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  • • Can be saccular, fusiform

    • Common etiologies include:

    • -Atherosclerosis

      -Medial degeneration of aortic wall

      -Marfan syndrome (defect in fibrillin gene)

      -Trauma and infection

    • Increased aneurysm rupture rate depend on:

    • -Size

      -Marfan syndrome

      -Family history of rupture or dissection

      -Advancing age

      -Chronic obstructive pulmonary disease

      -Growth rate > 0.1 cm yearly

    • Affect the ascending, arch, or descending aorta (descending is most common)

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Epidemiology

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  • • More common in men

    • History of hypertension usual

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Symptoms and Signs

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  • • Symptoms, if present, are due to local pressure or obstruction of adjacent structures

    Ascending aorta

    • -Aortic regurgitation

      -Superior vena cava obstruction

      -Chest pain

    Aortic arch: Tracheal compression

    Descending aorta

    • -Recurrent laryngeal nerve compression

      -Phrenic paralysis

      -Dysphagia

      -Stridor

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Imaging Findings

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  • Chest x-ray: May show convex right cardiac border in ascending aneurysms, prominent aortic knob in arch aneurysms, posterior lateral thoracic mass in descending aneurysms

    CT scans or magnetic resonance angiography (MRA): Define anatomy and extent of aneurysm

    Aortography: Occasionally useful

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  • • Evaluate for peripheral aneurysms

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  • • Chest CT/MRA: Diagnostic

    • Consider aortography

    Stress test: Examine for coronary artery disease

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  • • Primary determinants for repair: Aneurysm size, etiology, and symptoms

    • For asymptomatic aneurysms measuring ≤ 5.5 cm, aggressive blood pressure control with β-blockers

    • Consider repair when aneurysm measures > 5.5 cm, especially if symptoms present

    • Dacron replacement is standard

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Surgery

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  • Ascending aorta

    • -Cardiopulmonary bypass via RA and right femoral artery cannulation

      -If extends proximal toward sinuses of Valsalva, need composite prosthetic valve-ascending aortic graft conduit (patients with Marfan syndrome)

      -Isolated ascending aortic aneurysm, replace with Dacron graft

    Arch

    • -Provide cerebral protection during repair via hypothermic circulatory arrest

      -Dacron graft, anastomose great vessels as single button

    Descending aorta

    • -Dacron replacement via left thoracotomy with spinal cord protection via replacement of large intercostals, drainage of CSF

      -Percutaneous stent grafts now being used

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Indications

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  • • Aneurysm > 5.5 cm, consider repair especially if symptoms are present

    • Marfan syndrome: Aneurysm > 5 cm

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Complications

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  • • Spinal cord ischemia in descending aortic repair 5-15%

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Prognosis

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  • • Operative mortality, 5-15%

    • 10-year survival: Ascending = 50%, descending = 38%

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References

Chuter TA et al: Endovascular treatment of thoracoabdominal aortic aneurysms. J Vasc Surg 2008;47:6.  [PubMed: 17980540]
Umana JP, Mitchell RS. Endovascular treatment of aortic dissections and thoracic aortic aneurysms. Semin Vasc Surg. 2000;13:290.  [PubMed: 11156057]

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