Anatomy Anatomy



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tarix06.02.2017
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Anatomy

  • Anatomy

  • Definitions

  • Epidemiology

  • Etiology

  • Pathophysiology

  • Presentation

  • Diagnosis

  • Natural History

  • Treatment

  • Prognosis

  • Underwriting Considerations





Normal Dimensions

  • Normal Dimensions

    • Mid-descending 26-28 mm
  • Dilation (Ballooning, Bulging, Ectasia)

  • Aneurysm

    • Types
      • Saccular
      • Fusiform
    • Definition
      • When the diameter exceeds 4 cm or diameter exceeds 1.5 times normal
  • Dissection

    • Tear in vessel wall results in false lumen
    • Types
      • Type A – involves ascending aorta
      • Type B – involves descending aorta
















Thoracic aneurysms

  • Thoracic aneurysms

    • Prevalence greater than 3-4% of those over 65
    • 6 cases per 100,000 person-years
    • Incidence increasing
    • In the top 15 causes of death
    • Thoracic aortic aneurysm – rupture 3.5/100,000 persons
  • Thoracic aortic dissection

    • 2000 new cases/year
    • Acute - 3.5/100,000 persons
    • Male:Female ratio 2:1


Underlying Etiologies

  • Underlying Etiologies

    • Atherosclerosis
    • Marfan’s
    • Type IV Ehlers-Danlos
    • Infection (syphillis)
    • Arteritis (giant cell, Takayasu, Behcet’s)
    • Trauma
  • Risk Factors

    • Smoking
    • COPD
    • HTN
    • Male gender
    • Older age
    • High BMI
    • Abnormal aortic valve (e.g., bicuspid valve)
    • Family history


Aneurysm

  • Aneurysm

    • Most asymptomatic
    • Superior vena cava syndrome
    • Hoarseness
    • Bronchial obstruction
    • Dysphagia
    • Hemoptysis
    • Paralysis/paraplegia
    • Lower extremity embolism
  • Dissection

    • Chest/back/neck pain
    • Neurologic signs
    • Horner syndrome
    • Hoarseness
    • Acute aortic regurgitation


Chest x-ray

  • Chest x-ray

    • Widened mediastinum
  • Echocardiogram

    • Transthoracic – aortic root
    • Transesophageal – ascending and descending
  • Aortography

    • Delineates the lumen
  • CT scan

    • Most widely used diagnostic tool
  • MRI

    • Avoids contrast dye






Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple Prediction Based on Size

  • Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple Prediction Based on Size

    • 304 patients; 58.9% male; median age 65.8
    • Aneurysm size – 43.7% were 4.0-4.9 cm
    • Location – 72% ascending
    • Follow up – average 43.1 months
    • End points


















Medical

  • Medical

    • BP control
    • Smoking cessation
    • No heavy lifting
  • Surgical

    • Dacron tube graft
    • Ascending – may need to replace valve
    • Arch – graft
    • Descending – graft, stent grafts


Type A

  • Type A

    • Surgical
  • Type B

    • Medical
    • Surgical
      • Acute with rupture, leak or distal ischemia.


Aortic size

  • Aortic size

    • Ascending diameter >5.5 cm
    • Descending diameter >6.5 cm
    • Growth rate >1 cm/yr (avg ascending 0.07 cm/yr; descending 0.19 cm/yr)
  • Symptomatic aneurysm

  • Traumatic rupture

  • Pseudoaneurysm

  • Large saccular aneurysm

  • Mycotic aneurysm

  • Aortic coarctation

  • Bronchial compression

  • Aortobronchial or aortoesophageal fistuala





Bleeding

  • Bleeding

  • CVA – 2-5%

  • CHF

  • Respiratory failure

  • Graft leaks

  • Fistula formation

  • Spinal cord damage

  • Renal failure



Aneurysm

  • Aneurysm

    • Early post-op mortality 4-10%; lower for descending aneurysm repair; much higher for aortic arch repair
    • Stroke occurs 2-5%
    • Renal failure requiring dialysis – 7%
    • Spinal cord injury – 3%
  • Dissection

    • Treated 10-yr survival rate 60%
    • Type A
      • 30% mortality surgical
      • 60% mortality medical
    • Type B
      • 10% mortality medical
      • 30% mortality surgical


Obtain cardiology and/or vascular medical records

  • Obtain cardiology and/or vascular medical records

  • Review serial echos/scans as available

  • Review blood pressure control

  • Higher Risk

    • Aneurysm >5 cm
    • Poorly controlled blood pressure
    • Increase in size >0.5 cm/yr
    • Ongoing tobacco usage
    • Associated cardiovascular disease (CAD, PVD, carotid disease)
    • Non-atherosclerotic vascular disorders (Marfan’s, Ehlers-Danlos, etc)
  • Lower Risk

    • Aneurysm <5 cm/stable/ well followed
    • Aneurysm repaired/stable


Thoracic aortic dilation/aneurysm fairly common with age

  • Thoracic aortic dilation/aneurysm fairly common with age

  • Risk factors are traditional cardiovascular risk factors

  • Most are asymptomatic

  • Thoracic aortic rupture rare

  • Thoracic dissection rare

  • Ascending aorta most common site of aneurysm formation

  • Low risk for aneurysms less than 4 cm



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