Thoracic aortic aneurysm surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]

Overview

Indication for surgery depend upon the size of the aneurysm. Aneurysms in the ascending aorta may require surgery at a smaller size than aneurysms in the descending aorta.

Evaluating The Patient's Risk Of Dissection And Rupture

The risk of rupture is closely related to aneurysm size (3% for TAAs <4 cm and 7% for >6 cm).

Shown below is the annual risk of thoracic aortic rupture, dissection or death for different diameters of thoracic aortic aneurysms. This draft forms the basis for performing surgery when the aorta is 5.0 to 6 cm in diameter depending upon whether the patient has Marfan syndrome or not.

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Indications for Surgery

• Rupture
• Symptomatic states
  • Pain consistent with rupture
  • Compression of adjacent organs
  • Significant aortic regurgitation
• Growth ≥ 0.5 - 1 cm/year
• Bicuspid aortic valve
  • Immediate surgical repair is recommended, as this condition is associated with faster rate of aortic dilatation
• Absolute size

	Marfan's	Non-Marfan's
Ascending aorta	5.0 cm	5.5 cm
Descending aorta	6.0 cm	6.5 cm

Complications Of Thoracic Aorta Aneurysm Surgery

Bleeding

• Bleeding is a potential complication of all aneurysm repairs, particularly a large one such as aortic aneurysm repair

Neurologic injuries

• Stroke- major cause of mortality
• Due to an obstructed blood vessel by embolized atherosclerotic debris
• Patients undergoing aortic arch repairs are at the highest risk of neurologic complications
• Paraparesis and paraplegia

Cardiac

• Myocardial infarction due to technical problems with coronary ostia implantation during root replacement for ascending aortic aneurysms; may require reoperation
• Congestive heart failure

Pulmonary

Acute respiratory distress syndrome)

Endovascular Stenting Complications

• Endoleaks
• Stent fractures
• Stent graft migration or thromobosis
• Iliac artery rupture
• Retrograde dissection
• Microembolization
• Aortoesophageal fistula

ACC/ AHA Guidelines - Recommendation for Asymptomatic patients with Ascending aortic aneurysm (DO NOT EDIT)

Class I

1. Asymptomatic patients with degenerative thoracic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, or pseudoaneurysm, who are otherwise suitable candidates and for whom the ascending aorta or aortic sinus diameter is 5.5 cm or greater should be evaluated for surgical repair (Level of Evidence: A)

2. Patients with Marfan syndrome or other genetically mediated disorders (vascular Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, or familial thoracic aortic aneurysm and dissection) should undergo elective operation at smaller diameters (4.0 to 5.0 cm depending on the condition; to avoid acute dissection or rupture (Level of Evidence: C)

3.Patients with a growth rate of more than 0.5 cm/y in an aorta that is less than 5.5 cm in diameter should be considered for operation. (Level of Evidence: C)

4.Patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta (Level of Evidence:C)

Class IIa

1.Elective aortic replacement is reasonable for patients with Marfan syndrome, other genetic diseases, or bicuspid aortic valves, when the ratio of maximal ascending or aortic root area (πr2) in cm2 divided by the patient's height in meters exceeds 10 (Level of Evidence:C)

2.It is reasonable for patients with Loeys-Dietz syndrome or a confirmed TGFBR1 or TGFBR2 mutation to undergo aortic repair when the aortic diameter reaches 4.2 cm or greater by transesophageal echocardiogram (internal diameter) or 4.4 to 4.6 cm or greater by computed tomographic imaging and/or magnetic resonance imaging (external diameter. (Level of Evidence:C)

ACC/ AHA Guidelines - Recommendations for Symptomatic patients with Thoracic aortic aneurysms (DO NOT EDIT)

Class I

1. Patients with symptoms suggestive of expansion of a thoracic aneurysm should be evaluated for prompt surgical intervention unless life expectancy from comorbid conditions is limited or quality of life is substantially impaired.(Level of Evidence: A)

ACC/ AHA Guidelines - Recommendation for Open surgery for ascending aortic aneurysm (DO NOT EDIT)

Class I

1.Separate valve and ascending aortic replacement are recommended in patients without significant aortic root dilatation, in elderly patients, or in young patients with minimal dilatation who have aortic valve disease (Level of Evidence: C)

2.Patients with Marfan, Loeys-Dietz, and Ehlers-Danlos syndromes and other patients with dilatation of the aortic root and sinuses of Valsalva should undergo excision of the sinuses in combination with a modified David reimplantation operation if technically feasible or, if not, root replacement with valved graft conduit. (Level of Evidence: B)

ACC/ AHA Guidelines - Recommendations for surgery for Aortic arch aneurysm (DO NOT EDIT)

Class IIa

1.For thoracic aortic aneurysms also involving the proximal aortic arch, partial arch replacement together with ascending aorta repair using right subclavian/axillary artery inflow and hypothermic circulatory arrest is reasonable (Level of Evidence:B)

2.Replacement of the entire aortic arch is reasonable for acute dissection when the arch is aneurysmal or there is extensive aortic arch destruction and leakage (Level of Evidence:B)

3. Replacement of the entire aortic arch is reasonable for aneurysms of the entire arch, for chronic dissection when the arch is enlarged, and for distal arch aneurysms that also involve the proximal descending thoracic aorta, usually with the elephant trunk procedure(Level of Evidence:B)

4.For patients with low operative risk in whom an isolated degenerative or atherosclerotic aneurysm of the aortic arch is present, operative treatment is reasonable for asymptomatic patients when the diameter of the arch exceeds 5.5 cm (Level of Evidence:B)

5.For patients with isolated aortic arch aneurysms less than 4.0 cm in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 12-month intervals, to detect enlargement of the aneurysm. (Level of Evidence:C)

6.For patients with isolated aortic arch aneurysms 4.0 cm or greater in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 6-month intervals, to detect enlargement of the aneurysm (Level of Evidence:C)

ACC/ AHA Guidelines - Recommendations for descending thoracic aneurysm surgery (DO NOT EDIT)

Class I

1. For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended (Level of Evidence: B)

2. For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible(Level of Evidence: B)

3.For patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present (Level of Evidence: C)

4. For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure is recommended(Level of Evidence:B)