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AORTIC ANEURYSM

Abnormal dilatation of the thoracic or abdominal aorta; in ascending aorta most commonly secondary to medial degeneration (e.g., familial, Marfan’s syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome type IV, bicuspid aortic valve); aneurysms of descending thoracic and abdominal aorta are primarily atherosclerotic. Rare causes of aneurysms are infections (syphilis, tuberculosis, mycotic), vasculitis (e.g., Takayasu’s arteritis, giant cell arteritis), and spondyloarthropathies (e.g., rheumatoid aortitis).

HISTORY

May be clinically silent, but thoracic aortic aneurysms can result in deep, diffuse chest pain, dysphagia, hoarseness, hemoptysis, dry cough; abdominal aneurysms may result in abdominal or lower back pain or sense of abdominal pulsation.

PHYSICAL EXAMINATION

Abdominal aneurysms are often palpable, most commonly in periumbilical area. Pts with ascending thoracic aneurysms may show features of Marfan’s syndrome (Chap. 406, HPIM-20).

LABORATORY

Suspect thoracic aneurysm by abnormal CXR (enlarged aortic silhouette) and confirm by echocardiography, contrast CT, or MRI. Confirm abdominal aneurysm by abdominal plain film (rim of calcification), ultrasound, CT, MRI, or contrast aortography. If clinically suspected, obtain serologic test for syphilis, especially if ascending thoracic aneurysm shows thin shell of calcification. Screening abdominal ultrasound to assess for abdominal aortic aneurysm (AAA) is recommended for men aged 65–75 who have ever smoked, for individuals with a history of a thoracic aortic aneurysm, and for first-degree relatives of pts with AAA.

TREATMENT

TREATMENT Aortic Aneurysm

Pharmacologic control of hypertension (Chap. 119) is essential, usually including a beta blocker for thoracic aortic aneurysms (losartan may have similar benefit in reducing rate of growth in pts with Marfan’s syndrome). Surgical resection for symptoms, for large aneurysms (ascending thoracic aortic aneurysms ≥5.5 cm, descending thoracic aortic aneurysms >6.0 cm, or AAA ≥5.5 cm), for persistent pain despite bp control, or for evidence of rapid expansion (>0.5 cm/year). In pts with Marfan’s syndrome thoracic aortic aneurysms >4−5 cm usually warrant repair. Less invasive endovascular repair is an option for some pts with descending thoracic or AAAs.

AORTIC DISSECTION

Potentially life-threatening condition in which disruption or aortic intima allows dissection of blood into vessel wall; may involve ascending aorta (type II), descending aorta (type III), or both (type I) (Fig. 127-1). More commonly used classification: Type A—dissection involves ascending aorta; type B—limited to transverse and/or descending aorta. Involvement of the ascending aorta is most lethal form. Variant acute aortic syndromes include intramural hematoma without an intimal flap, and penetrating atherosclerotic ulcer.

FIGURE 127-1

Classification of aortic dissections. Stanford classification: Top panels illustrate type A dissections that involve the ascending aorta independent of site of tear and distal extension; type B dissections (bottom panels) involve transverse and/or descending aorta without involvement of the ascending aorta. DeBakey classification: ...

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