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The Thoracic Aorta Everything You Wanted to Know….but were afraid to ask September 8, 2010 Bruce Margolis, DO, MBA ©2010 Genworth Financial, Inc. All rights.

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Presentation on theme: "The Thoracic Aorta Everything You Wanted to Know….but were afraid to ask September 8, 2010 Bruce Margolis, DO, MBA ©2010 Genworth Financial, Inc. All rights."— Presentation transcript:

1 The Thoracic Aorta Everything You Wanted to Know….but were afraid to ask September 8, 2010 Bruce Margolis, DO, MBA ©2010 Genworth Financial, Inc. All rights reserved. Company Confidential Thoracic Aorta 1

2 Agenda Anatomy Definitions Epidemiology Etiology Pathophysiology
Presentation Diagnosis Natural History Treatment Prognosis Underwriting Considerations Thoracic Aorta

3 Anatomy Thoracic Aorta

4 Definitions Normal Dimensions Dilation (Ballooning, Bulging, Ectasia)
Mid-descending mm Dilation (Ballooning, Bulging, Ectasia) Aneurysm Types Saccular Fusiform Definition When the diameter exceeds 4 cm or diameter exceeds 1.5 times normal Dissection Tear in vessel wall results in false lumen Type A – involves ascending aorta Type B – involves descending aorta Thoracic Aorta

5 Normal Aortic Dimensions
Hager A. et al.; J Thorac Cardiovasc Surg 2002;123: Thoracic Aorta

6 Aortic Aneurysm Thoracic Aorta

7 Aortic Aneurysm  (A) Tomodensitometric and (B) echocardiographic views of an aortic root aneurysm. Nataf P , Lansac E Heart 2006;92: Thoracic Aorta

8 Aortic Aneurysm Figure 23. Atherosclerotic vascular dis-ease in an aortic aneurysm. Axial postcontrast image (window = 440, level = 40) reveals a large contrast collection projecting from the undersurface of the aortic arch, consistent with aneurysm (arrow). the low attention material within the aneurysm represents thrombus Thoracic Aorta

9 Aortic Aneurysm Figure 24. Aortic aneurysm rupture. Axial postcontrast image (window = 440, level = 40) through the aortic arch reveals an aortic aneurysm with contrast penetrating the thrombus within the aneurysm (open arrow). Thoracic Aorta

10 Aortic Dissection Thoracic Aorta

11 Aortic Dissection Figure 12. Stanford type B (Debakey Type III) aortic dissection: descending thoracic aorta. (A) Axial postcontrast image (window = 440, level = 40) reveals intimal flap (arrow), t = true lumen, f = false lumen. (B) Oblique sagittal reconstruction reveals complex nature of the intimal flap (arrows). Thoracic Aorta

12 Epidemiology Thoracic aneurysms Thoracic aortic dissection
Prevalence greater than 3-4% of those over 65 6 cases per 100,000 person-years Incidence increasing In the top 15 causes of death Thoracic aortic aneurysm – rupture 3.5/100,000 persons Thoracic aortic dissection 2000 new cases/year Acute /100,000 persons Male:Female ratio 2:1 Thoracic Aorta

13 Etiologies Underlying Etiologies Risk Factors Atherosclerosis Marfan’s
Type IV Ehlers-Danlos Infection (syphillis) Arteritis (giant cell, Takayasu, Behcet’s) Trauma Risk Factors Smoking COPD HTN Male gender Older age High BMI Abnormal aortic valve (e.g., bicuspid valve) Family history Thoracic Aorta

14 Presentation Aneurysm Dissection Most asymptomatic
Superior vena cava syndrome Hoarseness Bronchial obstruction Dysphagia Hemoptysis Paralysis/paraplegia Lower extremity embolism Dissection Chest/back/neck pain Neurologic signs Horner syndrome Acute aortic regurgitation Thoracic Aorta

15 Diagnosis Chest x-ray Echocardiogram Aortography CT scan MRI
Widened mediastinum Echocardiogram Transthoracic – aortic root Transesophageal – ascending and descending Aortography Delineates the lumen CT scan Most widely used diagnostic tool MRI Avoids contrast dye Thoracic Aorta

16 Echocardiography Nataf P , Lansac E Heart 2006;92:1345-1352
Thoracic Aorta

17 ASI = aortic dia (cm)/body surface area (m2)
Natural History ASI = aortic dia (cm)/body surface area (m2) Thoracic Aorta

18 Natural History Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple Prediction Based on Size 304 patients; 58.9% male; median age 65.8 Aneurysm size – 43.7% were cm Location – 72% ascending Follow up – average 43.1 months End points 44 Death alone 15 Dissection alone 5 Rupture alone 4 Rupture and death (no dissection) Dissection, death (no rupture) 2 Dissection, rupture (no death) Dissection, rupture and death No. Patients Events Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

19 Natural History Cumulative incidence of acute dissection or rupture as a function of initial aneurysm size. Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

20 Kaplan-Meier cumulative hazard function of rupture or dissection.
Natural History Kaplan-Meier cumulative hazard function of rupture or dissection. Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

21 Natural History Average yearly rates of negative outcomes during the first 5 years after presentation Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

22 Kaplan-Meier cumulative hazard function of rupture.
Natural History Kaplan-Meier cumulative hazard function of rupture. Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

23 Kaplan-Meier cumulative survival before operative repair.
Natural History Kaplan-Meier cumulative survival before operative repair. Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

24 Kaplan-Meier cumulative survival
Natural History Kaplan-Meier cumulative survival Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

25 Kaplan-Meier cumulative survival
Natural History Kaplan-Meier cumulative survival Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

26 Kaplan-Meier cumulative survival
Natural History Kaplan-Meier cumulative survival Davies RR, et al. Ann Thorac Surg 2002;73:17 Thoracic Aorta

27 Treatment - Aneurysm Medical Surgical BP control Smoking cessation
No heavy lifting Surgical Dacron tube graft Ascending – may need to replace valve Arch – graft Descending – graft, stent grafts Thoracic Aorta

28 Treatment - Dissection
Type A Surgical Type B Medical Acute with rupture, leak or distal ischemia. Thoracic Aorta

29 Treatment – Indications for Intervention
Aortic size Ascending diameter >5.5 cm Descending diameter >6.5 cm Growth rate >1 cm/yr (avg ascending 0.07 cm/yr; descending 0.19 cm/yr) Symptomatic aneurysm Traumatic rupture Pseudoaneurysm Large saccular aneurysm Mycotic aneurysm Aortic coarctation Bronchial compression Aortobronchial or aortoesophageal fistuala Thoracic Aorta

30 Composite valve and graft replacement.
Treatment - Surgical  Composite valve and graft replacement. Nataf P , Lansac E Heart 2006;92: Thoracic Aorta

31 Complications Bleeding CVA – 2-5% CHF Respiratory failure Graft leaks
Fistula formation Spinal cord damage Renal failure Thoracic Aorta

32 Prognosis Aneurysm Dissection
Early post-op mortality 4-10%; lower for descending aneurysm repair; much higher for aortic arch repair Stroke occurs 2-5% Renal failure requiring dialysis – 7% Spinal cord injury – 3% Dissection Treated 10-yr survival rate 60% Type A 30% mortality surgical 60% mortality medical Type B 10% mortality medical Thoracic Aorta

33 Underwriting Approach and Considerations
Obtain cardiology and/or vascular medical records Review serial echos/scans as available Review blood pressure control Higher Risk Aneurysm >5 cm Poorly controlled blood pressure Increase in size >0.5 cm/yr Ongoing tobacco usage Associated cardiovascular disease (CAD, PVD, carotid disease) Non-atherosclerotic vascular disorders (Marfan’s, Ehlers-Danlos, etc) Lower Risk Aneurysm <5 cm/stable/ well followed Aneurysm repaired/stable Thoracic Aorta

34 In the end, it’s not what you call it………it’s size that matters!
Summary Thoracic aortic dilation/aneurysm fairly common with age Risk factors are traditional cardiovascular risk factors Most are asymptomatic Thoracic aortic rupture rare Thoracic dissection rare Ascending aorta most common site of aneurysm formation Low risk for aneurysms less than 4 cm REMEMBER In the end, it’s not what you call it………it’s size that matters! Thoracic Aorta


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