Thoracic Aortic Aneurysm

Al-Momtan, Ahmed Tahir B.E-6

Dr. Emad Hijazi

Background

Anatomy and cardiac skeleton Histology of Blood vessels What is an aneurysm? And whats

TAA? True vs False aneurysms Thoracic vs Abdominal Classification of thoracic aortic

aneurysms Dissection .. Little talk.. Ayaman

Further anatomy

Shapes of aneurysms

Anatomy

Hager A. et al.; J Thorac Cardiovasc Surg 2002;123:1060-1066

Classification

Crawford clssification

Epidemiology

Prevalence greater than 3-4%of those over 65 years.

6th-7th ..decade The estimated incidence of thoracic aortic

aneurysms is 6 cases per 100,000 person-years. The overall prevalence of aortic aneurysms has

increased significantly in the last 30 years..Causes?

The prevalence of fatal and nonfatal rupture has also increased..

Males > females

Aetiology

Aging population..Laplace law Arteriolosclerosis and HTN (60%) Smoking A previous aortic dissection with a persistent false

channel. trauma False aneurysms Genetics (19%), CT, Females --FHx Connective tissue; Marfan’s (young), Ehler Danols. ATHEROSCLEROSIS! Does it? Bicuspid AV (52% have TA) Others; infxn, arteritis, trauma, aortitis Multifactorial? With risk factors (smoking, COPD high

BMI…..)

Facts!

13% have multiple 20-25% with TA have and AAA.

Presentation

Range.. Asymptomatic ..Mostly..thoracic Pain? Exp.. Acute vs chronic,, Location? SVC Obstruction Tymponade Sx and Symptoms Murmurs, pulse pressure (Acute AR) Voice changes? Dyspnoea, stridor, wheezes, cough.. Dysphagia, Haemoptysis, haematemesis Back pain Paraparesiss, paraplegia Distal embolic disease Echymoses, petaechiae Life threatening

Indications for surgery

Elefteriades: (size)- 5.5 ascending aneurysms- No FHx e.g Marfan’s (5)- 6.5 descending aneurysms-No FHx (6)

aortic aneurysm size in relation to body surface- ASI (aortic diameter in cm / body surface area (m2) --Risk

- ASI < 2.75 cm/m2 low risk (4%/y)- ASI 2.75-4.25 cm/m2 moderate (8%/y)- ASI > 4.25 cm/m2 high risk (20-25%)

Rapid expansion ( Growth rate)- 0.07 cm/y asc- 0.19 cm/y desc- If > 1cm/y >> repair!

Symptomatic patients

Summary of indcations

Aortic size Ascending aortic diameter ≥5.5 cm or twice the diameter of the normal

contiguous aorta Descending aortic diameter ≥6.5 cm Subtract 0.5 cm from the cutoff measurement in the presence of Marfan

syndrome, family history of aneurysm or connective tissue disorder, bicuspid aortic valve, aortic stenosis, dissection, patient undergoing another cardiac operation

Growth rate ≥1 cm/y Symptomatic aneurysm Traumatic aortic rupture Acute type B aortic dissection with associated rupture, leak, distal ischemia Pseudoaneurysm Large saccular aneurysm Mycotic aneurysm Aortic coarctation Bronchial compression by aneurysm Aortobronchial or aortoesophageal fistula Relevant Anatomy

Contraindications for surgery

Patients who have high morbidity and mortality; eg elderly with ESRD, respi insufficiency, cirhosis..

For descending ..ENDOVASCULAR stenting ..

F/U ..

Investingations

Lab:- CBC, Electrolytes, KFT, PT, PTT, INR,

BG, XM, LFT, amylase and lactate. Imaging

- Next slide..

Diagnosis

CXR (aneurysm vs tortuous aorta) – 61%

Echo – TTE vs TEE CT-contrast MRI Contrast Angiography ECG Cath?

CXR

CT-contrast

Ascending aortogram

http://www.medscape.com/viewarticle/406630_15

Post-Op

Appreciate it?

Treatment and Management

Medical- Control HTN- Smoking cessation- Control other risk factors..

Surgical

- Depends on the location, the extension, the patient comorbidities, the age, the staff, and the hospital setup!

- Principally; TEE is needed for assessment of coronary artery bypass grafting!, the patient need of valve replacement or if the patients need valve sparing procedures.

- Aortic arch aneurysms; comorbidities; neurologic injury (permenant), steroids are given at the onset of procedure if hypothermic circulatory aarrest is anticipated

- Descending aneurysms; spinal complications, paraplagia, paraparessis– spinal arteriograms for reimplantation of Adankiewics artery!

- Brain protection, DHCA, and intraoperative EEG monitoring, pacjing the patients head in ice, trendelenburg position, mannitol, CO2 flooding, thiopental, steroids, antergrade and retrograde cerebral perfusion.

Surgical Summary

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

Follow-up

Development of another aneurysm postoperatively is not uncommon!

Serial evaluations (CT, MRI –for ascending, arch or descending, echo for ascending) may be performed 3-6 months in 1st post-op year, and every 6 months thereafter.

There was a difference in female and male patients undergoing thoracic endo repairs, FDA approved, females had higher rates of procedural complications, requiring more blood transfusions, longer hospital stay, more major adverse events after 30 days! BUT they are more often have successful

treatment at 1 year F/U!

Outcome and prognosis

Early hospital mortality following Asc TAA is 4-10%, stroke in 2-5% Arch aneurysms; mortality is 6-12%,, stroke 3-22%, renal failure

requiring dialysis is 7% Descending; mortality is 12-15%

overall; survivial rate is 60% at 5 years and 30-40% at 10 years Endovascular stenting stent grafting vs open surgery mortality is

3% and 14%, and operative mortality was 1% vs 6% Endovascular achieved shorter hospital stay, quicker recovery time

and lower incidence of major adverse effects (except vascular compications.

Endovascular complications at 2 years, 4% proximal stent migration, 6% migration of graft components and 15% had an endoleak!

Survival rates between Endo and open groups are almost the same aat 2 years and 5 years (80% and 70%), no difference in rates of paraplagia!

Dacron tube

 Composite valve and graft replacement.Nataf P , Lansac E Heart 2006;92:1345-1352

Natural History

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

Davies RR, et al. Ann Thorac Surg 2002;73:17

44Death alone15Dissection alone5Rupture alone4Rupture and death (no dissection)5Dissection, death (no rupture)2Dissection, rupture (no death)2Dissection, rupture and deathNo. PatientsEvents

Trials and comparisons ENDOVASCULAR STENT GRAFT TRIALS vs OPEN

Endovascular Stent Graft Repair

HOME MESSEGE

In the end, it’s not what you call it………it’s size that matters!

REMEMBER

Thank you ..