This document discusses thoracic aortic aneurysms. It defines a thoracic aneurysm and notes their locations in the aorta. While less common than abdominal aortic aneurysms, thoracic aneurysms carry a high mortality. They develop due to degradation of the tunica media layer of the aorta. Risk factors include family history, hypertension, smoking, and advancing age. Symptoms vary depending on the location but often include chest or back pain. Imaging such as CT scan is used to diagnose. Management involves medical therapy as well as surgical intervention depending on the location and size of the aneurysm.

1. Thoracic aneurysm
Name: Nayana
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2. • An aneurysm is defined as a persistent, abnormal
dilatation of an artery to 1.5 times its normal diameter.
• A thoracic aortic aneurysm can involve the ascending aorta or
aortic root (60%), aortic arch (10%), descending aorta (40%), or
thoracoabdominal aorta (10%) segments*.
• Whilst thoracic aneurysms are less common than abdominal
aortic aneurysms, they are associated with high mortality.
They have an incidence of 6 in 100,000 person-years, with an
increasing prevalence with age.

3. Etiology
•
Thoracic aortic aneurysms develop due to degradation of the tunica media, the
layer of the artery which provides tensile strength and elasticity to the wall.
• As a result, the artery loses structural integrity and dilates, and as the
diameter increases, the wall tension rises and further increases the diameter in a
vicious cycle.
• The main causes of thoracic aneurysm are:
• Connective tissue diseases (e.g. Marfan’s syndrome or Ehlers-Danlos
syndrome)
• Bicuspid aortic valve
• Other causes include trauma, aortic dissection, aortic arteritis (e.g. Takayasu
Arteritis), and tertiary syphilis
• Thoracic aortic aneurysms grow at a mean rate of 1-2mm/year. This rate is higher
in those with Marfan’s syndrome, descending aneurysms (compared to
ascending aneurysms), and a dissected aneurysm (compared to a non-dissected

4. Risk factors
• The main risk factors for developing a thoracic aortic aneurysm
include family
history*, hypertension, atherosclerosis (specifically
descending aneurysms), smoking, high BMI, male
gender, and advancing age.
• *19% of patients have a positive family history

5. Clinical features
• Typically thoracic aneurysms are asymptomatic and are found
incidentally.
• In those that are symptomatic, the most common presenting
complaint is pain, with the location of the pain potentially
localising the aneurysm:

6. • Other symptoms of thoracic aneurysms include:
• Back pain – secondary to spinal compression by descending or
thoracoabdominal aneurysm
• Hoarse voice – from damage to the left recurrent laryngeal nerve in
arch aneurysms
• Distended neck veins – from SVC compression
• Symptoms of heart failure – from involvement of the aortic valve
• Dyspnoea or cough – secondary to tracheal or bronchial
compression
• Clinical signs are not commonly found on examination, however
chronic disease may present with the signs of aortic root disease or
heart failure.
• Thoracic aneurysms have a risk of rupture or dissection, which
are potentially lethal. An acute aortic syndrome will present
with sudden onset pain in the back, chest, neck, and/or abdomen

7. Differential diagnosis
• As thoracic aneurysms are mostly found incidentally on
imaging, other differential diagnosis are rarely considered
before the definitive diagnosis is determined.
• In symptomatic patients, the scope of symptoms for a thoracic
aneurysm is wide. However for those presenting with chest or
back pain (the most common presentation), diagnoses of ACS,
PE, pneumothorax, and aortic dissection should all be
considered.

8. Investigation
• Thoracic aneurysms are diagnosed through imaging. However, initial work-up should
include routine bloods (FBC, U&Es, clotting), an ECG, and a chest radiograph (CXR)
performed.
• Imaging
• Many thoracic aneurysms are first identified as incidental findings on imaging.
• A thoracic aneurysm can be seen on plain film chest radiograph demonstrating a
widened mediastinal silhouette, an enlarged aortic knob, and possible tracheal deviation
(Fig. 3). However, a radiograph is not sensitive enough to make the definitive diagnosis
and further imaging is required
• A CT chest scan with contrast is the preferred imaging modality for thoracic aneurysms,
providing sufficient detail to ascertain the level and the size of the aneurysm*.
• Transoesophageal echocardiography (TOE) can be used to good effect to further detect
any concurrent aortic insufficiency or dissection; TOE should form part of the routine
assessment of patients with Marfan’s disease and suspected thoracic aortic disease.
• *Due to the potentially tortuous nature of the thoracic aorta and the use of axial images in
CT scans, care must be taken to ensure the actual aortic diameter is being measured, not
simply measuring through the aorta off-axis; reconstructing axial imaging into 3D images via
CT angiography or MR angiography can overcome this issue

9. • Management
• Despite limited evidence, patients with a confirmed thoracic
aneurysm should be started on medical management,
alongside any concurrent further investigations and definitive
management planned.
• These patients are at increased cardiovascular risk, therefore
should be initiated on statin and anti-platelet therapy to
decrease the risk of myocardial infarction. Blood pressure
should be controlled and smoking cessation is imperative.
• Surgical Management
• Surgical management is dependent on the location of the
aneurysm, with the threshold for surgery varying according to
the health of the patient. Patients suffering from Marfan’s
syndrome or having a previous thoracic dissection have a
greater risk of dissection and rupture, and threshold levels for
intervention are often lower

10. Abdominal aortic aneurysm

18. Case presentation
History

19. Incidental findings on USG

20. Confirmation CT Finding

21. Additional findings

22. Endovascular Stent graft

23. Post deployment of
graft
Patient needs follow up CT.
Patient needs constant observation .
POSSIBLE Operations in the future.

24. Thank you