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Aortic aneurysm imaging
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Thoracic aortic aneurysm

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Thoracic aortic aneurysm

  1. 1. Thoracic Aortic Aneurysm Al-Momtan, Ahmed Tahir B. E-6 Dr. Emad Hijazi
  2. 2. Background Anatomy and cardiac skeleton Histology of Blood vessels What is an aneurysm? And whats TAA? True vs False aneurysms Thoracic vs Abdominal Classification of thoracic aortic aneurysms Dissection .. Little talk.. Ayaman
  3. 3. Further anatomy Shapes of aneurysms
  4. 4. Anatomy
  5. 5. Hager A. et al.; J Thorac Cardiovasc Surg 2002;123:1060-1066
  6. 6. Classification
  7. 7. Crawford clssification
  8. 8. Epidemiology Prevalence greater than 3-4%of those over 65 years. 6th-7th ..decade The estimated incidence of thoracic aortic aneurysms is 6 cases per 100,000 person-years. The overall prevalence of aortic aneurysms has increased significantly in the last 30 years..Causes? The prevalence of fatal and nonfatal rupture has also increased.. Males > females
  9. 9. Aetiology Aging population..Laplace law Arteriolosclerosis and HTN (60%) Smoking A previous aortic dissection with a persistent false channel. trauma False aneurysms Genetics (19%), CT, Females --FHx Connective tissue; Marfan’s (young), Ehler Danols. ATHEROSCLEROSIS! Does it? Bicuspid AV (52% have TA) Others; infxn, arteritis, trauma, aortitis Multifactorial? With risk factors (smoking, COPD high BMI…..)
  10. 10. Facts! 13% have multiple 20-25% with TA have and AAA.
  11. 11. Presentation Range.. Asymptomatic ..Mostly..thoracic Pain? Exp.. Acute vs chronic,, Location? SVC Obstruction Tymponade Sx and Symptoms Murmurs, pulse pressure (Acute AR) Voice changes? Dyspnoea, stridor, wheezes, cough.. Dysphagia, Haemoptysis, haematemesis Back pain Paraparesiss, paraplegia Distal embolic disease Echymoses, petaechiae Life threatening
  12. 12. Indications for surgery Elefteriades: (size) - 5.5 ascending aneurysms- No FHx e.g Marfan’s (5) - 6.5 descending aneurysms-No FHx (6) aortic aneurysm size in relation to body surface- ASI (aortic diameter in cm / body surface area (m2) --Risk - ASI < 2.75 cm/m2  low risk (4%/y) - ASI 2.75-4.25 cm/m2  moderate (8%/y) - ASI > 4.25 cm/m2  high risk (20-25%) Rapid expansion ( Growth rate) - 0.07 cm/y asc - 0.19 cm/y desc - If > 1cm/y >> repair! Symptomatic patients
  13. 13. Summary of indcations Aortic size Ascending aortic diameter ≥5.5 cm or twice the diameter of the normal contiguous aorta Descending aortic diameter ≥6.5 cm Subtract 0.5 cm from the cutoff measurement in the presence of Marfan syndrome, family history of aneurysm or connective tissue disorder, bicuspid aortic valve, aortic stenosis, dissection, patient undergoing another cardiac operation Growth rate ≥1 cm/y Symptomatic aneurysm Traumatic aortic rupture Acute type B aortic dissection with associated rupture, leak, distal ischemia Pseudoaneurysm Large saccular aneurysm Mycotic aneurysm Aortic coarctation Bronchial compression by aneurysm Aortobronchial or aortoesophageal fistula Relevant Anatomy
  14. 14. Contraindications for surgery Patients who have high morbidity and mortality; eg elderly with ESRD, respi insufficiency, cirhosis.. For descending ..ENDOVASCULAR stenting .. F/U ..
  15. 15. Investingations Lab: - CBC, Electrolytes, KFT, PT, PTT, INR, BG , XM, LFT, amylase and lactate. Imaging - Next slide..
  16. 16. Diagnosis CXR (aneurysm vs tortuous aorta) – 61% Echo – TTE vs TEE CT-contrast MRI Contrast Angiography ECG Cath?
  17. 17. CXR
  18. 18. CT-contrast
  19. 19. Ascending aortogram
  20. 20. http://www.medscape.com/viewarticle/406630_15
  21. 21. Post-Op
  22. 22. Appreciate it?
  23. 23. Treatment and Management Medical - Control HTN - Smoking cessation - Control other risk factors..
  24. 24. Surgical- Depends on the location, the extension, the patient comorbidities, the age, the staff, and the hospital setup!- Principally; TEE is needed for assessment of coronary artery bypass grafting!, the patient need of valve replacement or if the patients need valve sparing procedures.- Aortic arch aneurysms; comorbidities; neurologic injury (permenant), steroids are given at the onset of procedure if hypothermic circulatory aarrest is anticipated- Descending aneurysms; spinal complications, paraplagia, paraparessis– spinal arteriograms for reimplantation of Adankiewics artery!- Brain protection, DHCA, and intraoperative EEG monitoring, pacjing the patients head in ice, trendelenburg position, mannitol, CO2 flooding, thiopental, steroids, antergrade and retrograde cerebral perfusion.
  25. 25. Surgical Summary Dacron tube graft Ascending – may need to replace valve Arch – graft Descending – graft, stent grafts
  26. 26. Follow-up Development of another aneurysm postoperatively is not uncommon! Serial evaluations (CT, MRI –for ascending, arch or descending, echo for ascending) may be performed 3-6 months in 1st post-op year, and every 6 months thereafter. There was a difference in female and male patients undergoing thoracic endo repairs, FDA approved, females had higher rates of procedural complications, requiring more blood transfusions, longer hospital stay, more major adverse events after 30 days!  BUT they are more often have successful
  27. 27. Outcome and prognosis Early hospital mortality following Asc TAA is 4-10%, stroke in 2-5% Arch aneurysms; mortality is 6-12%,, stroke 3-22%, renal failure requiring dialysis is 7% Descending; mortality is 12-15%  overall; survivial rate is 60% at 5 years and 30-40% at 10 years Endovascular stenting stent grafting vs open surgery mortality is 3% and 14%, and operative mortality was 1% vs 6% Endovascular achieved shorter hospital stay, quicker recovery time and lower incidence of major adverse effects (except vascular compications. Endovascular complications at 2 years, 4% proximal stent migration, 6% migration of graft components and 15% had an endoleak! Survival rates between Endo and open groups are almost the same aat 2 years and 5 years (80% and 70%), no difference in rates of paraplagia!
  28. 28. Dacron tubeNataf P , Lansac E Heart 2006;92:1345-1352 Composite valve and graft replacemen
  29. 29. Natural History Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple Prediction Based on Size  304 patients; 58.9% male; median age 65.8  Aneurysm size – 43.7% were 4.0-4.9 cm  Location – 72% ascending  Follow up – average 43.1 months  End points Events No. Patients Dissection, rupture and death 2 Dissection, rupture (no death) 2 Dissection, death (no rupture) 5 Rupture and death (no dissection) 4 Rupture alone 5 Dissection alone 15 Death alone 44Davies RR, et al. Ann Thorac Surg 2002;73:17
  30. 30. Trials and comparisons ENDOVASCULAR STENT GRAFT TRIALS vs OPEN
  31. 31. Endovascular Stent Graft Repair
  32. 32. HOME MESSEGE REMEMBERIn the end, it’s not what you call it………it’s size that matters!
  33. 33.  Thank you ..
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