Multiple inflammatory aneurysms: A rare complication of idiopathic inflammatory aortitis

A 64-year-old man, with a left primary nephrectomy, was referred for evaluation of a para-umbilical hernia. On examination, a large expansile abdominal mass was noted. Computerised tomography (CT) demonstrated (i) multiple diffuse aneurysmal dilatations of the thoraco-abdominal aorta, (ii) peripheral arterial aneurysms and (iii) stenoses of the coeliac, superior mesenteric and right renal arteries. Persistently elevated inflammatory markers (ESR: 22 and CRP: 44) and the absence of atherosclerotic risk factors, including a smoking history, suggested an underlying diagnosis of idiopathic inflammatory aortitis. This was supported by fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) which demonstrated increased tracer activity in the root, ascending, proximal arch and descending aorta. Initial treatment to suppress the active inflammatory component of the disease involved steroid therapy. Open surgical or endovascular repair of the aortic aneurysms was however deemed unfeasible. Percutaneous transluminal renal artery angioplasty (PTRA) of his sole renal artery was attempted; unfortunately this was unsuccessful resulting in renal arterial occlusion with subsequent infarction of the right kidney leaving the patient haemodialysis dependent. This case highlights the clinical variability and complications of severe idiopathic inflammatory aortitis and the risk in performing PTRA in patients with complex anatomy of the aorta.