Thoracic Aneurysms &

Aortic Dissection
Schwartzs Chapter 22
Betsy White DO, PGY1

Anatomy of Aorta
Proximal Aorta
Ascendingaortic valve

to origin of innominate a.
Transversearea from
which the brachiocephalic
branches arise
Distal Aorta
Descending Thoracic

distal to origin of L
subclavian to
disphragmatic hiatus
Abdominalhiatus to
iliacs

Thoracic Aortic Aneurysms

Permanent, localized dilatation of aorta diameter at

least 50% greater than normal

Incidence 5.9 per 100,000 persons
May be single or multiple segment, thoracoabdominal
or mega-aorta
True (fusiform or saccular) or False
(pseudoaneurysms, leaks in wall cause pouches of
scar tissue on exterior)
Consistently increase in size; most require surgical
intervention; all require aggressive HTN management
Aortic diameter strong predictor of rupture, dissection,
mortality (>6cm annual rate of complications-- 3.6%
rupture, 3.7% dissection, 10.8% death)

Etiology & Pathogenesis

Elastin content highest ascending aorta; decreases

distally. Multiple factors can lead to aneurysms:

turbulent blood flow, increase diameter/wall tension
(Laplaces Law), poststenotic aortic dilatation (AoV
stenosis, coarctation), atherosclerosis.
Nonspecific Medial Degeneration
Aortic Dissection
Genetic Disorders--Marfan, Ehlers-Danlos, LoeysDietz, Familial Aortic Aneurysms, Congenital
Bicuspid AoV
Infection
AortitisTakayasus, Giant cell, Rheumatoid
Pseudoaneurysms

Clinical Manifestations
Expansion & impingement on adjacent structures

cause chronic pain. MC sx anterior chest discomfort,

mimicking angina especially in ascending aortia
aneursyms.
Compression of SVC, PA(erosion causing hemoptysis),
airway(causing cough, wheezing, stridor, pneumonitis),
sternum; Hoarseness and/or L vocal cord paralysis due
recurrent laryngeal nerve; back/scapula pain, small
bowel obstruction, GI bleeding, jaudice.
Aortic valve regurgitation due to displaced aortic valve
commissures & annular dilatation
Distal embolization
Rupturesudden, severe pain in anterior chest,
back/left chest, left flank abdomen causing cardiac
tamponade, severe hemorrhagic shock, and/or
respiratory failure.

Evaluation
Plain Film Radiology
Ultrasoundmore useful infrarenal aneurysms
EchocardiographyTTE/TEE provide visualization of

ascending aorta, including root; TEE allows

visualization descending aorta (not ideal for
transverse aorta)
CTMC used; provides visualization of
thoracic/abdominal aorta and info of aneurysms
location, extent, anomalies, relationship to branches,
and diameter. W/ contrast provides info on lumen,
aortic dissection, fibrosis, hematomas.
MRAvisualization of entire aorta; branching vessel
stenosis
Cardiac Cathuse to be gold standard especially
ascending disease; determines function of heart
although increase risks of procedure itself

Treatment
Asymptomatic patients: education, thorough H&P,

surveillance CT scans, aggressive BP control until

symptomatic/growing aneurysm then surgical
treatment.
Commonly have multiple aneurysm in which staged
operations occur treating most life threatening first.
Indications for surgery
Ascending diameter >5.5 cm,
Descending diameter > 6.5cm, or
Rate of dilatation is >1cm/yr.
*Marfans, Loeys-dietz , AoV regurgitation lower threshold
Symptomatic patientsincrease rupture/dissection

Pre-op evaluation for CAD, pulmonary and renal

function

Open vs Endovascular Repair

Descending Thoracic AneursymsEndovascular

repair consideration if:

Hemodynamically stable
Proximal neck >20mm from L subclavian artery
Distal neck >20mm from left celiac artery
Maximum neck diameter <37mm and minimum 23

mm
Absence of large, mobile aortic atheroma
Consider in patient with severe pulmonary
disease, advanced age, or multiple co-morbidities.
When anatomic criteria not met, open repair

preferred

Operation

spectrum varies:
From simple graft
replacement of
tubular portion of
scending aorta to
graft replacement
of the entire
proximal aorta,
including aortic
root &
reattachment of
coronary arteries &
brachiocephalic
branches.

Proximal Thoracic Aortic

Aneurysms
Aortic Valve Disease & Root Aneurysms
Performed through midsternal incision and require CPB.
Mild to moderate valve regurg with annular dilatation
is addressed by pilcating annulus with mattress
sutures place below each commisuure. Valve is
replaced w/ stented biologic or mechanical prosthesis
in more severe regurg pts.
Aortic root is replaced mech/biologic graftboth valve
and aortic conduit.
Ross procedure (pulmonary artery root is excised and
placed in aortic position) not used in patient w/ CT
disease
Valve-sparing or aortic root reimplantation excision
of aortic sinuses, attach prosthetic graft to patients
annulus & resuspend the native aortic valve inside
graft.

Ascending aorta repair

Tubular portion of ascending

aorta replaced by graft, and the
native aortic root & arch intact.

Modified Bentall procedureaortic valve

and entire ascending aorta replaced by
mechanical graft. Coronary arteries with
buttons reattached

Proximal Thoracic Aortic

Aneurysms
Coronary arteries must be reattached to graft
Bentall and De Bono--Suturing intact aortic wall

surrounding each coronary a. to openings in graft

Cabrols modification--Small tube graft sutured to
cornary ostia & main aortic graft (tension-free
anastomoses)
Kouchoukoss button modificationaneurysmal aorta
excised, buttons of aortic wall are left surrounding oth
coronary arteries which are mobilized and sutured to
graft
Zubiate and Kayconstruction of bypass grafts by
using interposition saphenous vein or synthetic grafts.

Proximal Thoracic Aortic

Aneurysms
Aortic Arch Aneurysms
Saccular aneurysms that arise from the lesser
curvature & take up <50% of aortic circumference
are treated by patch graft aortoplasty.
Fusiform aneurysms a single beveled replacement
of lower curvature is performed.
Extensive arch aneurysms require total
replacement (distal anastomosis to proximal
descending thoracic aorta, separate reattachment
of brachiocephalic branches).
Extreme cases involving entire arch, extending
into descending aorta requires the Borsts
elephant trunk technique of staged total arch
replacement.

Borsts elephant trunk

EVAR & Hybrid Repairs

EVARlimited for proximal aortic

repairs due to anatomy and

uninterrupted cerebral perfusion
Hybrid Arch repairsinvolve
form of debranching of
brachiocephalic vessels,
followed by endovacular
exclusion of arch.
Risk of embolization/stroke due to

wire & device manipulation within

arch. No large scale studies
completed (at time of book
published). Used for high risk
surgical candidates.

Distal Thoracic Aortic

Aneurysms

DTAAinvolves the portion of aorta from L

subclavian to diaphragm; open repair

requires left thoracotomy. Double lumen
ETT for selective ventilation
Thoracoabdominalentire aorta from L
subclavian to bifurcation (Crawford
classification); open repair requires
extended thoracotomy across costal margin
& into abdomen. Transperitoneal exposure
by medial visceral rotation & division of
diaphragm.

Crawford Classification
Extent I--involves most of the

descending thoracic aorta,

beginning near the left
subclavian, and extending to
the aorta at the origins of the
celiac & SMA (renals maybe)
Extent II--arise near the left
subclavian but extends
distally into the infrarenal
abdominal aorta, often
reaches bifurcation.
Extent III--originates in the
lower DTA (below 6th rib) and
extends into the abdomen.
Extent IV--begins within the
diaphragmatic hiatus and
often involves the entire
abdominal aorta.

DTAA Complications/Risk
Clamping of distal DTA causes ischemia of the

spinal cord & abdominal viscera (less common

hepatic, pancreatic, bowel). Several strategies
to prevent and/or improve these events:
All repairs--Systemic heparinization (1mg/kg), mild

hypothermia (32-34C), reattachment of segmental

intercostal/lumbar arteries, sequential clamping,
perfusion of renal arteries with cold crystalloid
Crawford extent I & II repairscererospinal fluid
drainage used to improved spinal perfusion by
reducing pressure, left heart bypass to deliver
blood directly to celiac & SMA.

EVAR of DTAA
Primarily used to treat degenerative DTAA; now its the

less invasive options in pts w/ aortic dissection,

traumatic, mycotic, ruptured aneurysms, elderly pts w/
multiple comorbidities, or previous aortic procedures.
Vascular access obtained (femoral or iliac exposed);
heparinization, endograft advanced into aorta w/
fluoroscopic quidance, device deployed, prox/distal
ends expanded by balloon catheter, aortogram taken
r/o leaks, protamine given.
Commonly cover L subclavian during proximal landing
zone now can construct carotid-subclavian bypass or
place stent graft in subclavin to prevent loss of
collateral circulation to spinal cord.

DTAA Repairs Cont

Elephant Trunk Completion
Used when aneurysm extends from distal

arch to DTA; endograft is ideal compared to

open approach.
Can be deployed at time of trunk
construction or separate/staged procedure;
Radioactive markers placed at distal end
(first procedure) allows for retrograde
deployment with identification via
fluoroscopy.

EVAR of TAAA
Remains experimental (according to book);

complex procedures requiring at least 1 of

visceral vessels to be incorporated.
Stent graftsfenestrated, reinforced
fenestrated, branches, modular combinations;
some custom-made so limited to elective
repairs.
Hybrid Repair
Open surgical techniques to reroute blood
supply to visceral a so origins can be covered
by stent grafts w/o causing ischemia.
EVAR methods used (single or staged)

Postoperative Considerations
Open procedures
Initial 24-48 hrs, tight BP control to protect integrity

of anastomoses ; use nitroprusside gtt or B-blockers

for MAP 80-90mmHg (lower for Marfans MAP 7080mmHg); increase risk of infection to graft
therefore IV abx until D/C of all drains, CT, and CVLs

Endovascular procedures
Specific complications related to device deployment

and/or manipulation of delivery system including

aortic injury, iliac rupture, acute iatrogenic
retrograde dissection, endoleak (persistent blood
flow into aneurysm sac), misdeployment, device
migration, endograft kinking.

Endoleaks
Type I--incomplete seal btwn graft & aorta at attachment

sites, are the most unstable and can precipitate aortic

ruptureaggressive intervention!
Type II occur when sac is filled by collateral arteries, such as
patent intercostal arteries; Benign, can be monitored with
regular imaging. If grows/persist, percutaneous intervention
may be required.
Type III--caused by either a tear in the graft fabric or an
incomplete seal btwn two devices; Rare but treated
aggressively.
Type IV--extremely rare and were seen more often with earlier
devices made of porous materials through which blood could
leak
Type V--endotension, in which there is evidence of aneurysm
expansion even though the leak has no identifiable source.
Type IV and V endoleaks can be treated by overstenting the

existing graft with another stent graft.

Aortic Dissection
Progressive separation of aortic wall after tear forms

in intima and inner media; creating at least two

channels. MC catastrophic event involving aorta.
True lumenoriginal lumen lined by intima; False
lumennewly formed channel within layers of
media. Dissecting membrane separates the two;
may have communications (re-entry sites) Usually
progresses distally but may proceed proximal
(proximal extension ore retrograde dissection)
Severe consequencesfalse lumen thin/fragile
therefore, prone to expansion or rupture in stress
states, may compress true lumen (malperfusion
syndrome), or may cause acute valvular
regurgitation when aortic root involved.

DeBakey & Stanford

Classification
Describe segments of aorta involved in dissection rather than site of
initial intimal tear

Etiology, Pathogenesis,
Manifestation
Acute stage within first 14 days of initial tear; chronic

after 14 days. Variants include intramural hematoma

(IMH no intimal tear, 6-16% full dissection) and
penetrating aortic ulcer (PAU disrupted plaque
projecting into wall, higher rate of progression).
Incidence 3.5 per 100,000 in U.S; w/o appropriate care
90% die within 3 months (rupture).
Specific causes unknown but several risk fastors
Smoking, HTN, atherosclerosis, HLD, CT disorders,
aortitis, bicuspid AoV, MDD, injury during cardiac cath,
& cocaine/meth use.
Severe back/chest pain, MC tearing pain radiate
inferiorly; potential complications cardiac ischemia,
tamponade, Ao regurg/dyspnea, stroke, paraplegia,
mesenteric ischemia, kidney failure, limb
ischemia/loss of motor function; discrepancy bwtn
pulse and/or BP.

Evaluation
Obviously no lab markers but D-Dimer is

elevated in 97% cases, EKG/cardiac markers

will be normal in most dissections.
CXR shows widened mediastinum (but 16% of
pts w/ dissection with have normal CXR)
Constrast CT showing double lumen aorta
(Sensitivity 98%, specificity 87%)
MRA provides excellent imaging considering
gold standard (Sensitivity/Specificity 98%)
TEE can determine presence of dissection,
aneurysm or IMH in ascending aorta.
(Sensitivity 98%/Specificity 95%)

Treatment
Invasive ICU monitoring, aggressive BP monitoring/control

(usually with IV B-blockers, vasodilators, CCB, ACE-I) MAP

60-75mmHg with HR60-80, pain control.
Emergent graft replacement of ascending aorta in acute
symptomatic cases (unless acute stroke, elderly,
comorbidities, cardiac operations in past).
Nonoperative/pharmacologic management results in
lower morbidity & mortality rates (MCC death, end organ
malperfusion); serial CT on Day 2/3 & day 8/9 to rule out
expansion. Switch to po meds, SBP (100-110), with
aggressive follow up (6 wks, Q3months x1 yr, Q6 months
2nd yr, then annually)
Indications for surgeryaortic rupture, increasing
periaortic volume, expanding diameter, uncontrolled HTN,
persistent pain, malperfusion syndrome.

EVAR
Endovascular therapy is routinely used in patients

with descending aortic dissection complicated by

visceral malperfusion.

Endovascular fenestration, a balloon is used to create a

tear in the dissection flap, which allows blood to flow in

both the true and false lumens( when a visceral branch is
being supplied by an underperfused true or false lumen)
Placement of a stent graft in the true lumen of the aorta
can resolve a "dynamic" malperfusion. Sometimes small
stent must be placed directly in the lumen of a visceral or
renal artery because the dissection has propagated into
the branch.
Acute dissectiongoal to stent graft to eventually

causing thrombosis of false lumen. PAUwell suited

for EVAR, covering focal ulceration.

Open Repair Acute Dissection

Primary goal of surgery to prevent fatal

rupture and restore branch vessel

perfusion. (MC site of rupture descending is
proximal thirdtherefore upper half
repaired)
Graft replacement of entire aorta is not
attempted unless a large coexisting
aneurysm

Dissection vs. Aneurysm

Similar but separate entities.
Dissection occurs in patients without

aneurysms. Progressive dilatation of the

weakened outer aortic wall results in an
aneurysm.
Degenerative aneurysms, the ongoing
deterioration of the aortic wall can lead to a
superimposed dissection (dissecting
aneurysm)

Questions??