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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.

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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 surgical intervention.

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3. Ascending aortic aneurysms that are symptomatic or >5.5 cm should be repaired.

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4. Ascending aortic dissection is a life-threatening condition, and immediate operative repair is indicated.

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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.

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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.

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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.

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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.

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Fig. 22-1.
Graphic Jump Location

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.

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The volume of blood that flows through the thoracic aorta ...

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