Radiation and contrast use are limitations. After EVAR, you'll need regular imaging tests to check the graft for leakage. The aortic valve stays in place. 2020; doi:10.3390/biom10020182. In this, the first of 2 articles, we discuss thoracic aortic aneurysm (TAA); in the second article, we will discuss renal artery and splenic artery aneurysm. https://www.merckmanuals.com/professional/cardiovascular-disorders/diseases-of-the-aorta-and-its-branches/thoracic-aortic-aneurysms. Most people with a thoracic aortic aneurysm have open-chest surgery, but sometimes a less-invasive procedure called endovascular surgery can be done. Ultrasonography has a high sensitivity and specificity (95% and nearly 100%, respectively) for detecting AAA when performed in a setting experienced in the use of ultrasonography.4,9 Additionally, there are no significant harms associated with abdominal ultrasonography.4 Although larger studies are needed, preliminary data suggest that family physicians can be trained to successfully screen for AAA in the office setting.10, Four randomized, controlled, population-based studies provide much of the available data on AAA screening.1114 The Multicentre Aneurysm Screening Study was the largest, following approximately 70,000 men between 65 and 74 years of age for 10 years.11 Participants were randomized to an offer of ultrasonography or to a control group. Reprinted from Masri A, Kalahasti V, Svensson LG, et al. Your health care provider is likely to ask you a number of questions. Advanced Cardiac Imaging Fellow, Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Staff Cardiologist, Section of Cardiovascular Imaging and Medical Director, Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, Sign In to Email Alerts with your Email Address. Abdominal aortic aneurysm (AAA) is an abdominal aortic dilation of 3.0 cm or greater.1 The prevalence of AAA increases with age. Circ Cardiovasc Imaging 2017; 10(6):e006249. One-time screening for AAA with ultrasonography should be performed in men 65 to 75 years of age who have smoked 100 cigarettes or more in their lifetime. Burke CR, et al. Thoracic aortic aneurysm: Optimal surveillance and treatment, Optimal surveillance and treatment of renal and splenic artery aneurysms, DOI: https://doi.org/10.3949/ccjm.87a.19140-1, 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The graft strengthens the weakened section of the aorta to prevent rupture of the aneurysm. The USPSTF recommends that clinicians selectively offer screening in men 65 to 75 years of age who have never smoked (level C recommendation). Jan. 17, 2020. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are key to characterizing the aneurysm and the rest of the vasculature, while ultrasonography or echocardiography assist in assessment and surveillance, and catheter angiography is the gold standard for renal and splenic aneurysm. Which ICU patients need stress ulcer prophylaxis? Persons who have a stable abdominal aortic aneurysm should undergo regular surveillance or operative intervention depending on aneurysm size.
Accessed Feb. 1, 2022. Risk factors associated with a higher likelihood of AAA include first-degree relatives with AAA, history of other vascular aneurysms, coronary artery disease, cerebrovascular disease, atherosclerosis, hypercholesterolemia, obesity, and hypertension (Table 12,3). Oct. 25, 2021. 2015 Dec 22-29;314(24):26922693], Statins are associated with decreased mortality in abdominal, but not in thoracic aortic aneurysm patients undergoing endovascular repair: propensity score-adjusted analysis, Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies, Open versus endovascular repair of descending thoracic aortic aneurysm disease: a systematic review and meta-analysis, Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study, ESC guidelines for the management of grown-up congenital heart disease (new version 2010), Metastatic bone disease: Early referral for multidisciplinary care, Womens health update: A literature review impacting primary care. AAA may occasionally be visible on plain radiography, if the aneurysm wall is calcified.1, A ruptured AAA is a medical emergency associated with high mortality rates. On the other hand, an early follow-up scan (6 months after initial TAA diagnosis) is recommended to assess for growth of the aneurysm in patients who have genetic conditions, and annually thereafter if measurements have been stable or more frequently if there is accelerated growth. In particular, abdominal girth greater than 100 cm (39.4 in) is associated with decreased sensitivity for identification with palpation.6 An aneurysm may rarely produce findings related to compression of adjacent structures, such as lower extremity edema related to compression of the inferior vena cava.7, Diagnosis of AAA is often made as an incidental finding on imaging studies, such as abdominal ultrasonography or computed tomography (Figures 1 and 2). Should I tell other family members to be screened for an aneurysm? Related editorial: Pitfalls of Direct-to-Consumer Vascular Screening Tests. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. There are mixed views for the threshold of intervention, ie, whether it should be the same as in Marfan syndrome or even lower.1,2,25. CTA or MRA should be performed in every patient diagnosed with TAA to confirm the maximal dimensions and assess the entire length of the aorta.1,2,9, Other methods for aortic imaging include invasive aortography with fluoroscopy, positron-emission tomography, and intravascular ultrasonography, although they are never used solely for assessing TAA.1. Taking these steps can help prevent thoracic aortic aneurysm and its complications. If you want to participate in a particular activity, your health care provider may recommend an exercise stress test to see how exercise affects your blood pressure. Because appointments can be brief and there's often a lot to discuss, it's a good idea to be prepared for your appointment. An ascending aortic root aneurysm procedure may be done in two ways. Ask your health care provider whether it's right for you. Moderate physical activity is generally healthy for you. Abdominal auscultation may reveal the presence of a bruit. Those with AAA detected at screening were followed by ultrasound surveillance or elective surgery based on predefined criteria. 2021; doi:10.1016/j.jvs.2020.05.076. There are limited options for medical treatment beyond risk factor modification. Here's some information to help you get ready for your appointment, and what to expect from your health care provider. How often should I be screened for an aneurysm? The American guidelines further emphasize measuring the maximal TAA cross-sectional area. What's an appropriate level of physical activity? A diameter of 5.5 cm has been used in many protocols as a threshold for performing elective surgery, particularly for infrarenal and juxtarenal aneurysms. We do not capture any email address. Men in this age group without a history of smoking may benefit if they have other risk factors (e.g., family history of abdominal aortic aneurysm, other vascular aneurysms, coronary artery disease). The USPSTF continues to recommend one-time screening with ultrasonography for men 65 to 75 years of age with a history of smoking (level B recommendation).9 Of note, a history of smoking is defined as at least 100 cigarettes over the individual's lifetime. Indications for surgical or endovascular repair are based on aneurysm location and risk factors for rupture such as aneurysm size, rate of growth, and associated conditions, while medical management is also important.
Is there a generic alternative to the medicine you're prescribing me? If you have signs or symptoms of a thoracic aortic aneurysm, your health care provider may ask about your family's medical history. Mayo Clinic does not endorse companies or products. Using tobacco can worsen an aneurysm and overall health. Mayo Clinic. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. Emergent surgical intervention is indicated for a rupture but has a high operative mortality rate. Several nonsurgical options have been studied for the potential ability to slow aneurysm progression. Do you have a family history of aneurysms or other hereditary diseases, such as Marfan syndrome? What, if anything, appears to worsen your symptoms? Accessed Feb. 1, 2022. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. For an aortic aneurysm, some basic questions to ask your health care provider include: In addition to the questions that you've prepared to ask your health care provider, don't hesitate to ask additional questions during your appointment. It is associated with high prehospitalization mortality. Accessed Feb. 1, 2022. Ruptured AAAs cause an estimated 4% to 5% of sudden deaths in the United States. Blacks appear to be at lower risk.4, Beyond the inherent risk of rupture, patients with AAA are also at an increased risk of cardiovascular disease and death independent of other factors.5 The degree to which risk factors impact AAA vs. atherosclerosis varies. One study demonstrated improved survival with endovascular repair in patients younger than 70 years, whereas patients 70 years or older tended to do better with open repair.32, Emergent Repair of Ruptured AAA. You may find that connecting with others who have experienced similar situations may be helpful. For example, dyslipidemia is an important coronary artery disease risk factor, although its role in AAA remains uncertain, and diabetes mellitus may have a negative association with AAA.2,4, Physical examination with abdominal palpation is only moderately sensitive for the detection of AAA, with one study demonstrating a sensitivity of 68% and specificity of 75%.6 The most common finding is palpation of a pulsatile mass around the level of the umbilicus. A single copy of these materials may be reprinted for noncommercial personal use only. Once the modality is established, timing of surveillance and guideline recommendations depend on aortic dimensions and growth and presence of associated conditions.1,2,9 In the absence of conditions associated with TAA, the recommendation is routine surveillance at the discretion of the clinician, based on individual risk. Accessed Feb. 1, 2022. Usually, you'll have an echocardiogram, CT or magnetic resonance angiography (MRA) scan at least six months after your aneurysm is diagnosed, and at regular follow-up exams. This content does not have an English version. Management of thoracic aortic aneurysm in adults. Thoracic aortic aneurysm care at Mayo Clinic. This catheter-based procedure may allow a faster recovery. Ruptured abdominal aortic aneurysm is a medical emergency presenting with hypotension, shooting abdominal or back pain, and a pulsatile abdominal mass. One-time screening for AAA with ultrasonography should be selectively offered in men 65 to 75 years of age who have never smoked, but have risk factors for AAA. The operator should interrogate the aortic root and ascending aorta in the parasternal long-axis views, parts of the arch and descending thoracic aorta in the suprasternal view, and a segment of the abdominal aorta in the subcostal view.1,9, Transesophageal echocardiography (TEE) has a limited role in the primary assessment of TAA unless concurrent structural cardiac disease is suspected. On the other hand, aneurysm in the descending aorta can be addressed with endovascular repair using percutaneous access in suitable anatomy, with or without arch-vessel transposition (debranching).1 The potential benefits are lower perioperative mortality risk and faster recovery than with surgery, although late complications such as graft leak, migration, and rupture can occur, and the durability is unknown.32,33. I have other health conditions. All Rights Reserved. Open-chest surgery for thoracic aortic aneurysm, Ascending aortic root aneurysm repair and replacement, Endovascular repair for thoracic aortic aneurysm, NEW The Essential Diabetes Book - Mayo Clinic Press, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Our caring team of Mayo Clinic experts can help you with your thoracic aortic aneurysm-related health concerns, Aortic Surgery: What Patients Need to Know Mayo Clinic, Video: Valve-Sparing Aortic Root Replacement, Mayo Clinic Q and A: Thoracic aortic aneurysms, Mayo Clinic Q&A podcast: Detecting and treating thoracic aortic aneurysms. Does anything seem to improve your symptoms? EVAR can't be done on everyone. 1998-2022 Mayo Foundation for Medical Education and Research (MFMER). This site complies with the HONcode standard for trustworthy health information: verify here. Epidemiology, risk factors, pathogenesis, and natural history of thoracic aortic aneurysm. It can also be used for intraoperative evaluation as well as a contrast-free imaging option for diagnosing acute aortic syndromes.9 The aortic root and ascending aorta can be visualized in the midtransesophageal long-axis view at 100 to 140 degrees; the aortic valve and root in the short-axis view at 45 to 60 degrees; and the descending thoracic aorta up close at 0 degrees in the short-axis view and 90 degrees in the long-axis view, where atheroma and dissection flaps can be visualized up to the aortic arch with probe withdrawal.1,14. If you think you may have a thoracic aortic aneurysm or are worried about your aneurysm risk because of a strong family history, make an appointment with your care provider. Abdominal aortic aneurysm refers to abdominal aortic dilation of 3.0 cm or greater. Copyright 2015 by the American Academy of Family Physicians. The latter is preferred to avoid radiation exposure, but the former may be necessary if MRA is contraindicated, eg, because of a cardiac device or claustrophobia.3 Accurate and reproducible measurements are critical in surveillance, especially when nearing the threshold for intervention. Start Here. CTA is the recommended first-line imaging for assessing TAA, having high spatial resolution and a short scan time (34 seconds for the thoracic aorta, < 10 seconds for thoracoabdominal and iliofemoral vessels), enabling assessment of all segments and walls of the thoracic aorta with a 3-D dataset. https://www.nhlbi.nih.gov/health-topics/aneurysm. Aortic aneurysm. If the maximal TAA cross-sectional area (in cm2) divided by height (in meters) is greater than 10, this would be another indication for intervention.2 This threshold was derived from studies from Cleveland Clinic originally applied to patients with bicuspid aortic valves and Marfan syndrome,19,20 and more recently in all TAA patients,21 with major prognostic implications (Figure 4). Allscripts EPSi. Thoracic aortic aneurysm (adult). A metal mesh tube (graft) attached to the end of the catheter is placed at the aneurysm site. Aortic cross-sectional area/height ratio and outcomes in patients with bicuspid aortic valve and a dilated ascending aorta. CTA or MRA is useful at baseline to image the entire aorta and check agreement with TTE measurements. It can visualize a greater extent of the thoracic aorta than TTE and with superior spatial resolution, including with 3-dimensional techniques. Also searched were Essential Evidence Plus and the Cochrane database. Women without a smoking history should not undergo screening because the harms likely outweigh the benefits. No wonder, then, that the incidence of TAA and the number of surgical repairs are increasing.2,10, Thoracic aortic aneurysm: Risk factors, associations, and causes. Other health conditions will be treated and managed. Mayo Clinic; 2021. Treatment for thoracic aortic aneurysm may include: A Mayo Clinic health care provider talks to a patient. All rights reserved. The 2014 guideline has been updated to suggest that the benefit of screening in women 65 to 75 years of age with a history of smoking is inconclusive (level I statement).
For example, open repair has a mortality rate of 4.2% and a complication rate of 32%.4 However, this risk is smaller than that of AAA-related mortality in the absence of screening. Men 65 to 75 years of age with a history of smoking should undergo one-time screening with ultrasonography based on evidence that screening will improve abdominal aortic aneurysmrelated mortality in this population. The measurements recommended may also differ by condition, such as comparing to normalized values by age, sex, and body surface area and using Z scores in those with Marfan syndrome and indexing to body surface area in those with Turner syndrome.9 No specific recommendations for TAA surveillance and intervention for Ehlers-Danlos syndrome have been made because there is no evidence that intervening is beneficial.1,2,9, TAA patients should be referred to a cardiologist to provide guideline-based medical management of the aorta, and to a cardiac surgeon when nearing a threshold for intervention.1,2. Thus, these persons could be considered for retesting, although present data do not support the cost effectiveness of this approach.11,22. Copyright 2022 American Academy of Family Physicians. Feb. 28, 2022. The aorta is larger in men and in larger people generally, and therefore sex and body size are taken into account when determining the normal ranges and severity thresholds.9 The aorta also tends to increase in size with age. Patient education regarding warning symptoms and signs of TAA complications warranting immediate medical attention is important.1,2 Cardiovascular risk reduction is important, with nonpharmacologic measures such as healthy diet and smoking cessation, which have positive effects on blood pressure and lipids. Search dates: January 13, 2012; May 13, 2012; and August 18, 2014. The information provided is for educational purposes only. The less-invasive endovascular approach has gained favor because of improved early outcomes, with a 30-day mortality risk between 1% and 2%.30 However, studies have shown that the mortality benefits initially reported with endovascular repair are essentially gone by two to three years postprocedure.3032, In addition, patients undergoing endovascular repair have a higher rate of graft complications and need for secondary interventions compared with patients undergoing open repair. Marfan syndrome. The reduction in AAA-related mortality improved from 42% at four-year follow-up to 48% at 10-year follow-up, demonstrating continued benefit over the duration of the study.11 This program also demonstrated continued cost-effectiveness, particularly as the study progressed, because the major costs of screening occur early with initial screening and intervention.15 Other data have substantiated the cost-effectiveness of AAA screening.16, As studies such as the Multicentre Aneurysm Screening Study indicate, the main benefit of screening is decreased AAA-related mortality.15 However, this does not translate to improved all-cause mortality in men or women.17 Persons with the greatest potential benefit from screening have the major risk factors of male sex, increased age, and history of smoking. Note that the motion artifact indicated by the white arrow in (A) is not seen in (B). A meta-analysis found that each 0.5-cm increase in diameter increases the growth rate by 0.6 mm per year; however, this study also suggests that overall growth rates and risk of rupture are somewhat less than previously suggested and may support longer intervals for surveillance21 (Table 41,21,22). The surgeon inserts a thin, flexible tube (catheter) into a blood vessel, usually in the groin, and guides it to the aorta. The type of surgery done depends on the specific health condition and the location of the thoracic aortic aneurysm. Medical care includes traditional cardiovascular risk factor management. Such activities can increase blood pressure, putting additional pressure on your aneurysm. Available mortality data have not demonstrated significant benefit from screening women.4,18 Family history of AAA may be an important screening consideration because it doubles the risk, and some recommendations include this as a consideration for men and women.20, The risks of screening include the morbidity and mortality associated with elective repair. Free e-newsletter and email table of contents. If an aneurysm is found early, treatment may be easier and more effective. Mayo Clinic. What websites do you recommend visiting for more information? At this size, it is thought that the benefits of surgery outweigh the risks. First-degree relative with abdominal aortic aneurysm, Ultrasonography or computed tomography every six to 12 months, Consider surgical consultation for an aneurysm 5.0 cm or greater, or if expanding at a rate greater than expected for its size, Surgical consultation for elective repair. Beta blockers are known to improve perioperative mortality for AAA repair; however, randomized trial results indicate that their effects on AAA enlargement are not significant. Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine. Note that without 3-D-MPR, the aortic root size is underestimated (A). A randomized trial28 found beta-blockers reduced expansion and even mortality in patients with Marfan syndrome with TAA, though this was not consistently reported in other studies. In 2005, the guideline recommended against screening in all women. The key risk factors are male sex, smoking, age older than 65 years, coronary artery disease, hypertension, previous myocardial infarction, peripheral arterial disease, and a family history of AAA1,3,4 (Table 12,3). Although men and women 74 to 84 years of age have increased risk of AAA, this group is less likely to benefit from screening and subsequent surgery because of competing comorbidities.1,9. If TTE measurements have close agreement with CTA or MRA, then TTE can be used for regular monitoring, although CTA or MRA should still be performed, though less often, for monitoring segments of the aorta not visible on TTE and checking TTE accuracy over time. Smoking cessation may help because smoking causes an incremental increased growth rate of up to 0.4 mm per year.25 In terms of pharmacologic therapy, statins, antihypertensives, and antibiotics have been studied. Genetic conditions associated with TAA such as Marfan syndrome are less common but nevertheless important because the prognosis and management are different.1,2,9 Some risk factors or conditions increase wall stress, while others increase medial degeneration.10 Although only 5% of cases of TAA are associated with genetic syndromes, another 20% are in patients who have a family history of TAA, which has important implications for assessment, management, and counselling.11 And many cases are idiopathic, lacking obvious causes or risk factors. List your questions from most important to least important in case time runs out. Management of TAA is multidisciplinary, with many aspects beyond medications and interventions. Accessed Feb. 1, 2022. Our caring team of Mayo Clinic experts can help you with your thoracic aortic aneurysm-related health concerns
Table 3 summarizes the American 2010 and European 2014 guidelines and our recommendations on indications for TAA repair.1,2 The main determinants include aneurysm dimensions, rate of expansion, and associated conditions. Exercise is controversial in patients with TAA. There is also a weak association of acute aortic syndromes with fluoroquinolones, so avoidance may be considered.34. Surgical evaluation is necessary when there are symptoms thought to be related to the TAA, irrespective of other factors.2, Indications for prophylactic intervention for thoracic aortic aneurysm, TAAs grow by 0.7 to 1.9 mm per year in undilated aortas, but growth can be faster in patients with a dilated aorta or associated conditions.17, TAA size is the strongest predictor of acute aortic syndromes.18 In patients who have no other conditions, the guidelines recommend surgery when the aortic root, ascending aorta, or aortic arch reaches 5.5 cm and when the descending aorta reaches 6.0 cm ( 5.5 cm with endovascular stenting).1,2 This is based on a sharp rise in the risk of aortic dissection when the ascending aorta reaches 6 cm and the descending aorta reaches 7 cm.17, Factors that lower the threshold include associated conditions, faster rate of growth (measured by the same modality and exceeding the margin of error of 35 mm/year), and the need for adjacent aneurysm or aortic valve surgery.1,2. Therefore, in persons found to have aneurysms on initial screening, regular surveillance is needed every six months to three years, depending on aneurysm size. Tests may include: Health care providers evaluate a CT scan at Mayo Clinic. Surveillance with various imaging tests is critical before and after intervention to guide treatment. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Computed tomography angiography aortic root measurements on (A) axial source image and (BD) 3-dimensional multiplanar reconstruction (3-D-MPR) double-oblique planes. Counseling should be considered in patients with genetic conditions associated with TAA, women considering pregnancy or who are pregnant, and patients with indications for aortic interventions but who are being conservatively managed because of medical comorbidities and surgical risk. In endovascular thoracic aortic aneurysm repair, the surgeon inserts a thin, flexible tube (catheter) through an artery in the groin area and guides it to the aorta. Turner syndrome is associated with short stature and greater risk of rupture for the same aorta size, so indexed measurements are preferred.26 It is also associated with bicuspid aortic valve and aortic coarctation, so concurrent cardiovascular surgery is often required. Blood pressure control is the cornerstone of medical management of TAA, as it makes pathophysiologic sense to reduce aortic wall shear stress and expansion. If you're being screened for an aortic aneurysm, your health care provider will likely ask if anyone in your family has ever had an aortic aneurysm, so have that information ready. Enter multiple addresses on separate lines or separate them with commas. Clinical manifestations and diagnosis of thoracic aortic aneurysm. The patients overall estimated risk of acute aortic syndrome also needs to be balanced with the hospitals expertise and procedural risks for TAA repair. Computed tomography of thoracic aortic aneurysm without (A) and with (B) electrocardiographic gating. If there is poor agreement between TTE and CTA or MRA measurements, or poor visualization of the aorta with TTE, then CTA or MRA should be used instead for regular monitoring. Progress in Cardiovascular Diseases. The graft reinforces the weakened section of the aorta to prevent rupture of the aneurysm. The U.S. Preventive Services Task Force released updated recommendations for abdominal aortic aneurysm screening in 2014. Surgery in the surveillance groups occurred only when the aneurysm exceeded 5.5 cm, expanded by more than 1 cm per year (another risk factor for rupture), or became tender or symptomatic.23 At later points in the follow-up period, there was some weak evidence that suggested a benefit to early surgical repair. Although aerobic activity should probably be encouraged, weight-training activities such as heavy lifting should be avoided, particularly in those with genetic conditions such as Marfan syndrome or Loeys-Dietz syndrome. Also note that sinus-commissure measurements are often slightly less than sinus-sinus measurements in (B). This content is owned by the AAFP. Rurali E, et al. These patients have a risk of aortic dissection up to 8 times higher than that of the general population.23 A Cleveland Clinic study found the risk of aortic dissection in bicuspid aortic valve patients to be elevated at 4.7 to 5.3 cm, but the risk further accelerates beyond 5.3 cm, so a 5.0-cm threshold for intervention rather than a higher one may indeed be preferred in these patients.24, Marfan syndrome. Management strategies include surgery, which is mandatory in the acute setting and in cases of challenging anatomy, and endovascular techniques.