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Natural history of descending thoracic and thoracoabdominal aneurysms
R B Griepp1, M A Ergin, J D Galla
1Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
Insights
Nearly 20% of patients with thoracic aortic aneurysms managed nonoperatively ruptured, indicating a need for more aggressive surgical intervention. Individualized rupture risk assessment can guide elective surgery decisions for high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Aortic Aneurysm Research
Background:
- Review of 165 patients with chronic dissecting and degenerative descending thoracic and thoracoabdominal aortic aneurysms.
- Initial management strategy was nonoperative for all patients.
- Objective was to identify factors predicting aneurysm rupture risk.
Purpose of the Study:
- To ascertain factors associated with a high risk of rupture in patients with chronic thoracic and thoracoabdominal aortic aneurysms.
- To compare risk factors in dissecting versus nondissecting aneurysms.
- To evaluate the outcomes of nonoperative management.
Main Methods:
- Utilized three-dimensional reconstructions of computed tomograph scans for aneurysm change monitoring.
- Compared risk factors between patients who experienced rupture, those recommended for operation, and those without rupture or operation.
- Analyzed patient demographics, comorbidities, pain characteristics, blood pressure, and aneurysm dimensions.
Main Results:
- Nondimensional risk factors for rupture included older age, chronic obstructive pulmonary disease, and persistent pain.
- Ruptured dissections had higher blood pressures and smaller descending thoracic aortic diameters (median 5.4 cm) than degenerative aneurysms (median 5.8 cm).
- Mortality from rupture was significantly higher in chronic dissections (9/10) versus nondissecting aneurysms (26/34).
Conclusions:
- Nonoperative management of chronic thoracic and thoracoabdominal aortic aneurysms resulted in rupture in almost 20% of patients.
- Findings suggest a more aggressive surgical approach may be warranted for these patients.
- Individualized 1-year rupture risk calculation can now inform decisions for offering elective surgery.
Background:
A review of 165 patients with chronic dissecting and degenerative aneurysms of the descending thoracic and thoracoabdominal aorta initially managed nonoperatively was carried out to ascertain factors associated with a high risk of rupture.
Methods:
Changes in the aneurysms were followed with three-dimensional reconstructions of computed tomograph scans. Risk factors were compared in patients with dissecting and nondissecting aneurysms who experienced rupture, in whom operation was recommended during the course of follow-up, and in those without rupture or operation.
Results:
Nondimensional variables associated with an enhanced risk of rupture include age, the presence of chronic obstructive pulmonary disease, and even uncharacteristic continued pain. Patients with rupture of dissections had significantly higher blood pressures than survivors, and significantly smaller maximal descending thoracic aortic diameters (median 5.4 cm) than patients with rupture of degenerative aneurysms (median 5.8 cm). The extent of the aneurysm, as reflected by the maximal abdominal aortic diameter, was a significant risk factor for rupture only in nondissecting aneurysms. Mortality from rupture was significantly higher in patients with chronic dissections than in patients with nondissecting aneurysms: 9/10 vs 26/34 (p = 0.004).
Conclusions:
Almost 20% of patients followed nonoperatively succumbed to rupture, suggesting that a more aggressive surgical approach toward patients with chronic aneurysms of the descending thoracic and thoracoabdominal aorta is warranted. An individualized risk of rupture within 1 year can now be calculated, and patients whose operative risk is lower than their calculated risk should be offered elective surgery.