How Could These Mini leads.

Chest radiography revealed small bulging in the

contour of the aortic knob. Transthoracic echocardiog-
Saccular Aneurysms of raphy, showed mild dilatation of ascending aorta (35
Ascending Aorta Be Classified? mm), severe aortic regurgitation and preserved left
Anas Sarraj, MD, PhD, Daniel-Edgardo Mu~noz, MD, ventricular systolic function. Cardiac catheterization
Coraz
on-Mabel Calle Valda, MD, Emilio Monguio, MD, showed severe aortic valve regurgitation, mild dilation of
and Guillermo Reyes, MD, PhD ascending aorta (33 mm), left ventricular dilatation (left
ventricle diastolic diameter, 207 mL; left ventricle systolic
Department of Cardiovascular Surgery, Hospital Universitario diameter, 80 mL) with mild dysfunction, and no coronary
de La Princesa, Universidad Aut
onoma de Madrid, Madrid,
Spain artery disease. It revealed small bulging in the wall of
ascending aorta (mean diameter, 8  20 mm) above the
sinotubular junction (Fig 1). Because of the hemody-
The wall of a true aneurysm is composed of all histologic
namic stability and the absence of signs of impending
layers of the aorta. A false aneurysm represents a small,
rupture, cardiac computed tomography was used to
contained rupture of aorta followed by bulging of the
confirm the diagnosis (Fig 2A). Multislice spiral CT
corresponding area that is usually sustained by a fibrous
angiography revealed two saccular aneurysms 4 cm
peel. Aortic dissection is defined as a separation of the
above the aortic valve; one is anterior and the other is
lamellae of the aortic wall. Herein, we describe an
posterior (craniocaudal diameter: 33 and 34 mm,
unusual clinical presentation of aortic dissection in a
respectively). It showed another two smaller saccular
37-year-old male patient that presented severe aortic
aneurysms in the distal ascending aorta (anterior 13 mm,
regurgitation and unusual bulges with linear intimal fis-
lateral 12 mm; Fig 2B).
sures in ascending aorta underwent mechanical aortic
The patient was referred for surgery. A full sternotomy
valve replacement and interposition of tubular vascular
was performed, and the pericardium was opened. On
graft in ascending aorta.
exploration, we found multiple, small, saccular aneu-
(Ann Thorac Surg 2017;103:e331–3)
rysms in the ascending aorta corresponding to the
Ó 2017 by The Society of Thoracic Surgeons
description of multislice spiral CT angiography (Fig 3A).
The patient was placed on cardiopulmonary bypass via
distal ascending aorta and right atrium cannulations.
T he wall of true aneurysm is composed of the normal
histological components of aorta. It can be divided in
two types; fusiform and saccular. Saccular aneurysm is an
Myocardial protection was achieved by the administra-
tion of antegrade and retrograde interrupted cold blood
outbulging of certain part of aortic circumference main- cardioplegia. After aortotomy, we observed multiple and
taining the continuity with the aortic lumen. False aneu- paralleled linear intimal fissures in the wall of each
rysm (pseudoaneurysm) is produced by a contained aneurysm (Fig 3B). The ascending aorta was resected and
rupture of the aorta followed by outbulging of the histo- replaced with a tubular graft, and mechanical aortic valve
logical layers and is usually covered by a fibrous peel.
Aortic dissection is defined as a separation of the lamellae
of the aortic wall. In this case, we describe unusual bulges
in the ascending aorta, which is neither true aneurysm
nor pseudoaneurysm, because they presented linear
intimal fissures without perivascular hematoma. To our
knowledge, such a clinical presentation has not been
reported previously.

A 37-year-old male immigrant was admitted in our

department with a diagnosis of asymptomatic severe
aortic regurgitation. He was a smoker. The results of
physical examination were normal except for a diastolic
murmur heard on the right second intercostal space. The
routine laboratory results were within normal limits. The
viral markers, serology for ELISA/IFI and syphilis were
negative. The results of a coagulation study, protein-
gram, immune study (ANA screening), and HLA-B27
were normal. Electrocardiography demonstrated a
sinus rhythm and unspecific T wave in the precordial

Accepted for publication Sept 18, 2016.

Address correspondence to Dr Sarraj, Department of Cardiovascular
Surgery, Hospital Universitario de La Princesa, Diego de Le
on, 62. 28006 Fig 1. Aortography showed a saccular aneurysm of ascending aorta
Madrid, Spain; email: anas_sarraj@hotmail.com. above the sinotubular junction (asterisk).

Ó 2017 by The Society of Thoracic Surgeons 0003-4975/$36.00

Published by Elsevier Inc. http://dx.doi.org/10.1016/j.athoracsur.2016.09.072
e332 CASE REPORT SARRAJ ET AL
UNUSUAL ANEURYSM OF ASCENDING AORTA
Fig 2. (A) Computed tomographic
(CT) scan showing bilateral
saccular aneurysm of the
ascending aorta. (B) Multislice
spiral CT angiography showing
two saccular aneurysms 4 cm
above the aortic valve and another
two smaller saccular aneurysms in
the distal portion of ascending
aorta (asterisks).
replacement was performed. Histologic tests revealed
mucoid degeneration with fragmentation and disar-
rangement in the elastic layer of the aortic wall. The
postoperative period was uneventful, and the patient was
discharged 7 days after the operation and referred to a
rehabilitation program. At 2 months’ follow-up, the
patient is alive and asymptomatic.
Comment
The wall of true aneurysm is composed of the normal
histologic components of the aorta. It can be divided into
two types: fusiform (most common) and saccular. A
saccular aneurysm is an outward bulging of a certain part
of the aortic circumference maintaining the continuity
with the aortic lumen [1]. Saccular aneurysms typically
are caused by trauma, such as a motor vehicle crash, or a
penetrating aortic ulcer [2]. A naturally occurring saccular
aneurysm at the ascending aorta is an extremely rare
clinical entity [3]. False aneurysm (pseudoaneurysm) is
produced by a contained rupture of the aorta followed by
the outward bulging part of the histologic layers of aorta;
it is usually covered by a fibrous peel [1]. Aortic dissection
is defined as a rupture of the intima followed by splitting
of the layers of the aortic wall (within the media) with
Fig 3. Intraoperative view.
(A) Multiple saccular aneurysms
in the ascending aorta (arrows).
(B) Saccular aneurysms presented
paralleled linear intimal fissures.
Ann Thorac Surg
2017;103:e331–3
longitudinal and spiral propagation of the filled space
with blood within the aortic wall [1].
Svensson and colleagues [4] reported a new classifica-
tion of variants of aortic dissection: class I, classic
dissection is a well-recognized form of aortic dissection
and is characterized by a flap between true and false
aneurysm and clot in false lumen; class II, intramural
hematoma is less common, and the dissection is usually
filled with blood clot without a detectable intimal tear;
class III dissection is characterized by a limited stellate or
linear intimal tear associated with exposure of the
underlying aortic media or adventitial layers with
eccentric bulge at tear site, but without the progression
and separation of the medial layers; class IV dissection is
a penetrating atherosclerotic ulcer with surrounding
hematoma, usually subadventitial; class V dissection is
iatrogenic or traumatic dissection illustrated by coronary
catheter causing dissection.
Herein, we described an unusual presentation of aortic
dissection. We did not find any specific etiology (e.g.,
trauma, infectious, immune, or collagen vascular diseases)
can explain how this phenomenon has been produced.
Echocardiography could not identify the diagnosis. Aortic
root angiography showed small saccular aneurysm in the
ascending aorta without clarifying whether it is dissection,
true aneurysm, or pseudoaneurysm.
Ann Thorac Surg
2017;103:e331–3
Now, how we can classify this unusual case? Is it true
aneurysm, pseudoaneurysm, or aortic dissection? The
peculiarity of our clinical case is the presence of multiple,
small, saccular aneurysms in the ascending aorta with
multiple and parallel lineal fissures in each one. We do
not know whether this case could be considered as a
special presentation of aortic dissection type 3, according
Svensson.
We believe that the modern cardiac imaging tech-
niques, particularly three-dimensional, shaded-surface-
display angiography, could probably be much more
accurate than a CT scan in the differential diagnosis and
planning the correct surgical procedure. This case is
unusual and original, and it has not, to our knowledge,
been described in the literature. We think it may expand
CASE REPORT SARRAJ ET AL e333
UNUSUAL ANEURYSM OF ASCENDING AORTA
the medical knowledge overall in cardiology and cardio-
vascular surgery.
References
1. Fuster V, O’Rourke R, Walsh R, et al. Hurst’s the heart. Phil-
adelphia, PA: Saunders; 2011;167–17.
2. Borrello B, Nicolini F, Beghi C, et al. Saccular ascending aorta
aneurysm: report of an unusual presentation. Interact Car-
diovasc Thorac Surg 2008;7:508–9.
3. Ting AC, Cheng SW, Ho P, et al. Endovascular repair for
multiple Salmonella mycotic aneurysms of the thoracic aorta
presenting with Cardiovocal syndrome. Eur J Cardiothorac
Surg 2004;26:221–4.
4. Svensson LG, Labib SB, Eisenhauer AC, Butterfly JR. Intimal
tear without hematoma: an important variant of aortic
dissection that can elude current imaging techniques. Circu-
lation 1999;99:1331–6.