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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
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.
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 ..
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
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 tubeNataf P , Lansac E Heart 2006;92:1345-1352 Composite valve and graft replacemen
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 Events No. Patients Dissection, rupture and death 2 Dissection, rupture (no death) 2 Dissection, death (no rupture) 5 Rupture and death (no dissection) 4 Rupture alone 5 Dissection alone 15 Death alone 44Davies RR, et al. Ann Thorac Surg 2002;73:17
Trials and comparisons ENDOVASCULAR STENT GRAFT TRIALS vs OPEN