J Korean Med Assoc.  2014 Dec;57(12):1014-1025. 10.5124/jkma.2014.57.12.1014.

Diagnosis and treatment of thoracic aortic aneurysm

• Moon J
• Hong YS

• KMID: 1736630
• DOI: http://doi.org/10.5124/jkma.2014.57.12.1014

Abstract

Thoracic aortic aneurysm (TAA) is the most common pathology of the thoracic aorta. The incidence of TAA is increasing and the true incidence of TAA is likely to be higher than currently reported because of its inherently silent nature. TAAs are an increasingly recognized condition that is diagnosed incidentally on imaging studies performed to evaluate unrelated conditions because most patients with TAA have no symptoms. TAAs normally grow in an indolent manner, but can become rapidly lethal once dissection or rupture occurs. Indeed, aortic aneurysms (both abdominal and thoracic) represent the 15th leading cause of death in individuals older than 55 years, and the 19th leading cause of death in individuals of all ages in the United States. The etiologies underlying TAAs are diverse. Therefore, the evaluation and management of TAAs are complex. The present review summarizes the knowledge of the pathophysiology, natural history and diagnostic modalities, as well as current treatment strategies of TAA on the basis of current literature.

Keyword

Aortic aneurysm; Treatment; Prognosis

MeSH Terms

Aorta, Thoracic
Aortic Aneurysm
Aortic Aneurysm, Thoracic*
Cause of Death
Diagnosis*
Humans
Incidence
Natural History
Pathology
Prognosis
Rupture
United States

Figure

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  Figure 1 Aorta anatomy.

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  Figure 2 Thoracoabdominal aortic aneurysm classification.

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  Figure 3 Surgical approach based on the level of thoracic aortic aneurysm.

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  Figure 4 Surgical approach based on the level of thoracoabdominal aortic aneurysm.

Reference

1. Clouse WD, Hallett JW Jr, Schaff HV, Gayari MM, Ilstrup DM, Melton LJ 3rd. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA. 1998; 280:1926–1929.

2. Hannuksela M, Lundqvist S, Carlberg B. Thoracic aorta: dilated or not? Scand Cardiovasc J. 2006; 40:175–178.

3. Hager A, Kaemmerer H, Rapp-Bernhardt U, Blucher S, Rapp K, Bernhardt TM, Galanski M, Hess J. Diameters of the thoracic aorta throughout life as measured with helical computed tomography. J Thorac Cardiovasc Surg. 2002; 123:1060–1066.

4. Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollirer L, Stanley JC. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. Suggested standards for reporting on arterial aneurysms. J Vasc Surg. 1991; 13:452–458.

5. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. American Association for Thoracic Surgery. American College of Radiology. American Stroke Association. Society of Cardiovascular Anesthesiologists. Society for Cardiovascular Angiography and Interventions. Society of Interventional Radiology. Society of Thoracic Surgeons. Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010; 121:e266–e369.

6. Coady MA, Rizzo JA, Hammond GL, Mandapati D, Darr U, Kopf GS, Elefteriades JA. What is the appropriate size criterion for resection of thoracic aortic aneurysms? J Thorac Cardiovasc Surg. 1997; 113:476–491.

7. Albornoz G, Coady MA, Roberts M, Davies RR, Tranquilli M, Rizzo JA, Elefteriades JA. Familial thoracic aortic aneurysms and dissections: incidence, modes of inheritance, and phenotypic patterns. Ann Thorac Surg. 2006; 82:1400–1405.

8. Johansson G, Markstrom U, Swedenborg J. Ruptured thoracic aortic aneurysms: a study of incidence and mortality rates. J Vasc Surg. 1995; 21:985–988.

9. Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002; 74:S1877–S1880.

10. Elefteriades JA, Farkas EA. Thoracic aortic aneurysm clinically pertinent controversies and uncertainties. J Am Coll Cardiol. 2010; 55:841–857.

11. Dobrin PB, Mrkvicka R. Failure of elastin or collagen as possible critical connective tissue alterations underlying aneurysmal dilatation. Cardiovasc Surg. 1994; 2:484–488.

12. Halloran BG, Davis VA, McManus BM, Lynch TG, Baxter BT. Localization of aortic disease is associated with intrinsic differences in aortic structure. J Surg Res. 1995; 59:17–22.

13. Allaire E, Forough R, Clowes M, Starcher B, Clowes AW. Local overexpression of TIMP-1 prevents aortic aneurysm degeneration and rupture in a rat model. J Clin Invest. 1998; 102:1413–1420.

14. Cronenwett JL, Johnston KW, Rutherford RB. Rutherford's vascular surgery. 7th ed. Philadelphia: Saunders;2010.

15. Guo DC, Pannu H, Tran-Fadulu V, Papke CL, Yu RK, Avidan N, Bourgeois S, Estrera AL, Safi HJ, Sparks E, Amor D, Ades L, McConnell V, Willoughby CE, Abuelo D, Willing M, Lewis RA, Kim DH, Scherer S, Tung PP, Ahn C, Buja LM, Raman CS, Shete SS, Milewicz DM. Mutations in smooth muscle alpha-actin (ACTA2) lead to thoracic aortic aneurysms and dissections. Nat Genet. 2007; 39:1488–1493.

16. Suzuki R, Mikamo A, Kurazumi H, Sato M, Ikeda Y, Shirasawa B, Hamano K. Familial aortic dissection of non-Marfan syndrome with mutations in the transforming growth factor-beta receptor type 1 genes. Kyobu Geka. 2011; 64:99–104.

17. Pannu H, Fadulu VT, Chang J, Lafont A, Hasham SN, Sparks E, Giampietro PF, Zaleski C, Estrera AL, Safi HJ, Shete S, Willing MC, Raman CS, Milewicz DM. Mutations in transforming growth factor-beta receptor type II cause familial thoracic aortic aneurysms and dissections. Circulation. 2005; 112:513–520.

18. Panneton JM, Hollier LH. Nondissecting thoracoabdominal aortic aneurysms. Part I. Ann Vasc Surg. 1995; 9:503–514.

19. Von Kodolitsch Y, Nienaber CA, Dieckmann C, Schwartz AG, Hofmann T, Brekenfeld C, Nicolas V, Berger J, Meinertz T. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004; 116:73–77.

20. Agarwal PP, Chughtai A, Matzinger FR, Kazerooni EA. Multidetector CT of thoracic aortic aneurysms. Radiographics. 2009; 29:537–552.

21. Quint LE, Francis IR, Williams DM, Bass JC, Shea MJ, Frayer DL, Monaghan HM, Deeb GM. Evaluation of thoracic aortic disease with the use of helical CT and multiplanar reconstructions: comparison with surgical findings. Radiology. 1996; 201:37–41.

22. Francois CJ, Carr JC. MRI of the thoracic aorta. Cardiol Clin. 2007; 25:171–184.

23. Williams GM, Roseborough GS, Webb TH, Perler BA, Krosnick T. Preoperative selective intercostal angiography in patients undergoing thoracoabdominal aneurysm repair. J Vasc Surg. 2004; 39:314–321.

24. Shuford WH, Sybers RG, Weens HS. Problems in the aortographic diagnosis of dissecting aneuryms of the aorta. N Engl J Med. 1969; 280:225–231.

25. Authors/Task Force members. Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ. ESC Committee for Practice Guidelines (CPG). Document reviewers. Authors/Task Force members. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adultThe Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014; 11. 35(41):2873–2926.

26. Shores J, Berger KR, Murphy EA, Pyeritz RE. Progression of aortic dilatation and the benefit of long-term beta-adrenergic blockade in Marfan's syndrome. N Engl J Med. 1994; 330:1335–1341.

27. Ejiri J, Inoue N, Tsukube T, Munezane T, Hino Y, Kobayashi S, Hirata K, Kawashima S, Imajoh-Ohmi S, Hayashi Y, Yokozaki H, Okita Y, Yokoyama M. Oxidative stress in the pathogenesis of thoracic aortic aneurysm: protective role of statin and angiotensin II type 1 receptor blocker. Cardiovasc Res. 2003; 59:988–996.

28. Nagashima H, Aoka Y, Sakomura Y, Sakuta A, Aomi S, Ishizuka N, Hagiwara N, Kawana M, Kasanuki H. A 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, cerivastatin, suppresses production of matrix metalloproteinase-9 in human abdominal aortic aneurysm wall. J Vasc Surg. 2002; 36:158–163.

29. Schouten O, van Laanen JH, Boersma E, Vidakovic R, Feringa HH, Dunkelgrun M, Bax JJ, Koning J, van Urk H, Poldermans D. Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth. Eur J Vasc Endovasc Surg. 2006; 32:21–26.

30. Dapunt OE, Galla JD, Sadeghi AM, Lansman SL, Mezrow CK, de Asla RA, Quintana C, Wallenstein S, Ergin AM, Griepp RB. The natural history of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 1994; 107:1323–1332.

31. Davies RR, Goldstein LJ, Coady MA, Tittle SL, Rizzo JA, Kopf GS, Elefteriades JA. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002; 73:17–27.

32. Svensson LG, Khitin L. Aortic cross-sectional area/height ratio timing of aortic surgery in asymptomatic patients with Marfan syndrome. J Thorac Cardiovasc Surg. 2002; 123:360–361.

33. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg. 1993; 17:357–368.

34. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Thoracoabdominal aortic aneurysms associated with celiac, superior mesenteric, and renal artery occlusive disease: methods and analysis of results in 271 patients. J Vasc Surg. 1992; 16:378–389.

35. Mault JR, Ohtake S, Klingensmith ME, Heinle JS, Greeley WJ, Ungerleider RM. Cerebral metabolism and circulatory arrest: effects of duration and strategies for protection. Ann Thorac Surg. 1993; 55:57–63.

36. Bavaria JE, Pochettino A. Retrograde cerebral perfusion (RCP) in aortic arch surgery: efficacy and possible mechanisms of brain protection. Semin Thorac Cardiovasc Surg. 1997; 9:222–232.

37. Cachera JP, Vouhé PR, Loisance DY, Menu P, Poulain H, Bloch G, Vasile N, Aubry P, Galey JJ. Surgical management of acute dissections involving the ascending aorta. Early and late results in 38 patients. J Thorac Cardiovasc Surg. 1981; 82:576–584.

38. Zehr KJ, Orszulak TA, Mullany CJ, Matloobi A, Daly RC, Dearani JA, Sundt TM 3rd, Puga FJ, Danielson GK, Schaff HV. Surgery for aneurysms of the aortic root: a 30-year experience. Circulation. 2004; 110:1364–1371.

39. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Variables predictive of outcome in 832 patients undergoing repairs of the descending thoracic aorta. Chest. 1993; 104:1248–1253.

40. Coselli JS, LeMaire SA, Koksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg. 2002; 35:631–639.

41. Grobner T, Prischl FC. Patient characteristics and risk factors for nephrogenic systemic fibrosis following gadolinium exposure. Semin Dial. 2008; 21:135–139.

42. Khoynezhad A, Donayre CE, Bui H, Kopchok GE, Walot I, White RA. Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg. 2007; 83:S882–S889.

43. Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA, Eggebrecht H, Elefteriades JA, Erbel R, Gleason TG, Lytle BW, Mitchell RS, Nienaber CA, Roselli EE, Safi HJ, Shemin RJ, Sicard GA, Sundt TM 3rd, Szeto WY, Wheatley GH 3rd. Society of Thoracic Surgeons Endovascular Surgery Task Force. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008; 85:1 Suppl. S1–S41.

44. Riesenman PJ, Farber MA, Mendes RR, Marston WA, Fulton JJ, Keagy BA. Coverage of the left subclavian artery during thoracic endovascular aortic repair. J Vasc Surg. 2007; 45:90–94.

45. Piffaretti G, Mariscalco G, Bonardelli S, Sarcina A, Gelpi G, Bellosta R, De Lucia M, Nodari F, Cervi E, Carrafiello G, Antona C, Castelli P. Predictors and outcomes of acute kidney injury after thoracic aortic endograft repair. J Vasc Surg. 2012; 56:1527–1534.

46. Gabriel EA, Locali RF, Romano CC, Duarte AJ, Palma JH, Buffolo E. Analysis of the inflammatory response in endovascular treatment of aortic aneurysms. Eur J Cardiothorac Surg. 2007; 31:406–412.

47. Matsumura JS, Cambria RP, Dake MD, Moore RD, Svensson LG, Snyder S. TX2 Clinical Trial Investigators. International controlled clinical trial of thoracic endovascular aneurysm repair with the Zenith TX2 endovascular graft: 1-year results. J Vasc Surg. 2008; 47:247–257.

48. Von Allmen RS, Anjum A, Powell JT. Outcomes after endovascular or open repair for degenerative descending thoracic aortic aneurysm using linked hospital data. Br J Surg. 2014; 101:1244–1251.