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Complications
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With the exception of endovascular repair for discrete saccular aneurysms of the descending thoracic aorta, the morbidity and mortality of thoracic repair is considerably higher than that for infra-renal abdominal aortic aneurysm repair Paraplegia remains a rare, but devastating, complication Most large series report approximately 4% rate of paraplegia following endovascular repair of thoracic aortic aneurysms The spinal arterial supply is segmental through intercostal branches of the aorta with variable degrees of intersegmental connection Therefore, the more extensive the aneurysm, the greater is the risk of paraplegia with resection Prior to abdominal aortic surgery, compromise of the subclavian or internal iliac arteries and hypotension all increase the paraplegia risk Involvement of the aortic arch also increases the risk of stroke, even when the aneurysm does not directly affect the carotid artery Aneurysms that involve the proximal aortic arch or ascending aorta represent particularly challenging problems Some form of open surgery is usually required, which carries substantial risk of morbidity, including stroke, diffuse neurologic injury, and intellectual impairment
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Prognosis
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Generally, degenerative aneurysms of the thoracic aorta will enlarge and require repair However, stable aneurysms can be followed with CT scanning Saccular aneurysms, particularly those distal to the left subclavian artery and the descending thoracic aorta, have had good results with endovascular repair Resection of large complex aneurysms of the aortic arch involves major technical issues and requires a skilled surgical team and should only be attempted in low-risk patients Experimental branched technology for endovascular grafting holds promise for reduced morbidity and mortality
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Clinical Findings
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A Symptoms and Signs
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Severe persistent chest pain of sudden onset radiating down the back or possibly into the anterior chest is characteristic Radiation of the pain into the neck may also occur The patient is usually hypertensive Syncope, hemiplegia, or paralysis of the lower extremities may occur Intestinal ischemia or renal insufficiency may develop Peripheral pulses may be diminished or unequal A diastolic murmur may develop as a result of a dissection in the ascending aorta close to the aortic valve, causing valvular regurgitation, heart failure, and cardiac tamponade
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AORTIC DISSECTION
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B Electrocardiographic Findings
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ESSENTIALS OF DIAGNOSIS
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Sudden searing chest pain with radiation to the back, abdomen, or neck in a hypertensive patient
Left ventricular hypertrophy from long-standing hypertension is often present Acute changes suggesting myocardial ischemia do not develop unless dissection involves the coronary artery ostium Classically, inferior wall abnormalities predominate since dissection leads to compromise
Blood Vessels & Lymphatics
of the right rather than the left coronary artery In some patients, the ECG may be completely normal
CMDT 2008
relief Long-term medical care of patients should include blockers in their antihypertensive regimen
C Imaging
A CT scan is the immediate diagnostic imaging modality of choice; clinicians should have a low threshold for obtaining a CT scan in any hypertensive patient with chest pain and equivocal findings on ECG The CT scan should include both the chest and abdomen to fully delineate the extent of the dissected aorta MRI is an excellent imaging modality for chronic dissections, but in the acute situation, the longer imaging time and the difficulty of monitoring patients in the MRI scanner make the CT scan preferable Chest radiographs may reveal an abnormal aortic contour or widened superior mediastinum Although transesophageal echocardiography (TEE) is an excellent diagnostic imaging method, it is generally not readily available in the acute setting
B Surgical Intervention
Urgent surgical intervention is required for all type A aneurysms If a skilled cardiovascular team is not available, the patient should be transferred to an appropriate facility The procedure involves grafting and replacing the diseased portion of the arch and brachiocephalic vessels as necessary Replacement of the aortic valve may be required with reattachment of the coronary arteries Urgent surgery is required for type B aneurysms if the dissection is continuing or there is aortic branch compromise Endovascular repair of type B dissections is the treatment of choice if it is anatomically feasible
Prognosis & Follow-up
The mortality rate for untreated type A dissections is approximately 1% per hour for 72 hours and over 90% at 3 months Mortality is also extremely high for untreated complicated type B dissections The surgical and endovascular options for these patients are technically demanding and require an experienced team to achieve perioperative mortalities of less than 10% Patients with uncomplicated type B dissections whose blood pressure is controlled and who survive the acute episode without complications may have long-term survival without surgical treatment Aneurysmal enlargement of the false lumen may develop in these patients despite adequate antihypertensive therapy Yearly CT scans are required to monitor the size of the dissecting aneurysm Indications for repair are similar to undissected thoracic aneurysms Endovascular covering of the intimal tear in the acute setting prevents this complication; trials are underway to determine the appropriateness of early endovascular treatment Indications for repair are similar to those of undissected thoracic aneurysms
Bortone AS et al Endovascular treatment of thoracic aortic disease: four years of experience Circulation 2004 Sep 14; 110(11 Suppl 1):II262 7 [PMID: 15364873] Ince H et al Diagnosis and management of patients with aortic dissection Heart 2007 Feb;93(2):266 70 [PMID: 17228080] Shiga T et al Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis Arch Intern Med 2006 Jul 10;166(13):1350 6 [PMID: 16831999]
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