Management Of Aortitis Research Articles

Aortitis - An Interdisciplinary Challenge.

The term 'aortitis' comprises a heterogeneous spectrum of diseases, with varied etiology and clinical presentations, whose common characteristic is the inflammation of the aortic wall. Since aortitis can mimic almost all common cardiovascular disorders, its clinical recognition remains a challenge. Some cases of aortitis remain undetected for a long time and may be diagnosed after severe life-threatening complications have already arisen. The diagnosis of aortitis is based on the presence of homogeneous circumferential thickening of the aortic wall detected on aortic imaging, or typical histological features in combination with clinical findings and laboratory parameters. Management of aortitis is usually conservative (immunosuppressive drugs in noninfectious aortitis; antimicrobial drugs in infectious). However, if vascular complications such as aortic aneurysm, rupture, or steno-occlusive events appear, aortic surgery or endovascular therapy may be required. This review article summarizes the current knowledge regarding the etiology, clinical presentation, diagnosis, and treatment of inflammatory diseases of the aorta to promote better clinical management of these entities.

Etiology, Diagnosis and Management of Aortitis.

Aortitisincludes conditions with infectious or non-infectious etiology, characterized by inflammatory changes in one or more layers in aortic wall. Age at onset, geographic predilections, distribution and pattern of involvement in aorta, its branches and pulmonary arteries, and systemic associations provide a clue to etiology. Clinical presentations are often non-specific. An integrated approach including clinical, laboratory and imaging assessment is essential to confirm diagnosis and plan treatment. Assessment of disease activity is the key as it influences timing and outcome of treatment. Markers of activity include clinical, laboratory and imaging. Medical management remains the first-line therapy. Revascularization is indicated in the presence of hemodynamically significant stenosis and inactive disease. In the presence of flash pulmonary edema, left ventricular dysfunction or hypertensive encephalopathy, revascularization is performed irrespective of disease activity. Endovascular management is favored over surgery due to its high success and low restenosis rates. Symptomatic aneurysmal disease is usually managed by surgery.

Imaging modalities in the management of aortitis.

Aortitis is a pathological term that refers to the inflammation of one or more layers of the aortic wall. It is associated with a wide spectrum of inflammatory diseases of infectious and non-infectious origins, and often present with vague clinical findings and non-specific laboratory results that can model other entities. As a result, aortitis may not form part of the initial workup and appropriate treatment can be delayed or missed. Therefore, imaging modalities are required to assess for inflammation and structural changes in the aorta to support or exclude the diagnosis of aortitis. This review presents current literature on the imaging modalities utilized in the diagnosis and management of aortitis, which surgeons and physicians should be familiar with for providing optimal patient care.

18F-FDG PET/CT in the Management of Aortitis.

Aortitis is a generic term defined as an inflammatory condition involving the aortic wall, of infectious or noninfectious origin. This inflammatory process may deteriorate the aortic wall, resulting in potentially life-threatening vascular complications. Therefore, it is important to establish a diagnosis as early as possible. During a 4-year period, 428 consecutive patients referred to our department for aortic diseases underwent FDG PET/CT examinations. Among these, 18 patients (4.2%) were suspected to have aortitis. All of them had an initial positive FDG PET/CT uptake occurring in the aorta and major branches as evaluated by visual analysis of images and assessed with the final diagnosis of aortitis. During follow-up, after surgery and/or upon immunosuppressive treatment, each of these patients underwent a second PET/CT that was compared with the initial evaluation. In all cases, normalization of FDG uptake was correlated with clinical improvement. Our study aimed to illustrate the potential clinical value of functional monitoring with PET/CT in the management of aortitis. FDG PET/CT constitutes a valuable imaging modality to establish an early diagnosis, monitor disease progression and treatment, and evaluate vascular complication and relapse. We highlight the importance of an early detection of inflammatory large-vessel pathology, which may represent a major threat.

Fluorine-18–Labeled Deoxyglucose Positron Emission Tomography in the Diagnosis and Management of Aortitis With Pulmonary Artery Involvement

A 58-year-old woman presented with a complex history of constitutional symptoms, heart block requiring pacemaker, and subsequent heart failure. Initial echocardiograms reported some periaortic thickening but no definite vegetations. The patient had received antibiotic therapy before initial presentation. She had multiple negative serial blood cultures and was treated for culture-negative endocarditis. Over the ensuing months, however, her condition progressively worsened. At the time of her presentation to our facility, she had persistent elevations of her C-reactive protein (CRP; 66 mg/dL), an accelerated erythrocyte sedimentation rate (ESR; 60 mm/h), and a P-antineutrophil cytoplasmic antibody (ANCA) immunofluorescence assay that was positive. She had negative serology for bartonella, coxiella, and brucella, as well as nonreactive syphilis and human immunodeficiency virus …

Issue Highlights

HomeCirculationVol. 111, No. 22Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published7 Jun 2005https://doi.org/10.1161/circ.111.22.2865Circulation. 2005;111:2865FREEDOM FROM ATRIAL TACHYARRHYTHMIAS AFTER CATHETER ABLATION OF ATRIAL FIBRILLATION: A RANDOMIZED COMPARISON BETWEEN 2 CURRENT ABLATION STRATEGIES, by Karch et al.Catheter ablation for maintaining sinus rhythm increasingly is considered when atrial fibrillation is highly symptomatic despite antiarrhythmic drug therapy. Rapidly activating regions in and around the pulmonary veins are causative in many patients. Ablation techniques targeting these regions, reported results, and complications vary among centers. Comparative data for different approaches are limited. The randomized trial by Karch et al in this issue of Circulation compared 2 more commonly used approaches: ablation encircling a wide area around the pulmonary vein ostia guided by anatomy, versus an electrogram-guided approach ablating only segments of the pulmonary vein ostia. In contrast to a previous trial, the segmental ablation approach was associated with better arrhythmia control. Many recurrences were asymptomatic in both groups. Serious complications included tamponade, pulmonary vein stenosis, and thromboemboli. These findings add fuel to the continuing controversy as to the optimal method and support the practice of confining this procedure to highly symptomatic patients. See p 2875.PERCUTANEOUS CORONARY INTERVENTION VERSUS CONSERVATIVE THERAPY IN NONACUTE CORONARY ARTERY DISEASE: A META-ANALYSIS, by Katritsis and Ioannidis.Clinicians have often debated the incremental benefit of percutaneous coronary interventions for patients with stable angina. This study sought to synthesize the existing data by conducting a meta-analysis of the 11 randomized clinical trials of medical therapy versus percutaneous coronary intervention (PCI) in patients with angiographically documented coronary stenoses in nonacute coronary artery disease settings. The study specifically sought to determine whether PCI was associated with a subsequent reduction in risk of mortality, cardiac death or myocardial infarction, nonfatal myocardial infarction, and coronary artery bypass grafting or PCI. The follow-up was more than 2 years for 5 of the studies. This meta-analysis provides the best current evidence about whether PCI for patients with stable angina does more than improve symptoms. See p 2906.REDUCED NUMBER OF CIRCULATING ENDOTHELIAL PROGENITOR CELLS PREDICTS FUTURE CARDIOVASCULAR EVENTS: PROOF OF CONCEPT FOR THE CLINICAL IMPORTANCE OF ENDOGENOUS VASCULAR REPAIR, by Schmidt-Lucke et al.Endothelial function has been linked to the future risk of cardiovascular events in patients at risk. An emerging concept in vascular disease is the notion that circulating endothelial progenitor cells repopulate the vasculature to preserve normal endothelial function. Cardiovascular risk factors have been associated with a reduced number of circulating endothelial progenitor cells, suggesting that availability of these cells is key to maintaining normal vascular function. In this issue, Schmidt-Lucke and colleagues add important new information to this paradigm by demonstrating that the availability of endothelial progenitor cells is directly linked to the future incidence of cardiovascular events. See p 2981.Visit www.circ.ahajournals.org:Images in Cardiovascular MedicineSpontaneous Left Atrial Dissection Presenting as Pulmonary Edema. See p e372.ST Elevation During Open Heart Surgery: Floating Air Bubble in Saphenous Vein Graft. See p e374.Fluorine-18–Labeled Deoxyglucose Positron Emission Tomography in the Diagnosis and Management of Aortitis With Pulmonary Artery Involvement. See p e375.Download figureDownload PowerPointCorrespondenceSee p e377. Previous Back to top Next FiguresReferencesRelatedDetails June 7, 2005Vol 111, Issue 22 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.111.22.2865 Originally publishedJune 7, 2005 PDF download Advertisement