thoracic aortic aneurysm
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Etiology
- atherosclerosis
- *connective tissue disease
- *genetic disease/congenital disorder
- TAAD syndrome
- bicuspid aortic valve
- Turner syndrome
- family history of thoracic aortic aneurysm or aortic dissection
- *vasculitis
- *infections
- septic embolism
- *direct bacterial innoculation
- *bacterial seeding
- *contiguous infection
- syphilis
- *aortic injury
- prior acute aortic syndrome
- thoracic traums
Epidemiology
see aortic aneurysm
Clinical manifestations
- chest pain, abdominal pain, flank pain, back pain
- murmur of aortic insufficiency
- heart failure
- blood pressure differential between arms
- hoarseness, dysphagia, recurrent pneumonia, superior vena cava syndrome
Laboratory
- plasma D-dimer < 500 ug/L within 1st 24 hours of symptom onset with 95% negative predictive value[3]
Diagnostic procedures
- echocardiogram
- follow-up measurement of aortic root diameter
- yearly, until aortic root >= 4.5 cm, then every 6 months
- aortic root > 5.5 cm (general threshold for surgery)
- aortic root > 4.5 cm (with other heart surgery)
- aortic root growth > 0.5 cm/year
- different schedule for Marfan syndrome & Loeys-Dietz syndrome
- aortic root > 4.0-5.0 cm
- screening asymptomatic patients for thoracic aortic aneurysm reserved for 1st degree relatives of patients with:
- bedside transesophageal echocardiogram (diagnostic)
- critically ill patients
- need for continuous monitoring
Radiology
- chest X-ray may show widened mediastinum
- computed tomography (CT) with contrast (diagnostic)
- magnetic resonance imaging (diagnostic)
- with familial form, CT or MRI baseline, at 6 months, then annually if aortic size is stable[1]
- imaging of thoracic aorta with angiography reserved for patients in whom percutaneous intervention is planned[1]
Complications
- rupture of aneurysm
- aortic dissection
- thrombolism, ischemic stroke
- 2-5-8% with endovascular repair
- myocardial infarction
- cardiac tamponade
Management
- see aortic aneurysm
- advise against pregnancy if > 4 cm
- monitor aortic root diameter: see echocardiogram
- surgical repair (aortic aneurysm repair)
- indications
- aortic root > 5.5 cm;
- 4.5-5.0 cm if due to Marfan's syndrome, Ehlers-Danlos syndrome or familial form of thoracic aortic aneurysm[1]
- threshold for Loeys-Dietz syndrome is 4.5 cm
- descending thoracic aorta > 6.0 cm[1]
- rapid rate of growth: > 0.5 cm/year[1]
- aortic dissection
- symptoms (hoarseness, dysphagia, back pain)
- aortic root > 5.5 cm;
- endovascular repair & grafting
- not recommended unless prohibitive surgical risk
- no need for anticoagulation
- low-dose aspirin if comorbid atherosclerosis[5]
- prophylaxis for bacterial endocarditis not needed
- indications
- patients with Marfan's syndrome should be evaluated with echocardiogram, immediately after diagnosis & then in 6 months to assess progression[2]
- patient education
- 1st-degree relatives of patients with thoracic aortic aneurysm or thoracic aortic dissection should undergo aortic imaging to identify asymptomatic disease.
- smoking cessation
More general terms
More specific terms
Additional terms
- dissecting aortic aneurysm; aortic dissection (acute aortic syndrome)
- endovascular graft (endovascular repair)
- intramural aortic hematoma
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16. 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022
- ↑ 2.0 2.1 Hiratzka LF et al 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease. J Am Coll Cardiol. 2010 Apr 6;55(14):e27-e129 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/20359588 <Internet> http://content.onlinejacc.org/cgi/reprint/j.jacc.2010.02.015v1.pdf (corresponding NGC guideline withdrawn Nov 2015)
Hiratzka LF et al 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease. Executive Summary J Am Coll Cardiol. 2010 Apr 6;55(14):1509-44 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/20359609 <Internet> http://content.onlinejacc.org/cgi/reprint/j.jacc.2010.02.010v1.pdf (corresponding NGC guideline withdrawn Nov 2015) - ↑ 3.0 3.1 Suzuki T, Distante A, Zizza A et al Diagnosis of acute aortic dissection by D-dimer: the International Registry of Acute Aortic Dissection Substudy on Biomarkers (IRAD-Bio) experience. Circulation. 2009 May 26;119(20):2702-7 PMID: https://pubmed.ncbi.nlm.nih.gov/19433758
- ↑ Isselbacher EM, Preventza O, Hamilton Black J 3rd et al 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Dec 13;146(24):e334-e482. PMID: https://pubmed.ncbi.nlm.nih.gov/36322642 PMCID: PMC9876736 (available on 2023-12-13)
- ↑ 5.0 5.1 Wong KHF, Zlatanovic P, Bosanquet DC et al Antithrombotic Therapy for Aortic Aneurysms: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2022 Nov;64(5):544-556. PMID: https://pubmed.ncbi.nlm.nih.gov/35853579 Free article.