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Aortic aneurysm

An aortic aneurysm is a general term for any swelling (dilatation or aneurysm) of the aorta, usually representing an underlying weakness in the wall of the aorta at that location. While the stretched vessel may occasionally cause discomfort, it is the risk of rupture causing severe pain, massive internal hemorrhage and, without prompt treatment, resulting in a quick death. In addition the aneurysm may split (Aortic dissection) which may block vessels that branch off from the aorta or release blood clots (emboli) causing blockage to blood-flow elsewhere. more...

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Pathology

The physical change in the aortic diameter can occur secondary to an intrinsic defect in the protein construction of the aortic wall, trauma, infection, or due to progressive destruction of aortic proteins by enzymes. The last is the most common cause of aneurysmal disease although the origin of this enzymatic destruction is not known.

Signs, symptoms and diagnosis

  • Most intact aortic aneurysms do not produce any symptoms. Untreated, aneurysms tend to become progressively larger, although the rate of enlargement is unpredictable for any individual. Rarely, clotted blood which lines most aortic aneurysms can break off and result in an embolus. They may be found on physical examination. Medical imaging is necessary to confirm the diagnosis.

Abdominal Aortic Aneurysm

Aortic aneurysms are more common in the abdominal aorta, one reason for this is that elastin, the principle load bearing protein present in the wall of the aorta, is reduced in the abdominal aorta as compared to the thoracic aorta (nearer the heart). Most are true aneurysms that involve all three layers (tunica intima, tunica media and tunica adventitia), and are are generally asymptomatic before rupture.

The prevalence of AAAs increases with age, with an average age of 65-70 at the time of diagnosis. AAAs have been attributed to atherosclerosis, though other factors are involved in their formation.

An AAA may remain asymptomatic indefinitely. There is a large risk of rupture once the size has reached 5 cm, though some AAAs may swell to over 15 cm in diameter before rupturing. Before rupture, an AAA may present as a large, pulsatile mass above the umbilicus. A bruit may be heard from the turbulent flow in a severe atherosclerotic aneurysm or if thombosis occurs. Unfortunately, however, rupture is usually the first hint of AAA. Once an aneurysm has ruptured, it presents with a classic pain-hypotension-mass triad. The pain is classically reported in the abdomen, back or flank. It is usually acute, severe and constant, and may radiate through the abdomen to the back.

The diagnosis of an abdominal aortic aneurysm can be confirmed at the bedside by the use of ultrasound. Rupture could be indicated by the presence of free fluid in potential abdominal spaces, such as Morrison's pouch, the splenorenal space, subdiaphragmatic spaces and peri-vesical spaces. A contrast-enchanced abdominal CT scan is needed for confirmation.

Only 10-25% of patients survive rupture due to large pre- and post-operative mortality. Annual mortality from ruptured abdominal aneurysms in the United States alone is about 15 000. Another important complication of AAA is formation of a thrombus in the aneurysm.

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Succesfull surgical repair of an Accute Type A dissecting aortic aneurysm associated with a right-sided-aortic arch and right sided descending thoracic
From CHEST, 10/1/05 by Konstantinos E. Paziouros

INTRODUCTION: Acute Type A dissecting Aortic Aneurysm associated with a right-sided arch and descending Aorta is an extremelly rare situation. One or two such cases have been reported at all times. The situation is fatal especially when it is complicated with acute Aortic Regurgitation and/or myocardial Ischemia.

CASE PRESENTATION: A 64-year-old man with a known history of Aneurysmal dilation of the descending Thoracic Aorta, presented with acute retrosternal pain and hemodynamic instability, at a rural area Medical center. The patient being in cardiogenic shock was succesfully resuscitated and transported to the University Hospital where the CT scan revealed an acute Stanford A / DeBakey I Aortic dissection with a right-arch and descending Aorta (Fig 1). TTE findings--besides the dissection- were severe Aortic regurgitation, 2+/4+ Mitral regurgitation, LV hypertrophy and apical and inferior wall hypokinesia. ECG revealed obvious new-onset Ischemia. The patient was intubated in the ICU due to hypoxia and hemodynamic instability. Risk factors included known COPD and acute Renal Failure due to involvement of the Right Renal artery. The patient was febrile due to active upper respiratory Staphylococcal infection as proven by subsequent culture; nevertheless he was scheduled for emergent Surgery which was performed with a median Sternotomy, cannulation of the right subclavian artery and a two staged right Atrial venous cannula and performance of a Bentall procedure with distal reinforcement of the Aortic wall with Teflon-felt rings placed inside the intima and outside the adventitia. Fenestration was also performed distally in order to equalise pressures between true-false lumens. It is worth mentioning that intraoperative bleeding was controlled by felt wrapping of the heart, a technique not known to the new generation of cardiac surgeons. This is obvious as a white substernal rim in the postoperative CT scan (Fig 2) and involves the innominate vein, the superior vena cava, the pericardium next to the pulmonary artery and the epicardium of the right ventricle all along from the superior vena cava to pulmonary artery. The patient recovered during a long ICU stay and was finally discharged and went back to normal life. Chest computed tomography at three months after surgery demonstrated a disappearance of the false lumen of the arch and descending Aorta (Fig 2).

[FIGURES 1-2 OMITTED]

DISCUSSIONS: Acute Type A Aortic dissection associated with a right-sided arch and descending Aorta is an extremelly rare situation and to the best of our knowledge only two such cases have been reported worldwide. This condition is fatal when complicated with acute severe Aortic insufficiency and acute myocardial Ischemia. Surgery is idicated unless it is felt to carry a prohibitive risk because of medical debility, extensive renal, myocardial, or bowel infarction, or massive stroke. In our ease we believe that surgery was indicated keeping in mind the heavy risk it carried for an unfavorable outcome.

CONCLUSION: There seem to be some exceptions to the general rules of Cardiothoracic surgery concerning Risk stratification and decision making. The unexpected results of prompt and aggressive Surgical treatment of otherwise fatal situations make out for these exceptions.

REFERENCES:

(1) Moizumi Y., Komatsu T., Nagaya K., Sawamura Y., Sakurai M., Tabayashi K. Type A aortic dissection involving a right-sided Aortic Arch, J. Cardiovasc. Surg (Torino) 1999 Feb; 40(1):117-9

(2) Nomoto T, Ueda Y, Sugita T, Izumi C. A case of type A dissection involving a right aortic arch. Ear J Cardiothorac Surg. 1997 Dec;12(6): 922-4

DISCLOSURE: Konstantinos Paziouros, None.

Konstantinos E. Paziouros MD * Stavros Siminelakis MD Sokrates Sismanidis MD Leonidas Disnitsas MD Miltiadis Matsagas MD George Papadopoulos MD George M. Palatianos MD Onassis Cardiac Surgery Center, Athens, Greece

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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