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Natural history of descending and thoracoabdominal aortic aneurysms
J S Coselli1, L F de Figueiredo
1Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
Insights
Descending and thoracoabdominal aortic aneurysms inevitably enlarge and rupture, often fatally. Operative repair is the most effective treatment, though endovascular repair may be an option for high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Aortic Disease
Background:
- Natural history data for descending and thoracoabdominal aortic aneurysms are scarce.
- Aneurysms are characterized by progressive enlargement and rupture, regardless of underlying cause.
- Thrombus and calcification do not prevent aneurysm progression.
Purpose of the Study:
- To review the natural history and management of descending and thoracoabdominal aortic aneurysms.
- To highlight factors influencing aneurysm progression and patient outcomes.
- To discuss current treatment strategies and emerging options.
Main Methods:
- Review of existing literature on descending and thoracoabdominal aortic aneurysms.
- Analysis of factors influencing natural history, including size, location, symptoms, and etiology.
- Evaluation of outcomes associated with nonoperative management and surgical repair.
Main Results:
- Aneurysm enlargement and rupture are the primary adverse events, leading to high mortality.
- Size, location, symptoms, and etiology significantly impact the natural history.
- Nonoperative management with close follow-up is supported for aneurysms <5 cm, except in Marfan syndrome.
- Operative repair is the most effective intervention to alter the disease course.
Conclusions:
- Descending and thoracoabdominal aortic aneurysms have a malignant natural history primarily due to rupture.
- Operative repair remains the gold standard for managing these aneurysms.
- Endovascular repair presents a potential alternative for select high-risk patients, but its role requires further definition.
Abstract:
Data on the natural history of descending and thoracoabdominal aneurysms are limited to a few studies. They demonstrated that, independent from the different mechanisms of injury and degeneration affecting the structural integrity of the aortic wall, the biologic fate of all aneurysms is progressive enlargement and rupture. Laminated thrombus and calcification do not prevent this process. The natural history is markedly influenced by size, location, symptoms, and etiology of thoracic aneurysms. They may develop symptoms related to mechanical compression of adjacent structures, but more frequently they are asymptomatic until rupture occurs. Usually, aortic rupture causes death by exsanguination and shock before bleeding can be controlled. Occasionally, rupture can be contained by the parietal pleura or occur towards the mediastinum, esophagus, pulmonary parenchyma, or bronchi. Untreated aneurysms will cause death in the majority of patients because of rupture. Recent data evaluating smaller and asymptomatic thoracic aneurysms with CT scan support nonoperative management and close follow-up of descending and thoracoabdominal aortic aneurysms only when the diameter is less than 5 cm. Patients with Marfan syndrome may be operated upon with smaller aneurysms. Independent of etiology, operative repair is the most effective means to alter the otherwise malignant course of descending and thoracoabdominal aortic aneurysms. The role of endovascular repair of these aneurysms remains to be established; however, it may represent an alternative to treat thoracic aneurysmal disease in very high risk patients.