Clinical manifestations and diagnosis of thoracic aortic aneurysm
- Y Joseph Woo, MD
Y Joseph Woo, MD
- Department Chair, Cardiothoracic Surgery
- Stanford University
- Christina L Greene, MD
Christina L Greene, MD
- Cardiothoracic Surgery Resident
- Stanford University
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Complications of aortic aneurysmal disease (thoracic and abdominal) are a leading cause of death in the United States, particularly in individuals aged >55 years . Thoracic aortic aneurysm (TAA) represents approximately one-third of aortic aneurysm admissions, with the remainder of cases related to abdominal aortic disease . The prevalence of TAAs is lower than the reported prevalence of abdominal aortic aneurysms (AAAs), but unlike AAA, which appears to be decreasing, the incidence of TAA is increasing. Enlargement of the thoracic aorta is an increasingly recognized condition that is diagnosed incidentally on imaging studies performed to evaluate unrelated conditions.
Most patients with TAA have no symptoms. Aneurysms that produce symptoms are typically very large and are at an increased risk for rupture, which is associated with high mortality rates. When symptoms do occur, patients can present with chest or upper back pain, or with symptoms related to compression of surrounding structures leading to nerve dysfunction, or arterial compression causing ischemia or thromboembolism.
This topic will review the clinical features and diagnosis of TAA. Pseudoaneurysm (false aneurysm) represents a collection of blood and connective tissue outside the aortic wall, the result of a contained aortic rupture, which may be due to one of a variety of pathologic processes such as penetrating aortic ulcer, aortic dissection, blunt aortic injury, or other acute aortic syndromes. These disorders are discussed elsewhere. (See "Overview of acute aortic syndromes" and "Overview of acute aortic syndromes", section on 'Definition and pathophysiology'.)
The management and outcome of TAA and AAA are discussed separately. (See "Management of thoracic aortic aneurysm in adults" and "Overview of abdominal aortic aneurysm".)
Anatomy of the thoracic aorta — The aorta is the major arterial conduit conveying blood from the heart to the systemic circulation. It originates immediately beyond the aortic valve and ascends initially, then curves, forming the aortic arch, and descends caudally adjacent to the spine. The ascending thoracic aorta gives off the coronary arteries, and the aortic arch branches are typically the brachiocephalic trunk (branches to the right carotid and right subclavian arteries), left carotid, and left subclavian arteries; however, aortic arch anatomy can vary (figure 1). The descending thoracic aorta provides paired thoracic arteries (T1-T12) and continues through the hiatus of the diaphragm (figure 2A-B) to become the abdominal aorta, which extends retroperitoneally to its bifurcation into the common iliac arteries at the level of the fourth lumbar vertebra.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html (Accessed on June 28, 2013).
- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266.
- Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991; 13:452.
- Creager MA, Belkin M, Bluth EI, et al. 2012 ACCF/AHA/ACR/SCAI/SIR/STS/SVM/SVN/SVS Key data elements and definitions for peripheral atherosclerotic vascular disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards (Writing Committee to develop Clinical Data Standards for peripheral atherosclerotic vascular disease). J Am Coll Cardiol 2012; 59:294.
- Rylski B, Desjardins B, Moser W, et al. Gender-related changes in aortic geometry throughout life. Eur J Cardiothorac Surg 2014; 45:805.
- Devereux RB, de Simone G, Arnett DK, et al. Normal limits in relation to age, body size and gender of two-dimensional echocardiographic aortic root dimensions in persons ≥15 years of age. Am J Cardiol 2012; 110:1189.
- Rogers IS, Massaro JM, Truong QA, et al. Distribution, determinants, and normal reference values of thoracic and abdominal aortic diameters by computed tomography (from the Framingham Heart Study). Am J Cardiol 2013; 111:1510.
- Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation 2005; 111:816.
- Svensson LG, Crawford ES, Hess KR, et al. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993; 17:357.
- Safi HJ, Winnerkvist A, Miller CC 3rd, et al. Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1998; 66:1204.
- Ohki M. Thoracic Saccular Aortic Aneurysm Presenting with Recurrent Laryngeal Nerve Palsy prior to Aneurysm Rupture: A Prodrome of Thoracic Aneurysm Rupture? Case Rep Otolaryngol 2012; 2012:367873.
- Nathan DP, Xu C, Pouch AM, et al. Increased wall stress of saccular versus fusiform aneurysms of the descending thoracic aorta. Ann Vasc Surg 2011; 25:1129.
- Elefteriades JA, Barrett PW, Kopf GS. Litigation in nontraumatic aortic diseases--a tempest in the malpractice maelstrom. Cardiology 2008; 109:263.
- http://www.cdc.gov/nchs/nvss.htm (Accessed on June 28, 2013).
- Coady MA, Davies RR, Roberts M, et al. Familial patterns of thoracic aortic aneurysms. Arch Surg 1999; 134:361.
- Biddinger A, Rocklin M, Coselli J, Milewicz DM. Familial thoracic aortic dilatations and dissections: a case control study. J Vasc Surg 1997; 25:506.
- Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg 1985; 89:50.
- Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg 2002; 73:17.
- Wang Y, Barbacioru CC, Shiffman D, et al. Gene expression signature in peripheral blood detects thoracic aortic aneurysm. PLoS One 2007; 2:e1050.
- Trimarchi S, Sangiorgi G, Sang X, et al. In search of blood tests for thoracic aortic diseases. Ann Thorac Surg 2010; 90:1735.
- van Bogerijen GH, Tolenaar JL, Grassi V, et al. Biomarkers in TAA-the Holy Grail. Prog Cardiovasc Dis 2013; 56:109.
- Yuan SM, Shi YH, Wang JJ, et al. Elevated plasma D-dimer and hypersensitive C-reactive protein levels may indicate aortic disorders. Rev Bras Cir Cardiovasc 2011; 26:573.
- Diehm N, Baumgartner I. D-dimer measurement: a useful prognostic marker in surveillance of patients with abdominal aortic aneurysm? Eur Heart J 2011; 32:258.
- Golledge J, Muller R, Clancy P, et al. Evaluation of the diagnostic and prognostic value of plasma D-dimer for abdominal aortic aneurysm. Eur Heart J 2011; 32:354.
- Ziganshin BA, Theodoropoulos P, Salloum MN, et al. Simple Renal Cysts as Markers of Thoracic Aortic Disease. J Am Heart Assoc 2016; 5.
- Elefteriades JA. Indications for aortic replacement. J Thorac Cardiovasc Surg 2010; 140:S5.
- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27.
- Nuenninghoff DM, Hunder GG, Christianson TJ, et al. Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: a population-based study over 50 years. Arthritis Rheum 2003; 48:3522.
- Aboulafia DM, Aboulafia ED. Aortic aneurysm-induced disseminated intravascular coagulation. Ann Vasc Surg 1996; 10:396.
- Fisher DF Jr, Yawn DH, Crawford ES. Preoperative disseminated intravascular coagulation associated with aortic aneurysms. A prospective study of 76 cases. Arch Surg 1983; 118:1252.
- Loeys BL, Dietz HC, Braverman AC, et al. The revised Ghent nosology for the Marfan syndrome. J Med Genet 2010; 47:476.
- Loeys BL, Schwarze U, Holm T, et al. Aneurysm syndromes caused by mutations in the TGF-beta receptor. N Engl J Med 2006; 355:788.
- Braverman A, Thompson R, Sanchez L. Diseases of the aorta. In: Braunwald’s heart disease, 9th ed, Bonow R, Mann D, Zipes D, Libby P (Eds), Elsevier, Philadelphia 2011. p.1309.
- Hoey ET, Ganeshan A, Nadar SK, Gulati GS. Evaluation of the aortic root with MRI and MDCT angiography: spectrum of disease findings. AJR Am J Roentgenol 2012; 199:W175.
- Freeman LA, Young PM, Foley TA, et al. CT and MRI assessment of the aortic root and ascending aorta. AJR Am J Roentgenol 2013; 200:W581.
- Chu LC, Johnson PT, Dietz HC, Fishman EK. CT angiographic evaluation of genetic vascular disease: role in detection, staging, and management of complex vascular pathologic conditions. AJR Am J Roentgenol 2014; 202:1120.
- von Kodolitsch Y, Nienaber CA, Dieckmann C, et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med 2004; 116:73.
- Miller WT. Thoracic aortic aneurysms: plain film findings. Semin Roentgenol 2001; 36:288.
- Melville H, Costello J. Significant coincidence. Emerg Med J 2012; 29:414.
- Bicknell CD, Powell JT. Thoracic aortic aneurysms. Br J Surg 2013; 100:850.
- Fatimi SH, Panni RZ, Ashfaq A. Incidental finding of a giant aortic root aneurysm and its repair. J Pak Med Assoc 2012; 62:617.
- Rubin GD. Helical CT angiography of the thoracic aorta. J Thorac Imaging 1997; 12:128.
- Roberts DA. Magnetic resonance imaging of thoracic aortic aneurysm and dissection. Semin Roentgenol 2001; 36:295.
- Clouse WD, Marone LK, Davison JK, et al. Late aortic and graft-related events after thoracoabdominal aneurysm repair. J Vasc Surg 2003; 37:254.
- Lawrie GM, Earle N, DeBakey ME. Long-term fate of the aortic root and aortic valve after ascending aneurysm surgery. Ann Surg 1993; 217:711.
- François CJ, Carr JC. MRI of the thoracic aorta. Cardiol Clin 2007; 25:171.
- Tops LF, Wood DA, Delgado V, et al. Noninvasive evaluation of the aortic root with multislice computed tomography implications for transcatheter aortic valve replacement. JACC Cardiovasc Imaging 2008; 1:321.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- Parodi J, Berguer R, Carrascosa P, et al. Sources of error in the measurement of aortic diameter in computed tomography scans. J Vasc Surg 2014; 59:74.
- Asch FM, Yuriditsky E, Prakash SK, et al. The Need for Standardized Methods for Measuring the Aorta: Multimodality Core Lab Experience From the GenTAC Registry. JACC Cardiovasc Imaging 2016; 9:219.
- Nejatian A, Yu J, Geva T, et al. Aortic Measurements in Patients with Aortopathy are Larger and More Reproducible by Cardiac Magnetic Resonance Compared with Echocardiography. Pediatr Cardiol 2015; 36:1761.
- Bossone E, Yuriditsky E, Desale S, et al. Normal Values and Differences in Ascending Aortic Diameter in a Healthy Population of Adults as Measured by the Pediatric versus Adult American Society of Echocardiography Guidelines. J Am Soc Echocardiogr 2016; 29:166.
- Elefteriades JA, Farkas EA. Thoracic aortic aneurysm clinically pertinent controversies and uncertainties. J Am Coll Cardiol 2010; 55:841.
- Mendoza DD, Kochar M, Devereux RB, et al. Impact of image analysis methodology on diagnostic and surgical classification of patients with thoracic aortic aneurysms. Ann Thorac Surg 2011; 92:904.
- Rizzo JA, Coady MA, Elefteriades JA. Procedures for estimating growth rates in thoracic aortic aneurysms. J Clin Epidemiol 1998; 51:747.
- Goldstein SA, Evangelista A, Abbara S, et al. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular Imaging: endorsed by the Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2015; 28:119.
- Elefteriades JA, Rizzo JA, Coady MA. Thoracic aorta. Radiology 1999; 211:889.
- Sherrah AG, Andvik S, van der Linde D, et al. Nonsyndromic Thoracic Aortic Aneurysm and Dissection: Outcomes With Marfan Syndrome Versus Bicuspid Aortic Valve Aneurysm. J Am Coll Cardiol 2016; 67:618.
- Isselbacher EM, Lino Cardenas CL, Lindsay ME. Hereditary Influence in Thoracic Aortic Aneurysm and Dissection. Circulation 2016; 133:2516.
- Verma S, Siu SC. Aortic dilatation in patients with bicuspid aortic valve. N Engl J Med 2014; 370:1920.
- Criado FJ. Aneurysm morphology matters: fusiform vs. saccular. J Endovasc Ther 2013; 20:207.
- ANATOMIC ISSUES
- Anatomy of the thoracic aorta
- Definition of TAA
- CLINICAL PRESENTATIONS
- Asymptomatic TAA
- - Biomarkers of thoracic aortic disease
- - Clinical markers of thoracic aortic disease
- Symptomatic TAA
- - Rupture
- - Laboratory studies
- - ECG findings
- PHYSICAL EXAMINATION
- IMAGING DIAGNOSIS
- Incidental TAA
- Imaging asymptomatic, high-risk patients
- Imaging symptomatic patients
- Choice of imaging technique
- - Imaging standards
- DETERMINING TAA ETIOLOGY
- Sporadic versus genetically mediated
- Syndromic versus nonsydromic
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS