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Etiology, pathogenesis and management of thoracic aortic aneurysm

Abstract

Given the growing proportion of elderly people in Western societies and the increasing prevalence of chronic hypertension, the management of aneurysmal aortic disease is an ever growing challenge. Although degenerative changes in the aortic wall are common to thoracic aortic aneurysm (TAA) and to various types of dissection in general, TAA can result from specific heritable disorders of connective tissues. Today, increased awareness of vascular diseases and access to tomographic imaging equipment facilitate the diagnosis of TAA, even when asymptomatic. While most TAA cases with ascending aortic involvement are treated with surgical repair (primarily valve-preserving techniques), aneurysms of the distal arch and descending thoracic aorta are amenable to alternatives to classic open repair such as the emerging endovascular treatment techniques. In this Review, we provide a comprehensive overview of the etiology, pathophysiology and clinical management of patients with TAA, and discuss the most recent literature on the condition.

Key Points

  • The incidence of thoracic aortic aneurysm is estimated at 6 individuals per 100,000 per year and occurs most commonly in the 6th and 7th decade, with hypertension an important risk factor in 60% of cases

  • A broad variety of inflammatory and infectious disorders, clustered under the term 'aortitis', can occasionally cause thoracic aortic aneurysm

  • Patients with thoracic aortic aneurysms are often asymptomatic at the time of diagnosis

  • A variety of noninvasive and invasive methods, ranging from transesophageal ultrasonography to contrast-enhanced CT and MRI, are useful for the diagnosis and evaluation of a thoracic aortic aneurysm

  • Indications for surgery of atherosclerotic aneurysm include the following: ≥55 mm diameter for an ascending aortic aneurysm and ≥60 mm for a descending aortic aneurysm; accelerated growth rate (≥10 mm per year) if <55 mm diameter; recurrent symptoms; and proximal dissection

  • Use of endovascular stent-grafts for repair of suitable anatomic conditions is emerging as a promising alternative nonsurgical treatment

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Figure 1: Immunohistology and staining of biopsy samples from a patient with a thoracic aortic aneurysm compared with those of a patient with aortic dissection
Figure 2: Serial chest radiograph of a patient with a true aortic aneurysm
Figure 3: Contrast-enhanced CT imaging of the thoracic aorta with surface rendering for three-dimensional reconstruction
Figure 4: CT-angiogram showing a circumscript aneurysm of the descending thoracic aorta in a middle-aged male patient selected for endovascular stent-graft treatment
Figure 5: Contrast-enhanced magnetic resonance angiogram (maximum intensity projection and multiplanar reformatting) demonstrating an aneurysm involving the aortic arch
Figure 6: Actual survival after endovascular stent-graft repair in two groups of patients separated according to whether the patient was judged to be or not to be a reasonable candidate for open surgical repair

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Correspondence to Christoph A Nienaber.

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Ince, H., Nienaber, C. Etiology, pathogenesis and management of thoracic aortic aneurysm. Nat Rev Cardiol 4, 418–427 (2007). https://doi.org/10.1038/ncpcardio0937

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