Anatomy Anatomy

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