

Die Rolle des Thoraxröntgens in der Diagnose des thorakalen Aortenaneurysmas

Objective: To evaluate the role of routine chest radiographs in the diagnosis of thoracic aortic aneurysms (TAA). Methods: An electronic full-text search was performed in our radiological information system for all patients who underwent chest radiograph under standard conditions between 1998 and 2000 and who had suspected widening or aneurysm of the thoracic aorta as a diagnosis. Computed tomography (CT) of the thorax was used as the gold standard and had to be performed within a period of 30 days. Two independent and blinded observers evaluated different morphologic and morphometric parameters in the diagnosis and correlated the results with those of CT. Results: 28 patients were included in the present trial. With almost perfect interobserver correlation (r=0.95) both investigated morphometric parameters correlated well (r=0.85 and 0.83) with the diameter of the aorta as evaluated with CT. While a low subjective over-all probability for TAA had a negative predictive value of 100%, we found that, despite an almost perfect interobserver variability (Kappa>0.8), none of the investigated morphologic parameters (discrepancy between the ascending and descending aorta, displacement of the trachea to the right and caudal displacement of the left main bronchus) was significantly correlated with the final diagnosis. Conclusion: The investigated morphometric parameters help to estimate the diameter of the aorta in the arch and in the descending section, but none of the morphologic criteria can be used for the diagnosis of TAA.

The role of chest X-rays in the diagnosis of thoracic aortic aneurysms

To evaluate the role of routine chest radiographs in the diagnosis of thoracic aortic aneurysms (TAA). An electronic full-text search was performed in our radiological information system for all patients who underwent chest radiograph under standard conditions between 1998 and 2000 and who had suspected widening or aneurysm of the thoracic aorta as a diagnosis. Computed tomography (CT) of the thorax was used as the gold standard and had to be performed within a period of 30 days. Two independent and blinded observers evaluated different morphologic and morphometric parameters in the diagnosis and correlated the results with those of CT. 28 patients were included in the present trial. With almost perfect interobserver correlation (r = 0.95) both investigated morphometric parameters correlated well (r = 0.85 and 0.83) with the diameter of the aorta as evaluated with CT. While a low subjective over-all probability for TAA had a negative predictive value of 100 %, we found that, despite an almost perfect interobserver variability (Kappa > 0.8), none of the investigated morphologic parameters (discrepancy between the ascending and descending aorta, displacement of the trachea to the right and caudal displacement of the left main bronchus) was significantly correlated with the final diagnosis. The investigated morphometric parameters help to estimate the diameter of the aorta in the arch and in the descending section, but none of the morphologic criteria can be used for the diagnosis of TAA.