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Management of thoracic aortic aneurysm in adults

Authors
Emile R Mohler III, MD
Y Joseph Woo, MD
Christina L Greene, MD
Section Editors
James Hoekstra, MD
Heidi M Connolly, MD, FASE
Gabriel S Aldea, MD
Edward Verrier, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Thoracic aortic aneurysm (TAA) can be due to one of several etiologies. The natural history of TAA is one of progressive expansion, the rate of which depending upon the location of the aneurysm and its underlying cause. Although most TAAs produce no symptoms, patients who become symptomatic or have complications related to the aneurysm (eg, acute aortic regurgitation, dissection, aortic rupture) should undergo repair [1-5]. Conservative management of asymptomatic TAA aims to lessen stress on the aorta and limit further aortic expansion. Those who are asymptomatic and who do not meet the diameter criteria for elective TAA repair (open or endovascular) should be evaluated for possible underlying genetic conditions known to be related to thoracic aortic aneurysm and dissection (TAAD), and patients also require ongoing aneurysm surveillance. Where expertise in the management of thoracic aortic disease is not available, the patient should be transferred to a high-volume cardiovascular center to provide the best possible outcome [6].

The management of thoracic aortic aneurysm is reviewed here. The etiology, natural history, clinical features, and diagnosis of TAA, as well as specific techniques for repair of the thoracic aorta, are discussed separately. (See "Clinical manifestations and diagnosis of thoracic aortic aneurysm" and "Overview of open surgical repair of the thoracic aorta" and "Endovascular repair of the thoracic aorta".)

INDICATIONS FOR REPAIR

We agree with major cardiovascular society guidelines from the American College of Cardiology, American Heart Association, and Society of Vascular Surgery that recommend repair for all symptomatic TAA (ruptured, associated with dissection, causing pain) [1-5]. In general, repair of asymptomatic thoracic aortic aneurysm (TAA) is not recommended until the risk of rupture or other complications exceeds the risks associated with repair. Asymptomatic TAAs are selected for repair depending upon diameter, location, and expansion rate, with special considerations depending on the presence of underlying contributing etiologies (eg, Marfan syndrome, bicuspid aortic valve). Although morbidity and mortality associated with elective repair of the thoracic aorta remain high, for patients who meet criteria for repair, survival is improved for open surgery compared with medical therapy, and this should also be the case for endovascular repair given that endovascular repair compares favorably with open surgery. Asymptomatic patients with TAA who do not meet criteria for repair are managed medically. (See 'Management of asymptomatic TAA' below.)

Summary of indications — Recommendations for repair for TAA in the ascending and descending thoracic aorta include the following, which are discussed in detail below. (See 'Symptomatic (nonruptured) and ruptured TAA' below and 'Asymptomatic TAA' below.)

Symptomatic (nonruptured) or ruptured TAA

                         

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Literature review current through: Nov 2016. | This topic last updated: Wed Sep 07 00:00:00 GMT+00:00 2016.
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