Antineutrophil Cytoplasmic Antibody—Associated Multiple Giant Saccular Aortic Aneurysms Ryoji Kinoshita, MD, Tomohiro Mizuno, MD, PhD, Tsuyoshi Hachimaru,

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Antineutrophil Cytoplasmic Antibody—Associated Multiple Giant Saccular Aortic Aneurysms Ryoji Kinoshita, MD, Tomohiro Mizuno, MD, PhD, Tsuyoshi Hachimaru, MD, Keiji Oi, MD, PhD, Masafumi Yashima, MD, Eiki Nagaoka, MD, PhD, Tatsuki Fujiwara, MD, Hidehito Kuroki, MD, Dai Tasaki, MD, Hirokuni Arai, MD, PhD The Annals of Thoracic Surgery Volume 103, Issue 2, Pages e153-e155 (February 2017) DOI: 10.1016/j.athoracsur.2016.06.109 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Preoperative images. (A) Preoperative three-dimensional reconstructive computed tomographic view shows dilatation of thoracic aorta with giant multiple saccular aneurysms and the left iliac arterial aneurysm. (B) The ascending aorta was dilatated and had multiple saccular aneurysms. (C) The dilatated thoracoabdominal aorta with a saccular aneurysm. (D) Contained rupture of the left internal iliac artery aneurysm. The Annals of Thoracic Surgery 2017 103, e153-e155DOI: (10.1016/j.athoracsur.2016.06.109) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Intraoperative findings. (A) The ascending aorta and its saccular aneurysms were severely adhered to the pericardium and the surrounding tissue. White arrow, innominate vein; dotted arrow, left common carotid artery; PA, pulmonary artery; RV, right ventricle. (B) The aortic wall of the ascending aorta was very thin and had multiple aneurysmal necks of the saccular aneurysms. White arrows, multiple aneurysmal necks of the saccular aneurysms. Distal, distal aortic arch. The Annals of Thoracic Surgery 2017 103, e153-e155DOI: (10.1016/j.athoracsur.2016.06.109) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Results of pathologic analysis. (A) Elastic van Gieson staining of the aneurysmal wall shows degeneration and tearing of the elastic fibers of the media. Black arrow, tear and lack of elastic fibers (original magnification × 20). (B) Elastic van Gieson staining shows the thickened intima in wide contact with the adventitia as a result of the absence of the elastic fibers (original magnification × 40). (C) Higher magnification of the adventitia stained with hematoxylin and eosin demonstrates fibrosis of the vasa vasorum and infiltration of inflammatory cells in part of the vasa vasorum (original magnification × 200). The Annals of Thoracic Surgery 2017 103, e153-e155DOI: (10.1016/j.athoracsur.2016.06.109) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions