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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Ascending aortic diameter > 4 cm on imaging study

  • Descending aortic diameter > 3.5 cm on imaging study

GENERAL CONSIDERATIONS

  • Ascending aortic aneurysms usually fall into 1 of 3 patterns:

    1. Supracoronary sinus dilatation

    2. Annuloaortic ectasia (Marfan’s syndrome)

    3. Diffuse tubular enlargement

  • Descending aortic aneurysm are classified into 4 types (Crawford classification):

    1. Thoracic and upper abdominal aorta

    2. Entire thoracic and abdominal aorta

    3. Lower thoracic and abdominal

    4. Predominantly abdominal

  • Aortic aneurysms are often familial (eg, Marfan’s syndrome)

  • Aortic aneurysms grow about 1 mm/year and grow faster in the descending aorta compared with the ascending aorta

  • As the aorta enlarges, rupture becomes more likely in an exponential fashion with the rapid acceleration point of the curve at 6 cm for the ascending aorta and 7 cm for the descending aorta

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Generally no symptoms until rupture or dissection occurs

  • Deep visceral pain in upper anterior chest or back

  • Possible dysphagia or stridor

PHYSICAL EXAM FINDINGS

  • Possible aortic regurgitation murmur

  • Signs of Marfan’s syndrome

  • Rarely, anterior upper chest wall pulsations

DIFFERENTIAL DIAGNOSIS

  • Aortic dissection

  • Aortic rupture with contained hematoma

  • Mediastinal or thoracic tumor

DIAGNOSTIC EVALUATION

IMAGING STUDIES

  • Chest x-ray: thoracic aortic aneurysms are almost always visible

  • CT or MRI: defines the aortic anatomy very well

DIAGNOSTIC PROCEDURES

  • Aortography is rarely used today

TREATMENT

CARDIOLOGY REFERRAL

  • Significant aortic regurgitation

  • Suspected cardiac disease

HOSPITALIZATION CRITERIA

  • Pain likely from aneurysm

  • Planned surgery

THERAPEUTIC PROCEDURES

  • Endoluminal stent grafts are an alternative in selected cases

SURGERY

  • Surgical replacement with a synthetic graft is considered in asymptomatic patients at the following diameters:

    Favorite Table | Download (.pdf) | Print
      Non-Marfan’s Marfan’s
    Ascending 5.0 cm 5.5 cm
    Descending 6.0 cm 6.5 cm

  • Symptomatic aneurysms (pain, impingement on other structures) need immediate replacement

MONITORING

  • ECG monitoring in hospital as appropriate

DIET AND ACTIVITY

  • Restricted activity in symptomatic patients until surgery is completed

  • Asymptomatic patients should not do major weight lifting

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problem

  • Successful surgery

FOLLOW-UP

  • Stable, asymptomatic patients should have repeat imaging every 2 years

  • New patients with moderately large aneurysms should be imaged in 3–6 months; if stable in 1 year, then every 2 years

COMPLICATIONS

  • Dissection

  • Rupture

PROGNOSIS
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