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1Thoracic Aorta The Thoracic Aorta Company Confidential Everything You Wanted to Know….but were afraid to ask September 8, 2010 Bruce Margolis, DO, MBA.

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Presentation on theme: "1Thoracic Aorta The Thoracic Aorta Company Confidential Everything You Wanted to Know….but were afraid to ask September 8, 2010 Bruce Margolis, DO, MBA."— Presentation transcript:

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

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

3 3Thoracic Aorta Anatomy

4 4Thoracic Aorta Definitions ‏ Normal Dimensions –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 –Types Type A – involves ascending aorta Type B – involves descending aorta

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

6 6Thoracic Aorta Aortic Aneurysm

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

8 8Thoracic Aorta 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

9 9Thoracic Aorta 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).

10 10Thoracic Aorta Aortic Dissection

11 11Thoracic Aorta 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).

12 12Thoracic Aorta Epidemiology ‏ Thoracic aneurysms –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 - 3.5/100,000 persons –Male:Female ratio 2:1

13 13Thoracic Aorta Etiologies ‏ Underlying Etiologies –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

14 14Thoracic Aorta Presentation ‏ Aneurysm –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 –Hoarseness –Acute aortic regurgitation

15 15Thoracic Aorta Diagnosis ‏ Chest x-ray –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

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

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

18 18Thoracic Aorta 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 Davies RR, et al. Ann Thorac Surg 2002;73:17 44Death alone 15Dissection alone 5Rupture alone 4Rupture and death (no dissection) 5Dissection, death (no rupture) 2Dissection, rupture (no death) 2Dissection, rupture and death No. PatientsEvents

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

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

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

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

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

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

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

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

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

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

29 29Thoracic Aorta 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

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

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

32 32Thoracic Aorta Prognosis ‏ Aneurysm –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 30% mortality surgical

33 33Thoracic Aorta 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

34 34Thoracic Aorta 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 In the end, it’s not what you call it………it’s size that matters! REMEMBER


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