1. Assessing urgency of repair for an aortic aneurysm
is essential to developing an appropriate management plan. Although
emergent repair carries greater operative risk than does elective
repair, any inappropriate delay of repair risks death.
2. Surgical repair of an aortic aneurysm requires the development
of a patient-tailored plan based on careful preoperative medical
evaluation. When possible, optimization of a patient’s
health status to mitigate existing comorbidities is essential before
3. Ascending aortic aneurysms that are symptomatic or >5.5 cm should
4. Ascending aortic dissection is a life-threatening condition,
and immediate operative repair is indicated.
5. The natural progression of an aortic aneurysm is continued expansion
and eventual rupture. Hence, regular noninvasive imaging studies,
as part of a lifelong surveillance plan, are necessary to ensure
long-term patient health. Even small asymptomatic aneurysms are
routinely imaged to assess overall growth and yearly rate of expansion.
6. Although endovascular devices are approved for use in repairing
simple descending thoracic aortic aneurysms, the long-term durability
of this type of aortic repair has yet to be clearly established.
7. The development and use of surgical adjuncts like antegrade selective
cerebral perfusion and cerebrospinal fluid drainage have significantly
reduced morbidity rates associated with complex aortic repair.
The aorta consists of two major segments—the proximal
aorta and the distal aorta—whose anatomic characteristics
affect both the clinical manifestations of disease in these segments
and the selection of treatment strategies for such disease (Fig. 22-1). The proximal aortic segment includes
the ascending aorta and the transverse aortic arch. The ascending
aorta begins at the aortic valve and ends at the origin of the innominate
artery. The first portion of the ascending aorta is the aortic root,
which includes the aortic valve annulus and the three sinuses of
Valsalva; the coronary arteries originate from two of these sinuses.
The aortic root joins the tubular portion of the ascending aorta
at the sinotubular ridge. The transverse aortic arch is the area
from which the brachiocephalic branches arise. The distal aortic
segment includes the descending thoracic aorta and the abdominal
aorta. The descending
thoracic aorta begins distal to the origin of the left subclavian
artery and extends to the diaphragmatic hiatus, where it joins the
abdominal aorta. The descending thoracic aorta gives rise to multiple
bronchial and esophageal branches, as well as to the segmental intercostal
arteries, which provide circulation to the spinal cord.
Illustration of normal thoracic aortic anatomy. The brachiocephalic
vessels arise from the transverse aortic arch and are used as anatomic
landmarks to define the aortic regions. The ascending aorta is proximal
to the innominate artery, whereas the descending aorta is distal
to the left subclavian artery.
The volume of blood that flows through the thoracic aorta at ...