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aortic aneurysm

Dilation of a segment of the aorta. Etiology: 1) atherosclerosis* 2) cystic medial degeneration a) Marfan's syndrome b) Ehlers-Danlos syndrome c) idiopathic d) most common cause of ascending thoracic aortic aneurysms 3) vasculitis a) Takayasu's arteritis b) Giant cell arteritis 4) spondyloarthropathy a) ankylosing spondylitis b) relapsing polychondritis c) Reiter's syndrome d) rheumatoid arthritis 5) congenital anomalies a) bicuspid aortic valve (cystic medial degeneration) b) coarctation of the aorta c) aneurysm of the sinuses of Valsalva 6) infection a) syphilis b) tuberculosis c) Staphylococcus d) Streptococcus e) Salmonella 7) trauma * factors that contribute to atherosclerosis, i.e. cigarette smoking, hypertension, hypercholesterolemia may be primary causes of aortic aneurysms Epidemiology: 1) 0.28% above age 80 2) 4-fold more common in men than women a) 0.046-0.055% of men b) 0.007-0.012% of women 3) more prevalent among whites than among blacks, Asians, & Hispanics Pathology: 1) altered expression & synthesis of types 1 & 3 procollagen 2) destruction of matrix by cytokine-induced matrix metallo- proteinases 3) medial neovascularization 4) fragmentation of elastin 5) increased collagen content 6) aorta becomes less distensible 7) increased tension of the aortic wall leads to progressive dilation Genetics: - see dilated aorta Clinical manifestations: 1) depend upon location & size of aneurysm 2) thoracic aortic aneurysms a) symptoms related to compression or erosion of adjacent structures b) dyspnea c) dysphagia d) hoarseness e) cough f) risk of rupture is directly related to size Laboratory: - thrombocytopenia may be observed secondary to consumption of platelets by thrombi in aneurysm - genetic testing (see dilated aorta) Special laboratory: 1) ultrasound a) transesophageal echocardiography (thoracic) b) abdominal ultrasound 2) angiography/aortography 3) 12-lead EKG prior to repair [4] Radiology: 1) computed tomography with contrast 2) magnetic resonance imaging Management: 1) pharmacologic agents to treat hypertension (acute) a) beta blockers - propranolol - initially 5 mg IV push - then, 1 mg IV q5 min up to 10 mg - labetalol - initially 5-10 mg IV q2min - 10-20 mg for 1st hr, then 40-120 mg/hr - metoprolol - initially 5 mg IV q2 min up to 15 mg - then 50 mg PO q6h - esmolol - 30 mg IV bolus - 3-12 mg/min IV b) vasodilators - calcium channel blockers - nifedipine: 10 mg SL; 10-40 mg PO q8h - nitrates - nitroprusside - initially 20 ug/min IV - then 20-800 ug/min IV - ACE inhibitors - enalaprilat - 0.625 mg IV - 0.625-5.0 mg IV q6h 2) chronic pharmaceutical management - beta blockers 3) surgery (aortic aneurysm repair) a) see thoracic aortic aneurysm &/or abdominal aortic aneurysm a) open surgery b) endovascular stent-graft via femoral arteriotomy - Aneurex & Ancure stent grafts FDA approved Sept 1999 4) diagnostic imaging every 6-12 months to assess progression & need for surgery 5) prophylaxis for bacterial endocarditis if aortic prosthesis used in repair [4] 6) prevention: - smoking cessation - regular exercise & a favorable diet (i.e., adequate intake of fruit, vegetables, & nuts)

Interactions

disease interactions

Related

aorta

Specific

abdominal aortic aneurysm (AAA) dissecting aortic aneurysm; aortic dissection (acute aortic syndrome) familial aortic aneurysm ruptured aortic aneurysm thoracic aortic aneurysm

General

dilated aorta vascular aneurysm

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 865
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006.
  3. Journal Watch, Mass Med Soc 20(1):7 (Jan 1) 2000
  4. Abdominal Aortic Aneurysm. Society for Vascular Surgery In: Anello J, Feinberg B, Heinegg J et al New Clinical Practice Guidelines, February 2018. Medscape. February 07, 2018 https://reference.medscape.com/viewarticle/892328 - Glovicki P, Lawrence PF, Forbes TL. Update of the Society for Vascular Surgery abdominal aortic aneurysm guidelines. J Vasc Surg. 2018 Jan;67(1):1. http://www.jvascsurg.org/article/S0741-5214(17)32369-8/fulltext
  5. Isselbacher EM, Preventza O, Hamilton Black J 3rd et al 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Dec 13;146(24):e334-e482. PMID: 36322642 PMCID: PMC9876736 (available on 2023-12-13)