cardiovascular disorders
Thoracic Aortic Aneurysms
Treatment of Thoracic Aortic Aneurysms
Endovascular stent grafting or open surgical repair Control of hypertension and other comorbidities Immediate control of hypertension is essential. Medical management with optimal control of hypertension, dyslipidemia, diabetes, and respiratory disease is the appropriate treatment until surgery is indicated. Treatment is endovascular stent grafting when anatomically possible and open surgical repair for more complex aneurysms. Ruptured TAAs, if untreated, are universally fatal. They require immediate intervention, as do leaking aneurysms and those that cause acute dissection or acute valvular regurgitation. Transcatheter-placed endovascular stent grafts(endografts) for descending TAAs and TAAAs are a less invasive alternative to open surgery. Surgeryinvolves a median sternotomy (for ascending and aortic arch aneurysms) or left thoracotomy or thoraco-retroperitoneal exposure (for descending and thoracoabdominal aneurysms) and replacement with a synthetic graft. With emergency open surgery, the mortality rate at 1 month is about 40 to 50%. Patients who survive have a high incidence of serious complications (eg, renal failure, respiratory failure, severe neurologic damage). Elective surgery is indicated for aneurysms that are Large Rapidly enlarging (> 0.5 cm/year) Causing bronchial compression Causing aortobronchial or aortoesophageal fistulas Symptomatic Traumatic Mycotic Aneurysms of theascending aortaare generally considered large if the diameter is > 5.5 cm or twice the native size of the ascending aorta or if the aortic size index (aortic diameter in relation to body surface area) is ≥ 2.75 cm/m2. In thedescending aorta,aneurysms are generally considered large if they are > 6 cm. In patients withMarfan syndrome,large aneurysms are those that are ≥ 4.5 to 5 cm in any location. Treatment of mycotic aneurysms is aggressive antibiotic therapy directed at the specific pathogen. Generally, these aneurysms must also be surgically repaired. Although open surgical repair of an intact TAA improves outcome, mortality rate may still exceed 7% at 30 days ( Treatment references ). The mortality rate is lower with endovascular stent grafts, although life-long surveillance is still required ( Asymptomatic aneurysms that do not meet criteria for elective surgical or endovascular repair are treated with aggressive Treatment using a beta-blocker and other antihypertensives if necessary. Patients require frequent follow-ups to check for symptoms and serial CT or ultrasonography every 6 to 12 months. Imaging frequency depends on aneurysm size. 1.Goodney PP, Travis L, Lucas FL, et al. Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population.Circulation2011;124(24):2661-2669. doi:10.1161/CIRCULATIONAHA.111.033944 2.Desai ND, Burtch K, Moser W, et al. Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms.J Thorac Cardiovasc Surg2012;144(3):604-611. doi:10.1016/j.jtcvs.2012.05.049 