In the pre-antibiotic era cardiovascular syphilis occurred in 1/3 of untreated patients 10-40 years following primary infection with 10% having cardiovascular, 7% neurosyphilis and 16% gummas. [7] Spirochetes have predilection towards small vessels of vasa-vasorum supplying media and adventitia leading to end arteritis, patchy loss of elastic tissue, fibrous replacement and small microgummas may be visualized within the media. The affected intima thickens over areas of necrosis with intervening segments of wrinkling giving a “tree bark” appearance [1,8,9]