SlideShare a Scribd company logo
1 of 39
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
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




Nataf 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                                   44
Davies RR, et al. Ann Thorac Surg 2002;73:17
Trials and comparisons ENDOVASCULAR STENT GRAFT
                   TRIALS vs OPEN
Endovascular Stent Graft
        Repair
HOME MESSEGE


                      REMEMBER

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

More Related Content

What's hot

Endovascular repair of thoracic and abdominal aortic aneurysms
Endovascular repair of thoracic and abdominal aortic aneurysmsEndovascular repair of thoracic and abdominal aortic aneurysms
Endovascular repair of thoracic and abdominal aortic aneurysmsApollo Hospitals
 
Diseases of aorta
Diseases of aortaDiseases of aorta
Diseases of aortaavatar73
 
Cardiac cath complications
Cardiac cath complicationsCardiac cath complications
Cardiac cath complicationsFuad Farooq
 
Constrictive pericarditis
Constrictive pericarditisConstrictive pericarditis
Constrictive pericarditishodmedicine
 
IImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwar
IImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwarIImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwar
IImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwarPrithvi Puwar
 
In stent restenosis
In stent restenosis In stent restenosis
In stent restenosis Sahar Gamal
 
Mitral valve repair and related aspects
Mitral valve repair and related aspectsMitral valve repair and related aspects
Mitral valve repair and related aspectsDheeraj Sharma
 
Diseases of the aorta
Diseases of the aortaDiseases of the aorta
Diseases of the aortaFuad Farooq
 
Mitral valve surgical treatment
Mitral valve surgical treatmentMitral valve surgical treatment
Mitral valve surgical treatmentDR NIKUNJ SHEKHADA
 
Surgical management of tetralogy of fallot
Surgical management of tetralogy of fallotSurgical management of tetralogy of fallot
Surgical management of tetralogy of fallotrahul arora
 

What's hot (20)

Cardiac trauma management
Cardiac trauma managementCardiac trauma management
Cardiac trauma management
 
Aneurysm
AneurysmAneurysm
Aneurysm
 
Endovascular repair of thoracic and abdominal aortic aneurysms
Endovascular repair of thoracic and abdominal aortic aneurysmsEndovascular repair of thoracic and abdominal aortic aneurysms
Endovascular repair of thoracic and abdominal aortic aneurysms
 
Diseases of aorta
Diseases of aortaDiseases of aorta
Diseases of aorta
 
Cardiac cath complications
Cardiac cath complicationsCardiac cath complications
Cardiac cath complications
 
Constrictive pericarditis
Constrictive pericarditisConstrictive pericarditis
Constrictive pericarditis
 
IImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwar
IImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwarIImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwar
IImplantable Cardioverter Defibrillators (ICDs) - Dr Prithvi puwar
 
Cardiac transplantation
Cardiac transplantationCardiac transplantation
Cardiac transplantation
 
In stent restenosis
In stent restenosis In stent restenosis
In stent restenosis
 
Mitral valve repair and related aspects
Mitral valve repair and related aspectsMitral valve repair and related aspects
Mitral valve repair and related aspects
 
Acute Aortic Syndrome
Acute Aortic SyndromeAcute Aortic Syndrome
Acute Aortic Syndrome
 
Diseases of the aorta
Diseases of the aortaDiseases of the aorta
Diseases of the aorta
 
Mitral valve surgical treatment
Mitral valve surgical treatmentMitral valve surgical treatment
Mitral valve surgical treatment
 
Abdominal Aortic Aneurysm
Abdominal Aortic AneurysmAbdominal Aortic Aneurysm
Abdominal Aortic Aneurysm
 
PTMC/PBMC
PTMC/PBMCPTMC/PBMC
PTMC/PBMC
 
HOCM Hypertrophic cardiomyopathy
HOCM Hypertrophic cardiomyopathyHOCM Hypertrophic cardiomyopathy
HOCM Hypertrophic cardiomyopathy
 
Aortic SURGERY Intro
Aortic SURGERY IntroAortic SURGERY Intro
Aortic SURGERY Intro
 
Surgical management of tetralogy of fallot
Surgical management of tetralogy of fallotSurgical management of tetralogy of fallot
Surgical management of tetralogy of fallot
 
Prosthetic valve thrombosis
Prosthetic valve thrombosisProsthetic valve thrombosis
Prosthetic valve thrombosis
 
Abdomianl Aortic Aneurysm (AAA)
Abdomianl Aortic Aneurysm (AAA)Abdomianl Aortic Aneurysm (AAA)
Abdomianl Aortic Aneurysm (AAA)
 

Viewers also liked

Anaesthetic management of Abdominal aortic aneurysms
Anaesthetic management of Abdominal aortic aneurysmsAnaesthetic management of Abdominal aortic aneurysms
Anaesthetic management of Abdominal aortic aneurysmsAbhijit Nair
 
Image of Thoracic Aortic Disease
Image of Thoracic Aortic DiseaseImage of Thoracic Aortic Disease
Image of Thoracic Aortic DiseaseSun Yai-Cheng
 
2010 Guidelines on Thoracic Aortic Disease
2010 Guidelines on Thoracic Aortic Disease2010 Guidelines on Thoracic Aortic Disease
2010 Guidelines on Thoracic Aortic DiseaseSun Yai-Cheng
 
Thoracic aortic aneurysm
Thoracic aortic aneurysmThoracic aortic aneurysm
Thoracic aortic aneurysmFredric Carson
 
Abdominal Aortic Aneurysms
Abdominal Aortic AneurysmsAbdominal Aortic Aneurysms
Abdominal Aortic Aneurysmstgraphos
 

Viewers also liked (7)

Aortic aneurysm imaging
Aortic aneurysm imagingAortic aneurysm imaging
Aortic aneurysm imaging
 
Anaesthetic management of Abdominal aortic aneurysms
Anaesthetic management of Abdominal aortic aneurysmsAnaesthetic management of Abdominal aortic aneurysms
Anaesthetic management of Abdominal aortic aneurysms
 
Image of Thoracic Aortic Disease
Image of Thoracic Aortic DiseaseImage of Thoracic Aortic Disease
Image of Thoracic Aortic Disease
 
2010 Guidelines on Thoracic Aortic Disease
2010 Guidelines on Thoracic Aortic Disease2010 Guidelines on Thoracic Aortic Disease
2010 Guidelines on Thoracic Aortic Disease
 
Thoracic aortic aneurysm
Thoracic aortic aneurysmThoracic aortic aneurysm
Thoracic aortic aneurysm
 
Aortic aneurys mppt
Aortic aneurys mpptAortic aneurys mppt
Aortic aneurys mppt
 
Abdominal Aortic Aneurysms
Abdominal Aortic AneurysmsAbdominal Aortic Aneurysms
Abdominal Aortic Aneurysms
 

Similar to Thoracic aortic aneurysm

Severeasymtomaticas
SevereasymtomaticasSevereasymtomaticas
Severeasymtomaticasescts2012
 
Left-Right Shunt Natural history & Principles of Management
Left-Right ShuntNatural history & Principles of ManagementLeft-Right ShuntNatural history & Principles of Management
Left-Right Shunt Natural history & Principles of Managementdrranjithmp
 
2014session5 3
2014session5 32014session5 3
2014session5 3acvq
 
Aortic abdominal aneurism
Aortic abdominal aneurismAortic abdominal aneurism
Aortic abdominal aneurismTroy Pennington
 
Endovascular management of Aortic Dissection
Endovascular management of Aortic DissectionEndovascular management of Aortic Dissection
Endovascular management of Aortic DissectionSatyam Rajvanshi
 
Repairing Coronary Arteries, pumpsandpipesmdhc
Repairing Coronary Arteries, pumpsandpipesmdhcRepairing Coronary Arteries, pumpsandpipesmdhc
Repairing Coronary Arteries, pumpsandpipesmdhctmhsweb
 
danielle-deady---10-tavr-talk.pptx
danielle-deady---10-tavr-talk.pptxdanielle-deady---10-tavr-talk.pptx
danielle-deady---10-tavr-talk.pptxAsheOP
 
Asd in elderly surgery or leave it alone
Asd in elderly  surgery or leave it aloneAsd in elderly  surgery or leave it alone
Asd in elderly surgery or leave it alonerahul arora
 
Aortic disasters ahmed
Aortic disasters ahmedAortic disasters ahmed
Aortic disasters ahmedEM OMSB
 
Surgery For Aortic Stenosis
Surgery For Aortic StenosisSurgery For Aortic Stenosis
Surgery For Aortic Stenosisdrmaisano
 
Natural history of Pre tricuspid shunts
Natural history of Pre tricuspid shuntsNatural history of Pre tricuspid shunts
Natural history of Pre tricuspid shuntsdrabhishekbabbu
 
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And Training
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And TrainingAortic Aneurysm: Diagnosis, Management, Exercise Testing, And Training
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And TrainingJavidsultandar
 
Natural history of common congenital heart diseases
Natural history of common congenital heart diseasesNatural history of common congenital heart diseases
Natural history of common congenital heart diseasesRamachandra Barik
 
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...ahvc0858
 
Study of 89 Cases of Peripheral Vascular Disease by CT Angiography
Study of 89 Cases of Peripheral Vascular Disease by CT AngiographyStudy of 89 Cases of Peripheral Vascular Disease by CT Angiography
Study of 89 Cases of Peripheral Vascular Disease by CT AngiographyM A Hasnat
 
Cardiovasc j20113(2)155 162
Cardiovasc j20113(2)155 162Cardiovasc j20113(2)155 162
Cardiovasc j20113(2)155 162DrMAHasnat
 

Similar to Thoracic aortic aneurysm (20)

Severeasymtomaticas
SevereasymtomaticasSevereasymtomaticas
Severeasymtomaticas
 
Left-Right Shunt Natural history & Principles of Management
Left-Right ShuntNatural history & Principles of ManagementLeft-Right ShuntNatural history & Principles of Management
Left-Right Shunt Natural history & Principles of Management
 
Crest
CrestCrest
Crest
 
Blister Aneurysms
Blister Aneurysms Blister Aneurysms
Blister Aneurysms
 
2014session5 3
2014session5 32014session5 3
2014session5 3
 
Atrial septal defects
Atrial septal defectsAtrial septal defects
Atrial septal defects
 
Aortic abdominal aneurism
Aortic abdominal aneurismAortic abdominal aneurism
Aortic abdominal aneurism
 
Endovascular management of Aortic Dissection
Endovascular management of Aortic DissectionEndovascular management of Aortic Dissection
Endovascular management of Aortic Dissection
 
Repairing Coronary Arteries, pumpsandpipesmdhc
Repairing Coronary Arteries, pumpsandpipesmdhcRepairing Coronary Arteries, pumpsandpipesmdhc
Repairing Coronary Arteries, pumpsandpipesmdhc
 
danielle-deady---10-tavr-talk.pptx
danielle-deady---10-tavr-talk.pptxdanielle-deady---10-tavr-talk.pptx
danielle-deady---10-tavr-talk.pptx
 
Asd in elderly surgery or leave it alone
Asd in elderly  surgery or leave it aloneAsd in elderly  surgery or leave it alone
Asd in elderly surgery or leave it alone
 
Aortic disasters ahmed
Aortic disasters ahmedAortic disasters ahmed
Aortic disasters ahmed
 
Surgery For Aortic Stenosis
Surgery For Aortic StenosisSurgery For Aortic Stenosis
Surgery For Aortic Stenosis
 
Estenose c
Estenose cEstenose c
Estenose c
 
Natural history of Pre tricuspid shunts
Natural history of Pre tricuspid shuntsNatural history of Pre tricuspid shunts
Natural history of Pre tricuspid shunts
 
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And Training
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And TrainingAortic Aneurysm: Diagnosis, Management, Exercise Testing, And Training
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And Training
 
Natural history of common congenital heart diseases
Natural history of common congenital heart diseasesNatural history of common congenital heart diseases
Natural history of common congenital heart diseases
 
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
 
Study of 89 Cases of Peripheral Vascular Disease by CT Angiography
Study of 89 Cases of Peripheral Vascular Disease by CT AngiographyStudy of 89 Cases of Peripheral Vascular Disease by CT Angiography
Study of 89 Cases of Peripheral Vascular Disease by CT Angiography
 
Cardiovasc j20113(2)155 162
Cardiovasc j20113(2)155 162Cardiovasc j20113(2)155 162
Cardiovasc j20113(2)155 162
 

More from Ahmed Almumtin

Approach to Trauma in Urology
 Approach to Trauma in Urology Approach to Trauma in Urology
Approach to Trauma in UrologyAhmed Almumtin
 
Meconium ileus surgical management
Meconium ileus surgical managementMeconium ileus surgical management
Meconium ileus surgical managementAhmed Almumtin
 
Obstructive jaundice management
Obstructive jaundice managementObstructive jaundice management
Obstructive jaundice managementAhmed Almumtin
 
Surgical anatomy of breasts
Surgical anatomy of breastsSurgical anatomy of breasts
Surgical anatomy of breastsAhmed Almumtin
 
Pilonidal sinus defect closure, reconstruction methods
Pilonidal sinus defect closure, reconstruction methodsPilonidal sinus defect closure, reconstruction methods
Pilonidal sinus defect closure, reconstruction methodsAhmed Almumtin
 
Wounds in forensic medicine
Wounds in forensic medicineWounds in forensic medicine
Wounds in forensic medicineAhmed Almumtin
 
Blood spatter analysis
Blood spatter analysisBlood spatter analysis
Blood spatter analysisAhmed Almumtin
 
Surgical drains, tube, catheters and central lines
Surgical drains, tube, catheters and central linesSurgical drains, tube, catheters and central lines
Surgical drains, tube, catheters and central linesAhmed Almumtin
 
Overview management of postpartum haemorrhage
Overview management of postpartum haemorrhageOverview management of postpartum haemorrhage
Overview management of postpartum haemorrhageAhmed Almumtin
 
an Approach to Dyspepsia
an Approach to Dyspepsiaan Approach to Dyspepsia
an Approach to DyspepsiaAhmed Almumtin
 
orthopedic and rheumatologic disorders of the knee joint
orthopedic and rheumatologic disorders of the knee jointorthopedic and rheumatologic disorders of the knee joint
orthopedic and rheumatologic disorders of the knee jointAhmed Almumtin
 
regional anesthesia and beir block
regional anesthesia and beir blockregional anesthesia and beir block
regional anesthesia and beir blockAhmed Almumtin
 

More from Ahmed Almumtin (19)

Approach to Trauma in Urology
 Approach to Trauma in Urology Approach to Trauma in Urology
Approach to Trauma in Urology
 
Meconium ileus surgical management
Meconium ileus surgical managementMeconium ileus surgical management
Meconium ileus surgical management
 
Obstructive jaundice management
Obstructive jaundice managementObstructive jaundice management
Obstructive jaundice management
 
Surgical anatomy of breasts
Surgical anatomy of breastsSurgical anatomy of breasts
Surgical anatomy of breasts
 
Pilonidal sinus defect closure, reconstruction methods
Pilonidal sinus defect closure, reconstruction methodsPilonidal sinus defect closure, reconstruction methods
Pilonidal sinus defect closure, reconstruction methods
 
Carcinoid Tumour
Carcinoid TumourCarcinoid Tumour
Carcinoid Tumour
 
Arrhythmia
ArrhythmiaArrhythmia
Arrhythmia
 
Refractive errors
Refractive errorsRefractive errors
Refractive errors
 
Otitis externa
Otitis externaOtitis externa
Otitis externa
 
Wounds in forensic medicine
Wounds in forensic medicineWounds in forensic medicine
Wounds in forensic medicine
 
Blood spatter analysis
Blood spatter analysisBlood spatter analysis
Blood spatter analysis
 
Surgical drains, tube, catheters and central lines
Surgical drains, tube, catheters and central linesSurgical drains, tube, catheters and central lines
Surgical drains, tube, catheters and central lines
 
Overview management of postpartum haemorrhage
Overview management of postpartum haemorrhageOverview management of postpartum haemorrhage
Overview management of postpartum haemorrhage
 
an Approach to Dyspepsia
an Approach to Dyspepsiaan Approach to Dyspepsia
an Approach to Dyspepsia
 
orthopedic and rheumatologic disorders of the knee joint
orthopedic and rheumatologic disorders of the knee jointorthopedic and rheumatologic disorders of the knee joint
orthopedic and rheumatologic disorders of the knee joint
 
regional anesthesia and beir block
regional anesthesia and beir blockregional anesthesia and beir block
regional anesthesia and beir block
 
Psychotic disorders
Psychotic disordersPsychotic disorders
Psychotic disorders
 
Acute appendicitis
Acute appendicitisAcute appendicitis
Acute appendicitis
 
Anatomy of appendix
Anatomy of appendixAnatomy of appendix
Anatomy of appendix
 

Recently uploaded

Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersBook Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersnarwatsonia7
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi NcrDelhi Call Girls
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...saminamagar
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...rajnisinghkjn
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingArunagarwal328757
 
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi NcrDelhi Call Girls
 
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxDr.Nusrat Tariq
 
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...narwatsonia7
 
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdfHemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdfMedicoseAcademics
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbaisonalikaur4
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Modelssonalikaur4
 
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...narwatsonia7
 
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls ServiceCall Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Servicesonalikaur4
 
97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAAjennyeacort
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...rajnisinghkjn
 
Radiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptxRadiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptxDr. Dheeraj Kumar
 
Call Girls Service in Budigere - 7001305949 | 24x7 Service Available Near Me
Call Girls Service in Budigere - 7001305949 | 24x7 Service Available Near MeCall Girls Service in Budigere - 7001305949 | 24x7 Service Available Near Me
Call Girls Service in Budigere - 7001305949 | 24x7 Service Available Near Menarwatsonia7
 
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 

Recently uploaded (20)

Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbersBook Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, Pricing
 
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
 
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptx
 
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
 
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdfHemostasis Physiology and Clinical correlations by Dr Faiza.pdf
Hemostasis Physiology and Clinical correlations by Dr Faiza.pdf
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
 
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
 
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls ServiceCall Girls Thane Just Call 9910780858 Get High Class Call Girls Service
Call Girls Thane Just Call 9910780858 Get High Class Call Girls Service
 
97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
 
Radiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptxRadiation Dosimetry Parameters and Isodose Curves.pptx
Radiation Dosimetry Parameters and Isodose Curves.pptx
 
Call Girls Service in Budigere - 7001305949 | 24x7 Service Available Near Me
Call Girls Service in Budigere - 7001305949 | 24x7 Service Available Near MeCall Girls Service in Budigere - 7001305949 | 24x7 Service Available Near Me
Call Girls Service in Budigere - 7001305949 | 24x7 Service Available Near Me
 
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in munirka  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in munirka DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 

Thoracic aortic aneurysm

  • 1. Thoracic Aortic Aneurysm Al-Momtan, Ahmed Tahir B. E-6 Dr. Emad Hijazi
  • 2. 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
  • 3. Further anatomy  Shapes of aneurysms
  • 5.
  • 6.
  • 7. Hager A. et al.; J Thorac Cardiovasc Surg 2002;123:1060-1066
  • 10. 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
  • 11. 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…..)
  • 12. Facts!  13% have multiple  20-25% with TA have and AAA.
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. Contraindications for surgery  Patients who have high morbidity and mortality; eg elderly with ESRD, respi insufficiency, cirhosis..  For descending ..ENDOVASCULAR stenting ..  F/U ..
  • 17. Investingations  Lab: - CBC, Electrolytes, KFT, PT, PTT, INR, BG , XM, LFT, amylase and lactate.  Imaging - Next slide..
  • 18. Diagnosis  CXR (aneurysm vs tortuous aorta) – 61%  Echo – TTE vs TEE  CT-contrast  MRI  Contrast Angiography  ECG  Cath?
  • 19. CXR
  • 22.
  • 24.
  • 25.
  • 28. Treatment and Management  Medical - Control HTN - Smoking cessation - Control other risk factors..
  • 29. 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.
  • 30. Surgical Summary  Dacron tube graft  Ascending – may need to replace valve  Arch – graft  Descending – graft, stent grafts
  • 31. 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
  • 32. 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!
  • 33. Dacron tube Nataf P , Lansac E Heart 2006;92:1345-1352 Composite valve and graft replacemen
  • 34. 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 44 Davies RR, et al. Ann Thorac Surg 2002;73:17
  • 35. Trials and comparisons ENDOVASCULAR STENT GRAFT TRIALS vs OPEN
  • 37.
  • 38. HOME MESSEGE REMEMBER In the end, it’s not what you call it………it’s size that matters!
  • 39. Thank you ..

Editor's Notes

  1. Diameter of the thoracic aorta 1.5 times greater than normal (or larger)Thoracoabdominal aneurysms, comprising approximately 10% of thoracic aneurysms, may be repaired with the use of a partial bypass of the left atrium to the femoral artery
  2. Fusiform when the whole circumference is affected (ture)Saccular when only part of the circumference is involved. (false)
  3. Aneurysms of the thoracic aorta can be classified into four general anatomic categories, although some aneurysms involve more than one segment [2]:Ascending aortic aneurysms arise anywhere from the aortic valve to the innominate artery — 60 percentAortic arch aneurysms include any thoracic aneurysm that involves the brachiocephalic vessels — 10 percentDescending aortic aneurysms distal to the left subclavian artery — 40 percentThoracoabdominalaneurysms — 10 percent
  4. According to the Crawford classification,a type I aneurysm originates distal to the left subclavian artery and involves the visceral arteries. Type II involves the entire aorta distal to the left subclavian artery; type III involves the distal half of the descending thoracic aorta and the entire abdominal aorta; andtype IV involves the infradiaphragmatic aorta. Types I and II are associated with the highest rates of mortality and paraplegia
  5. 1.Death from aneurysmal rupture is one of the 15 leading causes of death in most series. 3.. due to an increase in diagnosis based on the widespread use of imaging techniques4.. The prevalence of fatal and nonfatal rupture has also increased..5. Male to female 2-4:1
  6. Aging results in changes in collagen and elastin.which lead to weakening of the aortic wall and aneurysmal dilation.According to the law of Laplace, luminal dilation results in increased wall tension and the vicious cycle of progressive dilation and greater wall stressArteriosclerotic (degenerative) disease is the most common cause of thoracic aneurysms.A previous aortic dissection with a persistent false channel.may produce aneurysmal dilation; such aneurysms are the second most common type. False aneurysms are more common in the descending aorta and arise from the extravasation of blood into a tenuous pocket contained by the aortic adventitia. Because of increasing wall stress, false aneurysms tend to enlarge over time5. Authorities strongly agree that genetics play a role in the formation of aortic aneurysms. Of first-degree relatives of patients with aortic aneurysms, 15% have an aneurysm .. This appears especially true in first-degree relatives of female patients with aortic aneurysm6.- Marfan syndrome is a potentially lethal connective-tissue disease characterized by skeletal, heart valve, and ocular abnormalities. Individuals with this disease are at risk for aneurysmal degeneration, especially in the thoracic aorta. Marfan syndrome is an autosomal dominant genetic condition that results in abnormal fibrillin, a structural protein found in the human aorta- Ehlers Danols type IV Type IV Ehlers-Danlos syndrome results in a deficiency in the production of type III collagen, and individuals with this disease may develop aneurysms in any portion of the aorta. Imbalances in the synthesis and degradation of structural proteins of the aorta have also been discovered, which may be inherited or spontaneous mutations.7. Atherosclerosis may play a role. Whether atherosclerosis contributes to the formation of an aneurysm or whether they occur concomitantly is not established. 8. Other causes of aortic aneurysms are infection (ie, bacterial [mycotic or syphilitic]), arteritis (ie, giant cell, Takayasu, Kawasaki, Behçet), and trauma. Aortitis due to granulomatous disease is rare, but it can lead to the formation of aortic and, on occasion, pulmonary artery aneurysms. Aortitis caused by syphilis may cause destruction of the aortic media followed by aneurysmal dilation. 9. The true etiology of aortic aneurysms is probably multifactorial, and the condition occurs in individuals with multiple risk factors. Risk factors include smoking, chronic obstructive pulmonary disease (COPD), hypertension, atherosclerosis, male gender, older age, high BMI, bicuspid or unicuspid aortic valves, genetic disorders, and family history. Aortic aneurysms are more common in men than in women and are more common in persons with COPD than in those without lung disease. 
  7. AR=Aortic regurge
  8. -These recommendations are based on the finding that the incidence of complications (rupture and dissection) exponentially increased when the size of the ascending aorta reached 6.0 cm (31% risk of complications) or when the size of the descending aorta reached 7.0 cm (43% risk)Symptomatic patients should undergo aneurysm resection regardless of size. Acutely symptomatic patients require emergent operation. Emergent operation is indicated in the setting of acute rupture. Rupture of the ascending aorta may occur into the pericardium, resulting in acute tamponade. Rupture of the descending thoracic aorta may cause a left hemothorax.Patients who undergo surgery for symptomatic aortic insufficiency or stenosis with an associated enlarged aneurysmal aorta should have concomitant aortic replacement if the aorta reaches 5 cm in diameter. Concomitant aortic replacement should be consider for patients with bicuspid aortic valves with an aorta &gt;4.5 cm in diameter.
  9. No absolute, mostly relative constrictions. Indivisualised, pt ability to have a major surgeryRisk/benefit ratioEndovascular stent grafting is less invasive is ideal alternative to open repair in these patientsPatients must understand that life-long follow-up is required and that long-term durability is unknown. 
  10. Chest radiographIn the case of ascending aortic aneurysms, chest x-rays may reveal a widened mediastinum, a shadow to the right of the cardiac silhouette, and convexity of the right superior mediastinum. Lateral films demonstrate loss of the retrosternal air space. However, the aneurysms may also be completely obscured by the heart, and the chest x-ray appear normal.Plain chest radiographs may show a shadow anteriorly and slightly to the left for arch aneurysms and posteriorly and to the left for descending thoracic aneurysms. Aortic calcification may outline the borders of the aneurysm in the anterior, posterior, and lateral views in both the chest and abdomen.EchocardiographyTransthoracic echocardiography demonstrates the aortic valve and proximal aortic root. It may help detect aortic insufficiency and aneurysms of the sinus of Valsalva, but it is less sensitive and specific than transesophageal echocardiography.Transesophageal echocardiography images show the aortic valve, ascending aorta, and descending thoracic aorta, but they are limited in the area of the distal ascending aorta, transverse aortic arch, and upper abdominal aorta. Transesophageal echocardiography can help accurately differentiate aneurysm and dissection, but the images must be obtained and interpreted by skilled personnel.Ischemia may be evaluated using dipyridamole-thallium or dobutamine echocardiography scans.UltrasonographyInfrarenal abdominal aortic aneurysms may be visualized using ultrasonography, but these images do not help define the extent for thoracoabdominal aneurysms.Carotid ultrasound may be needed for patients with carotid bruits, peripheral vascular disease, a history of transient ischemic attacks, or cerebrovascular accidents to evaluate for carotid disease.Intraoperative intravascular ultrasound (IVUS) can also be used to provide additional anatomical information and guidance during placement of endovascular stents.Intraoperative epiaortic ultrasound can be performed to scan the aorta for atherosclerotic disease or thrombus.For more information, see Bedside Ultrasonography, Abdominal Aortic Aneurysm.AortographyAortography images can delineate the aortic lumen, and they can help define the extent of the aneurysm, any branch vessel involvement, and the stenosis of branch vessels. It describes the takeoff of the coronary ostia.For patients older than 40 years or those with a history suggestive of coronary artery disease, aortography helps evaluate coronary anatomy, ventricular function by ventriculography, and aortic insufficiency. It does not help in defining the size of the aneurysm because the outer diameter is not measured, which may miss dissections.Disadvantages include the use of nephrotoxic contrast and radiation. The risk of aortography includes embolization from laminated thrombus and carries a 1% stroke risk.Computed tomography scanCT scans with contrast have become the most widely used diagnostic tool. They rapidly and precisely evaluate the thoracic and abdominal aorta to determine the location and extent of the aneurysm and the relationship of the aneurysm to major branch vessels and surrounding structures. They can help accurately determine the size of the aneurysm and assesses dissection, mural thrombus, intramural hematoma, free rupture, and contained rupture with hematoma.Sagittal, coronary, and axial images may be obtained with 3-dimensional reconstruction. Stent graft planning for endovascular descending thoracic aneurysm repairs requires fine-cut images from the neck through the pelvis to the level of the femoral heads. The takeoff of the arch vessels is critical to determine the adequacy of the proximal landing zone, as is assessing the patency of the vertebral arteries, if the left subclavian artery should be covered by the stent graft. Assessment of the common femoral artery access is essential to determine the feasibility of large-bore sheath access. A spiral CT scan with 1-mm cuts and 3-dimensional reconstruction with the ability to make centerline measurements is crucial to stent graft planning.Aortic size on imaging is widely used to guide clinical decision making in regards to patients who have thoracic aortic aneurysms. It has been found that the double-oblique plane yields improved agreement with planimetry and differed from the axial plane in proportion to aortic geometric obliquity; therefore, the double-oblique measurement is recommended.[19]CT angiography may create multiplanar reconstructions and cines. This requires nephrotoxic contrast and radiation, but the procedure is noninvasive.Magnetic resonance imagingMRI and magnetic resonance angiography have the advantage of avoiding nephrotoxic contrast and ionizing radiation compared with CT scans.MRI and magnetic resonance angiography can also help accurately demonstrate the location, extent, and size of the aneurysm and its relationship to branch vessels and surrounding organs. These studies also precisely reveal aortic composition. However, they are more time consuming, less readily available, and more expensive than CT scans.Other TestsElectrocardiogram: Baseline ECG should be performed. Transthoracic echocardiograms noninvasively screen for valvular abnormalities and cardiac function.Diagnostic ProceduresCardiac catheterization: Patients with a history of coronary artery disease or those older than 40 years should undergo cardiac catheterization.Histologic FindingsHistologic findings may include elastic fiber fragmentation, loss of elastic fibers, loss of smooth muscle cells, cystic medial necrosis, intraluminal thrombus, and atherosclerotic plaque and ulceration.
  11. Chest radiograph showing widening of the superior mediastinum.
  12. Computed tomography scan depicting a descending thoracic aortic aneurysm with mural thrombus at the level of the left atrium.
  13. Ascending aortogram showing ascending aortic aneurysm. The patient also underwent computed tomography scanning.
  14. Computed tomography scan from a patient whose ascending aortogram showed an ascending aortic aneurysm.
  15. A contrast enhanced CT demonstrating a large thoracic aneurysm of about 7 cm which has rupturedAtherosclerotic vascular dis-ease in an aortic aneurysm. Axial postcontrast image (window = 440, level = 40) reveals a large contrast collection projecting from the undersurface of the aortic arch, consistent with aneurysm (arrow). the low attention material within the aneurysm represents thrombus
  16. Ruptured thoracic aortic aneurysm resulting in cutaneous haematoma
  17. Chest radiograph in a patient with a thoracic aortic aneurysm following aneurysm surgery.
  18. Descending thoracic aneurysms with the appropriate anatomy may now be repaired by endovascular stent grafts. The GORE TAG is an FDA-approved nitinol-based stent graft designed for descending thoracic aneurysm repair. An appropriate proximal neck of 2 cm prior to the aneurysm is required. Ideally, the proximal landing zone is beyond the left subclavian artery, though, in some circumstances, the stent may be placed proximal to the left subclavian artery. Distally, a sufficient landing zone of 2 cm prior to the celiac artery is required. The aortic inner neck diameters in the proximal and distal landing zones must fall within 23-37 mm. In addition, appropriately sized femoral and iliac arteries (typically &gt;8 mm in diameter) that lack tortuosity and calcium are required for implantation. The GORE TAG graft has been FDA-approved since March 2005.[12] More recently, the Zenith TX2 endovascular graft (Cook Medical Inc.; Bloomington, Ind) was approved in March 2008, followed by the Talent Thoracic Stent Graft (Medtronic Inc.; Minneapolis, Minn) in June 2008.[31, 32] The Valiant Thoracic Stent Graft (Medtronic Inc.; Minneapolis, Minn) is approved for use outside the United States.-------- Thoracoabdominal aneurysms, comprising approximately 10% of thoracic aneurysms, may be repaired with the use of a partial bypass of the left atrium to the femoral artery. Crawford type I thoracoabdominal aneurysms involve Dacron graft replacement of the aorta from the left subclavian artery to the visceral and renal arteries as a beveled distal anastomosis, using sequential cross-clamping of the aorta. Crawford type II thoracoabdominal aneurysm repair requires a Dacron graft from the left subclavian to the aortic bifurcation with reattachment of the intercostal arteries, visceral arteries, and renal arteries. Crawford type III or IV thoracoabdominal aneurysm repairs, which begin lower along the thoracic aorta or upper abdominal aorta, may use either the partial bypass of the left atrial artery to the femoral artery or a modified atrio-visceral and/or renal bypass. Prevention of paraplegia is one of the principal concerns in the repair of descending and thoracoabdominal aneurysms.Brain protectionMethods used for brain protection during deep hypothermic circulatory arrest (DHCA) include intraoperative EEG monitoring, evoked somatosensory potential monitoring, hypothermia (to temperatures &lt; 20o C), packing the patient&apos;s head in ice, Trendelenburg positioning (ie, head down), mannitol, CO2 flooding, thiopental, steroids, and antegrade and retrograde cerebral perfusion.