case_images: PMC5803986_01
case_images: (a) Heart, anterior surface - cardiomegaly, aneurysmal dilatation A distal to the left subclavian artery, anomalous collaterals (arrow) distal to aneurysm; (b) heart, posterior surface -constriction beyond aneurysm A. Descending thoracic aorta DTA is supplied by bunch of anomalous collateral arteries (arrows). The ductus is closed. AA: Ascending aorta, LCCA: Left common carotid artery, LA: Left atrium, LPA: Left pulmonary artery, LV: Left ventricle, PT: Pulmonary trunk, RAA: Right atrial appendage, RBCA: Right brachiocephalic artery, RPA: Right pulmonary artery, RV: Right ventricle
case_images: APC-11-92-g001.jpg
case_images: PMC5803986_01_APC-11-92-g001.jpg
case_images: F1
case_images: Just distal to the origin of the left subclavian artery [LSA, Figure 1], however, there was fusiform aneurysmal dilation of the proximal 4 cm of the descending thoracic aorta, which had a diameter of 3.5 cm.
case_images: Serial longitudinal sections for the site of constriction show in (a and b) luminal discontinuity between the proximal and distal segments, (c) confirmed on histopathology (scanned slide); (d) (H and E, x250) and (e) (H and E, x400) shows complicated atherosclerosis in the aneurysmal wall proximal to the interruption with luminal thrombus T; (f) (H and E, x250) and (g) (H and E, x400) shows near normal wall distal to the interruption
case_images: APC-11-92-g002.jpg
case_images: PMC5803986_01_APC-11-92-g002.jpg
case_images: F2
case_images: A distinct constriction was found just beyond the aneurysm, with serial longitudinal sections at this site showing lack of communication with the descending thoracic aorta, a finding confirmed by subsequent microscopy [Figure 2].
case_images: (a) LV outflow tract showing bicuspid AV and a niche (arrow) in the interventricular septum. The LCA is critically stenosed (LV: Left ventricular, AV: Aortic valve LCA: Left circumflex artery, AA: Ascending arota, LAA: Left atrial appendage, MV: Mitral valve); (b) Fibrous tract (arrow) at the niche produced by the closed muscular ventricular septal defect (LVC: Left ventricular cavities, RVC: Right ventricular cavities); left anterior descending artery, (c and d) (scanned slide) critical stenosis by atheroma; (e) At shoulder S, there is fibrous cap FC erosion (arrows) with fresh thrombus. The core C is lipid rich (H and E, x250)
case_images: APC-11-92-g003.jpg
case_images: PMC5803986_01_APC-11-92-g003.jpg
case_images: F3
case_images: Further examination of the heart revealed bicuspid aortic valve (anterior to posterior type) [Figure 3a], moderate concentric left ventricular hypertrophy, and evidence of spontaneous closure of a preexisting trabecular muscular ventricular septal defect [Figure 3b]. All the coronary arteries were diffusely atherosclerotic, with multifocal critical stenosis [Figure 3c and d]. The left anterior descending artery, 3 cm from its origin, showed luminal occlusion for a length of 0.8 cm produced by a fresh organizing thrombus which had developed over an eroded atherosclerotic plaque [Figure 3e].