Thoracic Aortic Aneurysm Workup

  • Author: Elaine Tseng; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Oct 21, 2011
 

Laboratory Studies

  • CBC count
  • Electrolyte evaluation and BUN/creatinine value: Determining renal function is important for stratifying morbidity.
  • Prothrombin time, international normalized ratio, and activated partial thromboplastin time
  • Blood type and crossmatch
  • Liver function tests and amylase lactate values: These tests are indicated for patients with acute dissection or risk of distal embolization.
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Imaging Studies

  • Chest radiograph
    • In the case of ascending aortic aneurysms, chest x-rays may reveal a widened mediastinum, a shadow to the right of the cardiac silhouette, and convexity of the right superior mediastinum. Lateral films demonstrate loss of the retrosternal air space. However, the aneurysms may also be completely obscured by the heart, and the chest x-ray appear normal.
    • Plain chest radiographs may show a shadow anteriorly and slightly to the left for arch aneurysms and posteriorly and to the left for descending thoracic aneurysms. Aortic calcification may outline the borders of the aneurysm in the anterior, posterior, and lateral views in both the chest and abdomen.
  • Echocardiography
    • Transthoracic echocardiography demonstrates the aortic valve and proximal aortic root. It may help detect aortic insufficiency and aneurysms of the sinus of Valsalva, but it is less sensitive and specific than transesophageal echocardiography.
    • Transesophageal echocardiography images show the aortic valve, ascending aorta, and descending thoracic aorta, but they are limited in the area of the distal ascending aorta, transverse aortic arch, and upper abdominal aorta. Transesophageal echocardiography can help accurately differentiate aneurysm and dissection, but the images must be obtained and interpreted by skilled personnel.
    • Ischemia may be evaluated using dipyridamole-thallium or dobutamine echocardiography scans.
  • Ultrasonography
    • Infrarenal abdominal aortic aneurysms may be visualized using ultrasonography, but these images do not help define the extent for thoracoabdominal aneurysms.
    • Carotid ultrasound may be needed for patients with carotid bruits, peripheral vascular disease, a history of transient ischemic attacks, or cerebrovascular accidents to evaluate for carotid disease.
    • Intraoperative intravascular ultrasound (IVUS) can also be used to provide additional anatomical information and guidance during placement of endovascular stents.
    • Intraoperative epiaortic ultrasound can be performed to scan the aorta for atherosclerotic disease or thrombus.
    • For more information, see Bedside Ultrasonography, Abdominal Aortic Aneurysm.
  • Aortography
    • Aortography images can delineate the aortic lumen, and they can help define the extent of the aneurysm, any branch vessel involvement, and the stenosis of branch vessels. It describes the takeoff of the coronary ostia.
    • For patients older than 40 years or those with a history suggestive of coronary artery disease, aortography helps evaluate coronary anatomy, ventricular function by ventriculography, and aortic insufficiency. It does not help in defining the size of the aneurysm because the outer diameter is not measured, which may miss dissections.
    • Disadvantages include the use of nephrotoxic contrast and radiation. The risk of aortography includes embolization from laminated thrombus and carries a 1% stroke risk.
  • Computed tomography scan
    • CT scans with contrast have become the most widely used diagnostic tool. They rapidly and precisely evaluate the thoracic and abdominal aorta to determine the location and extent of the aneurysm and the relationship of the aneurysm to major branch vessels and surrounding structures. They can help accurately determine the size of the aneurysm and assesses dissection, mural thrombus, intramural hematoma, free rupture, and contained rupture with hematoma.
    • Sagittal, coronary, and axial images may be obtained with 3-dimensional reconstruction. Stent graft planning for endovascular descending thoracic aneurysm repairs requires fine-cut images from the neck through the pelvis to the level of the femoral heads. The takeoff of the arch vessels is critical to determine the adequacy of the proximal landing zone, as is assessing the patency of the vertebral arteries, if the left subclavian artery should be covered by the stent graft. Assessment of the common femoral artery access is essential to determine the feasibility of large-bore sheath access. A spiral CT scan with 1-mm cuts and 3-dimensional reconstruction with the ability to make centerline measurements is crucial to stent graft planning.
    • Aortic size on imaging is widely used to guide clinical decision making in regards to patients who have thoracic aortic aneurysms. It has been found that the double-oblique plane yields improved agreement with planimetry and differed from the axial plane in proportion to aortic geometric obliquity; therefore, the double-oblique measurement is recommended.[19]
    • CT angiography may create multiplanar reconstructions and cines. This requires nephrotoxic contrast and radiation, but the procedure is noninvasive.
  • Magnetic resonance imaging
    • MRI and magnetic resonance angiography have the advantage of avoiding nephrotoxic contrast and ionizing radiation compared with CT scans.
    • MRI and magnetic resonance angiography can also help accurately demonstrate the location, extent, and size of the aneurysm and its relationship to branch vessels and surrounding organs. These studies also precisely reveal aortic composition. However, they are more time consuming, less readily available, and more expensive than CT scans.
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Other Tests

  • Electrocardiogram: Baseline ECG should be performed. Transthoracic echocardiograms noninvasively screen for valvular abnormalities and cardiac function.
  • Pulmonary function tests: Patients with a smoking history and COPD should be evaluated using pulmonary function tests with spirometry and room-air arterial blood gas determinations.
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Diagnostic Procedures

  • Cardiac catheterization: Patients with a history of coronary artery disease or those older than 40 years should undergo cardiac catheterization.
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Histologic Findings

Histologic findings may include elastic fiber fragmentation, loss of elastic fibers, loss of smooth muscle cells, cystic medial necrosis, intraluminal thrombus, and atherosclerotic plaque and ulceration.

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Contributor Information and Disclosures
Author

Elaine Tseng  MD, Associate Professor of Surgery, Division of Cardiothoracic Surgery, University of California at San Francisco Medical Center; Chief of Cardiac Surgery, San Francisco VA Medical Center

Elaine Tseng is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Errol L Bush, MD  Resident Physician, Division of Cardiothoracic Surgery, University of California San Francisco School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Benson B Roe, MD  Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center

Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shreekanth V Karwande, MBBS  Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center

Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

Additional Contributors

We would like to acknowledge Mabelle Cohen, MD for her efforts in the previous version of this update.

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