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Key Features

Essentials of Diagnosis

  • Widened mediastinum on chest radiograph

  • With rupture, sudden onset chest pain radiating to the back

General Considerations

  • Aneurysms of the thoracic aorta account for < 10% of aortic aneurysms

  • Causes

    • Atherosclerosis

    • Trauma

    • Syphilis (rare)

    • Ehlers-Danlos and Marfan syndromes (also rare)

Clinical Findings

Symptoms and Signs

  • Most are asymptomatic

  • Substernal back or neck pain

  • Pressure on the trachea, esophagus, or superior vena cava can result in

    • Dyspnea, stridor, or brassy cough

    • Dysphagia

    • Edema in the neck and arms

    • Distended neck veins

  • Hoarseness due to stretching of the left recurrent laryngeal nerve

  • Aortic regurgitation with aneurysms of the ascending aorta

Differential Diagnosis

  • Usually asymptomatic

  • Other causes of chest pain, back pain, neck pain, dyspnea, or dysphagia

Diagnosis

Imaging Studies

  • Chest radiograph shows calcified outline of the dilated aorta

  • CT scanning is modality of choice

    • Demonstrates the anatomy and size of the aneurysm

    • Excludes lesions that can mimic aneurysms, such as neoplasms or substernal goiter

  • MRI can also be useful

Diagnostic Procedures

  • Cardiac catheterization and echocardiography may be required to describe the relationship of the coronary vessels to an aneurysm of the ascending aorta

Treatment

Surgery

  • Indications for repair depend on

    • Location of dilation

    • Rate of growth

    • Associated symptoms

    • Overall condition of patient

  • Aneurysms measuring ≥ 6 cm may be considered for repair

  • Open surgery is usually required for aneurysms that involve the proximal aortic arch or ascending aorta

Therapeutic Procedures

  • Endovascular grafting for aneurysms of the descending thoracic aorta

  • Complex branched endovascular reconstructions (custom made grafts with branches to the vessels that would be occluded by the grafts) for aneurysms involving the arch or visceral aorta

Outcome

Complications

  • With the exception of endovascular repair for discrete saccular aneurysms of the descending thoracic aorta, the morbidity and mortality of thoracic repair is higher than for infra-renal abdominal aortic aneurysm repair

  • Paraplegia (4–10% rate following endovascular repair of thoracic aortic aneurysms)

  • Open surgery for aneurysms that involve the proximal aortic arch or ascending aorta carries substantial risk of morbidity

    • Stroke

    • Diffuse neurologic injury

    • Intellectual impairment

Prognosis

  • Generally, degenerative aneurysms of the thoracic aorta will enlarge and require repair

  • Good with endovascular repair of saccular aneurysms, particularly those distal to the left subclavian artery and the descending thoracic aorta

  • Resection of aneurysms of the aortic arch should only be attempted in low-risk patients

  • Branched technology or fenestrated for endovascular grafting has demonstrated reduced morbidity and mortality

  • Rupture is catastrophic

When to Refer

  • Patients ...

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