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Assessing urgency of repair is essential to developing the appropriate management plan. Although emergent repair carries greater operative risk than does elective repair, any inappropriate delay of repair risks death.
The clinical 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 should be routinely imaged to assess overall growth and yearly rate of expansion.
Endovascular repair devices are approved for the treatment of descending thoracic aortic aneurysms, and some of the newer devices are also approved for the treatment of aortic trauma and penetrating aortic ulcer.
Practice guidelines were recently published that have helped to standardize the decision-making process and select an appropriate surgical intervention, as well as to standardize the use of imaging studies for patients with thoracic aortic disease.
Ascending aortic aneurysms that are symptomatic or >5.5 cm should be repaired. This threshold is lowered for patients with connective tissue disorders.
Surgical repair involves the development of a patient-tailored plan based on careful preoperative medical evaluation. When appropriate, optimizing a patient’s health status—to mitigate existing comorbidities—is important before surgical intervention.
The development and use of surgical adjuncts like antegrade selective cerebral perfusion and cerebrospinal fluid drainage have significantly reduced the morbidity rates traditionally associated with complex aortic repair.
Proximal aortic dissection is a life-threatening condition, and immediate operative repair is generally indicated, although definitive aortic repair may be delayed until after severe malperfusion has been treated.
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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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