Svensson et al

Acquired Cardiovascular Disease

Inflammatory disease of the aorta: Patterns and classification of giant

cell aortitis, Takayasu arteritis, and nonsyndromic aortitis
Lars G. Svensson, MD, PhD,a Amr Arafat, MD,a Eric E. Roselli, MD,a Jahanzaib Idrees, MD,a
Allison Clifford, MD,b Carmela Tan, MD,c Gary Hoffman, MD,b Charis Eng, MD, PhD,d
Carol Langford, MD, MHS,e E. Rene Rodriguez, MD,a Heather L. Gornik, MD,f Eugene Blackstone, MD,a
Joseph F. Sabik III, MD,a and Bruce W. Lytle, MDa
Objective: Inflammatory diseases of the aorta, other than those of known infective etiology, are poorly
understood. We analyzed a large series of affected patients who had histologic diagnoses with a view to
improving the classification of the extent of aortitis to enable a more targeted approach of treatment.
Methods: Between 1996 and 2012, we operated on 7551 patients with ascending or aortic arch disease, of whom
279 had clinically diagnosed inflammatory disease. Of these, 156 (2%) were found to have aortitis on histologic
examination.
Results: Patients were divided into 4 histologically based groups: giant cell aortitis, 31% (49/156); Takayasu
arteritis, 5.1% (8/156); isolated aortitis, 59% (92/156); and other, 4.5% (7/156). Patterns of anatomic extent
were also analyzed, and in particular it was noted that giant cell aortitis and isolated aortitis had more extensive
disease. In addition, specimen analysis suggested early indications of unrecognized preexistent infections. Death
after surgery occurred in 3.2% (5/156), and stroke in 1.9% (3/156). Kaplan-Meier survival at 8 years was 55%.
We present a classification for disease extent and management.

The literature on inflammatory disease of the aorta is difficult

to interpret, either because the etiology has not been
determined or because it is multifactorial, and the end stage
is diffuse inflammatory disease with some variability in histologic patterns and atherosclerosis or calcification.1-20 To date,
no universally accepted theory has been advanced that
conclusively determines all forms of etiology, nor is there a
generally accepted classification. Most authors would agree
that there are those forms of aortitis that are clearly related
to known bacterial or viral infections, such as syphilis,
tuberculosis, human immunodeficiency disease, Kawasaki
disease, and possibly lupus, in addition to frank mycotic
aneurysms. Of note, the latter are rarely fungal in origin and
appear to be mostly related to the following: bacterial

From the Departments of Cardiothoracic Surgery,a Rheumatology,b and Anatomic

Pathology,c the Genomic Medicine Institute,d and the Department of Rheumatic
and Immunologic Disease,e Heart and Vascular Institute,f Cleveland Clinic,
Cleveland, Ohio.
Disclosures: Authors have nothing to disclose with regard to commercial support.
Read at The American Association for Thoracic Surgery Aortic Symposium,
New York, New York, April 24-25, 2014.
Received for publication April 24, 2014; revisions received July 28, 2014; accepted
for publication Aug 4, 2014.
Address for reprints: Lars G. Svensson, MD, PhD, Aorta Center and Heart and
Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH
44915 (E-mail: svenssl@ccf.org).
0022-5223/$36.00
Copyright 2014 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2014.08.003

ACD

Conclusions: Aortitis continues to be a conundrum; however, good results are achievable with surgery.
Intervention should be based on a clearer understanding of the histologic pattern and extent of disease, which
helps in subsequent targeted disease management. (J Thorac Cardiovasc Surg 2014;-:1-6)
infections at sites of calcification, old grafts, penetrating
ulcers, or areas of turbulence. Furthermore, the subgroup of
patients with noninfectious aortitis are considered to have
acute phases, often missed subacute phases, and chronic
phases, the latter with some risk of repeated flare-ups. There
is, however, considerable overlap of histologic findings between the noninfective labeled types and chronic infective
types such as syphilis, tuberculosis, human immunodeficiency disease, and rickettsialike etiologies. This clearly raises the question of potential undetected subclinical infective
etiologies by bacteria that have not been defined, such as
the more recently discovered archaic or extremophile organisms and organisms detected in tumors.21 In the early nineties,
Svensson and Crawford20 did attempt to group patients with
Takayasu arteritis according to anatomic extent of their disease on the basis of reported histologic patterns. That analysis
was based on a smaller study of patients and observations.
This analysis from the Cleveland Clinic, in contrast, is based
on a larger series of more than 7500 patients, 12% of whom
were found to have inflammatory aortitis proved by histologic
analysis.22
MATERIALS AND METHODS
Between 1996 and 2012, we operated on 7551 patients with ascending
or arch disease. Of these patients, 279 had inflammatory disease, and
156 (2%) were found to have aortitis proved by histologic examination
and are the subject of this report. The study was approved by the institutional review board of the Cleveland Clinic, with patient consent waived.

The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -

Acquired Cardiovascular Disease

Svensson et al

TABLE 1. Preoperative data and aortitis characteristics

Variable

ACD

Sex
Male
Female
Age (y)
Range
Mean
SD
Diagnosis
Preoperative
Immunosuppressant
Preoperative
Postoperative
Comorbidities
DM
Carotid artery
COPD
CVA
Hypertension
PVD
Preoperative dialysis
History of smoking
History of MI
History of CHF
Preoperative AF
Aneurysm
Intramural hematoma
Penetrating ulcer
Acute dissection
Chronic dissection
Preoperative ascending diameter (mm, mean
SD)
Preoperative descending diameter (mm, mean
SD)

Giant cell
(n 50; 32%)

Takayasu
(n 8; 5%)

Isolated
(n 92; 58%)

Other
(n 6; 3%)

Total
(n 156)

13 (26%)
37 (74%)

2 (25%)
6 (75%)

23 (25%)
69 (75%)

5 (83.3%)
1 (16.7%)

43 (27.5%)
113 (72.5%)

44.08-84.14
69.6
9

23.16-56.4
36.2
13.5

19.82-86.91
66.8
14

65.19-79.5
70.1
4.9

20-87
66.2
14.3

20

26 (18%)

12
37

3
7

1
7

6
5

22 (14.1%)
57 (36.54%)

2 (4%)
10 (20%)
10 (20%)
3 (6%)
41 (82%)
9
0
25
6
8
4
43
1
1
4
1
53.2
6.7
39.6
10.4

0
0
2 (25%)
0
5 (62.5%)
1
0
4
0
1
0
8
0
0
0
0
55
12.6
36.2.7
12.9

10 (10.8%)
23 (25%)
28 (30.4%)
11 (12%)
71 (77.1%)
18
0
55
12
15
6
77
2
6
0
7
56.6
9
43
14.6

1 (16.6%)
1 (16.6%)
2 (33.3%)
0
6 (100%)
2
0
3
1
1
0
5
0
1
0
0
47.1
12.7
39.1
12.8

13 (8.3%)
34 (21.8%)
42 (27%)
13 (8.3%)
123 (78.8%)
30 (19.2%)
0
87 (55.7%)
19 (12.8%)
25 (16%)
10 (6.4%)
134
3
8
4
8
55.5
9.2
41.6
13.5

All data represent number of patients with percentage unless otherwise indicated. DM, Diabetes mellitus; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular
accident; PVD, peripheral vascular disease; MI, myocardial infarction; CHF, congestive heart failure; AF, atrial fibrillation; SD, standard deviation.

The series consisted of 36% male and 64% female patients with a mean
(
SD) age of 66.4
14.3 years. Preoperative indications for surgery
included aortic degenerative diseases (84%), acute aortic syndrome
(10%), chronic dissection (5%), and aortic rupture (1%) (Table 1). Among
those excluded were 34 patients with Takayasu arteritis who did not need
aortic surgical replacement. The study was approved by the institutional review board of the Cleveland Clinic, with patient consent waived. Data from
both the prospectively collected cardiovascular database and chart review
were combined. Late mortality data were obtained from regular prospective
interval follow-up and cross-checking with the Social Security Death Index
for death.
Aortitis was defined as a nonatherosclerotic and noninfectious
inflammatory process involving the tunica media with or without
involvement of the adventitia of the aorta.
In 4 patients with aortitis, we examined the microorganism signatures
and compared these with those from 3 patients without aortitis and found
a clustering of patients with aortitis.21

RESULTS
Of the total number of patients who underwent ascending
and/or arch aortic surgery (n 7551), 156 (12%) of them
had historically proven aortitis. Among these 156 patients,
2

33 (21%) had greater vessel or cerebrovascular arterial

disease, 66 (42%) had stenotic or aneurysmal disease, 29
(19%) had lower extremity peripheral vascular disease,
13 (8.3%) had had strokes, and 124 (80%) had hypertension. Before the operation, 20% were receiving steroids
and 15% were receiving other immunomodulatory
medications, such as antimetabolites and cytotoxic agents
(Table 2). The mean preoperative erythrocyte sedimentation
rate was 22.7
21.7 mm/h, and C-reactive protein was
1.62
1.72 mg/dL. Of the 156 patients, 27 (17%) ended
up needing coronary artery bypass grafting, 86 (55%)
underwent aortic valve surgery, and 91 (58%) required
circulatory arrest for a mean of 13.5
15.2 minutes.
The histologic examination showed aortitis in all 156
patients. Only 18% of the patients had symptoms before
the operation with evidence of elevated erythrocyte
sedimentation rate or C-reactive protein; in the vast
majority of cases (82%) the diagnosis was made after the
operation on the basis of histopathologic examination.
The disease was classified according to clinical presentation

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Svensson et al

Acquired Cardiovascular Disease

TABLE 2. Operative details and complications

Index procedure
Isolated root replacement
Ascending aortic repair
Hemiarch repair
Total arch replacement
Stage 1 ET
Other
Frozen ET
Reverse frozen ET
Aortoplasty
Aortic biopsy
Concomitant procedures
Aortic valve repair
Aortic valve replacement
Concomitant root replacement
Hemiarch
Total arch replacement
ET
CABG
Mitral valve repair
Tricuspid valve repair
Atrial fibrillation surgery
Other congenital correction
Subsequent aortic replacement after index
TEVAR
Thoracoabdominal repair
Proximal aortic repair
Index as reintervention
Root plus ascending
Total arch
ET
Stage 2 ET (n 25; 53%)
EEC
OEC
Complications
Death (in-hospital and 30 d)
Stroke
Spinal paralysis
Renal dialysis
Reoperation for bleeding
Myocardial infarction

Giant cell
(n 50; 32%)

Takayasu
(n 8; 5%)

Isolated
(n 92; 58%)

Other
(n 6; 3%)

Total
(n 156)

3
16
12
3
12

0
0
3
3
2

5
27
21
5
32

0
1
1
3
1

8
44
37
14
47

0
0
1
3

0
0
0
0

1
1
0
0

0
0
0
0

7
26

0
5

8
41

0
3

1
1
1
3
181
15
75

3
0
1

2
1
1

9
0
4

0
0
0

4
3
0

0
1
1

2
3
2

0
1
0

1
0
2

0
0
0

0
1
0

0
0
0

6
2

0
1

12
3

1
0

1
1
0
0
2
0

0
0
0
0
0
0

4
2
0
3
6
0

0
0
0
0
0
0

14
1
6
39
10
5
9
7
17
5
8
4
4
1
1
2
46
19
6

ACD

Variable

5 (3.2%)
3 (1.9%)
0
3
8 (5.1%)
0

All data represent number of patients. ET, Elephant trunk; CABG, coronary artery bypass grafting; TEVAR, total endovascular aortic repair; EEC, endovascular elephant trunk
completion; OEC, open elephant trunk completion.

and histopathologic findings as giant cell aortitis in 49 cases

(31%), Takayasu arteritis in 8 (5.1%), isolated aortitis in 92
(59%), and other in 7 (4.5%). In addition, 25 (16%) of the
patients were found at surgery to have areas of calcification.
The sites of the distal anastomosis were ascending in 45
cases (30%), distal ascending in 1 (0.66%), between the
innominate and carotid artery in 26 (17%), between the
carotid and subclavian artery in 46 (30%), beyond the left
subclavian in 28 (19%), and other in 1 (0.66%). The aortic
arch procedure (n 149) included 20 reoperations (13%)

and consisted of (1) hemiarch in 35 cases (23%), (2) tongue

peninsula 1 (0.67%), (3) elephant trunk in 49 (33%),
(4) total arch in 11 (7.4%), and (5) none in 53 (36%).
Patients with giant cell or isolated aortitis had
significantly larger proximal descending aortas (giant cell,
33.9
8.12 mm; isolated, 38.1
28.9 mm; Takayasu arteritis, 21.1
1.8 mm; P .0012) and thoracoabdominal
aortas (P .048) at discharge (Table 2). Postoperatively,
56 were discharged with a regimen of steroids and 57
(37%) with a regimen of immunomodulatory medications,

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Acquired Cardiovascular Disease

Svensson et al

FIGURE 1. Competing risk analysis after index procedure. The black

curve represents the event-free survival after the index operation, the blue
curve represents the rate of reintervention, and the red curve represents
the mortality. Freedoms from reintervention at 30 days, 1 year, 5 years,
and 8 years were 98.9%, 83.1%, 82.1%, and 77.6%, respectively.

ACD

including 12 (77%) receiving methotrexate (an antimetabolite and antifolate immunosuppressive and immunomodulatory agent similar to mycophenolate mofetil, and
azathioprine but with different metabolic pathways
affected). Some 49 patients required late reoperation, with
no difference in etiology types.
There were 5 in-hospital deaths (3.2%), and stroke
occurred in 3 patients (1.9%). There was reoperation for
bleeding in 7 cases (5.1%). The Kaplan-Meier survival
was 54.7% at 8 years, and reoperations increased with
time (Figure 1). Freedoms from reintervention at 30 days,
1 year, 5 years, and 8 years were 98.9%, 83.1%, 82.1%,
and 77.6%, respectively.
There was no significant difference in outcomes by age,
sex, race, greater vessel or cerebrovascular disease, nor
procedure, suggesting that the results can be generalized

for types and can thus be based on anatomic extent of repair.

Large vessel involvement was, however, as expected more
common with Takayasu arteritis at 100%, versus 35
patients (71%) with giant cell aortitis, 19 (21%) with
isolated aortitis, and 4 (57%) with other (P < .0001).
Patients with Takayasu arteritis were also as expected
younger (35.7
22.7 years; P .0002). Patients with giant
cell aortitis (24%) and Takayasu arteritis (38%) and other
types (100%) were more often (P < .0001) receiving
immunomodulatory medication, particularly methotrexate,
azathioprine, cyclophosphamide, etanercept, infliximab,
and mycophenolate mofetil. In our small exploratory
sample of aortic specimens, it would appear that rare
unrecognized microorganisms may be involved in aortitis
development, as is seen with tumors.21 This promises to
be an interesting new avenue of research on etiology.
DISCUSSION
This study has shown that histologically verified aortitis
is fairly common and occurs at a rate of 2% of aortic specimens. Earlier studies have reported the rate to be between
4.3%6 and 12%.22 The results achieved in this series are
similar to other ascending and arch reports, although in
the giant cell and isolated aortitis groups we more
frequently used prophylactic elephant trunk procedures,
anticipating that later second-stage procedures would be
required.23-30 The need for a second procedure can be
somewhat guided by the classification of the extent of
disease (Figure 2). We believe that, on the basis of this
and earlier reports, the histologic extent of aortic involvement falls into 4 classification groups and that greater vessel
arch artery or visceral branch artery influences requirements for additional procedures. Thus, type 1 disease consists of involvement of mostly the ascending aorta and

FIGURE 2. Aortic aneurysm narrowing classification.

The Journal of Thoracic and Cardiovascular Surgery c - 2014

Acquired Cardiovascular Disease

arch, with variable degrees of descending or thoracoabdominal dilation. Greater vessel involvement is variable but
often involves carotid disease at the bifurcation or more
distally. For those patients, there is little distinction between
giant cell and isolated aortitis, and thus these patients as a
group should be considered for prophylactic elephant trunk
procedures because their natural progression is continued
distal dilation with time that would necessitate repeated
intervention. Type 2 disease typically consists of ascending
aortic disease with proximal greater vessel involvement
proximal to the carotid bifurcation or proximal innominate
or subclavian involvement. Takayasu arteritis is typical of
the type 2 classification, and these patients should be
considered for greater vessel bypasses with prosthetic rather
than biologic material beyond the arch artery origins and
mechanical valve replacement for moderate or severe aortic
valve disease. Type 3 disease usually consists of thoracoabdominal disease with variable dilatation or atheroma or
atherosclerosis and proximal greater arch vessel or visceral
abdominal involvement. These patients require either specific procedures, such as bypasses or stenting of the greater
vessels, before thoracoabdominal aortic repairs to the
greater vessels or concurrent prosthetic material bypasses
to visceral arteries or left subclavian bypass. Type 4 disease
includes that group of subdiaphragmatic inflammatory aneurysms that may have variable visceral artery involvement
and appear to have a different type of etiology, possibly
related to lymphatic vessel disease. Pulmonary stenotic disease appears to represent a separate, rare disease group.
In short, the aim of surgical intervention for aortitis
should be to correct the anatomic disease problem, to
reduce the risk of pseudoaneurysm formation, to prevent
perivalvular aortic valve leaks, to prevent continued
destruction from the disease, and to prepare for later
disease progression. Greater vessel bypasses allow for later
extrathoracic cavity bypasses to be done, and prophylactic
elephant trunk procedures allow for safer second-stage
procedures, either open or by stenting. Vein grafts and biologic material, including aortic valve replacement, should
be avoided because of the high risk of failure.
Limitations
This is a retrospective study concentrating on histologically based diagnoses of aortitis. We are preparing
a separate article that is based on disease diagnosis
groups and medical or surgical treatment. Ideally,
continuing research will contribute to a better understanding of the disease etiology and determine the medications
and techniques that should be developed to halt disease
progression as well as potential complications with time.
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The Journal of Thoracic and Cardiovascular Surgery c - 2014

Svensson et al

Inflammatory disease of the aorta: Patterns and classification of giant cell

aortitis, Takayasu arteritis, and nonsyndromic aortitis
Lars G. Svensson, MD, PhD, Amr Arafat, MD, Eric E. Roselli, MD, Jahanzaib Idrees, MD, Allison
Clifford, MD, Carmela Tan, MD, Gary Hoffman, MD, Charis Eng, MD, PhD, Carol Langford, MD,
MHS, E. Rene Rodriguez, MD, Heather L. Gornik, MD, Eugene Blackstone, MD, Joseph F. Sabik
III, MD, and Bruce W. Lytle, MD, Cleveland, Ohio
The etiology of aortitis is poorly understood. When management is guided by anatomic
classification according to the pattern of disease, however, then good early results can be expected

ACD

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Acquired Cardiovascular Disease

The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number -