Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Thoracic Aortic Aneurysm Workup

  • Author: Elaine Tseng, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
 
Updated: Jul 20, 2016
 

Laboratory Studies

Laboratry studies to be consiered in this setting include the following:

  • Complete blood count (CBC)
  • Electrolyte evaluation and blood urea nitrogen (BUN)/creatinine value - Determining renal function is important for stratifying morbidity.
  • Prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT)
  • 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
Next

Imaging Studies

Chest radiography

In the case of ascending aortic aneurysms, chest x-rays may reveal a widened mediastinum (see the image below), 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.

Chest radiograph showing widening of the superior Chest radiograph showing widening of the superior mediastinum.

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 (TTE) 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 (TEE).

TEE 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. TEE 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 (AAAs) may be visualized by means of ultrasonography, but these images do not help define the extent of thoracoabdominal aortic aneurysms (TAAAs).

Carotid ultrasonography 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 ultrasonography (IVUS) can also be used to provide additional anatomic information and guidance during placement of endovascular stents.

Intraoperative epiaortic ultrasonography can be performed to scan the aorta for atherosclerotic disease or thrombus.

For more information, see Bedside Ultrasonography, Abdominal Aortic Aneurysm.

Aortography

Aortography (see the image below) can delineate the aortic lumen, and it 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.

Ascending aortogram showing ascending aortic aneur Ascending aortogram showing ascending aortic aneurysm. The patient also underwent computed tomography scanning.

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

Computed tomography (CT) with contrast has become the most widely used diagnostic tool. Contrast CT scans rapidly and precisely evaluate the thoracic and abdominal aorta to determine the location and extent of the aneurysm and the relation 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. (See the image below.)

Computed tomography scan depicting a descending th Computed tomography scan depicting a descending thoracic aortic aneurysm with mural thrombus at the level of the left atrium.

Sagittal, coronary, and axial images may be obtained with three-dimensional (3D) 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 3D 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 (TAAs). 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.[36]

CT angiography (CTA) may create multiplanar reconstructions and cines. This requires nephrotoxic contrast and radiation, but the procedure is noninvasive.

Magnetic resonance imaging

Compared with contrast CT, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have the advantage of avoiding nephrotoxic contrast and ionizing radiation.

MRI and MRA can also help accurately demonstrate the location, extent, and size of the aneurysm and its relation 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 is.

Previous
Next

Other Tests

Baseline electrocardiography (ECG) should be performed. Transthoracic echocardiograms noninvasively screen for valvular abnormalities and cardiac function.

Patients with a smoking history and chronic oibstructive pulmonary disease (COPD) should be evaluated by using pulmonary function tests with spirometry and room-air arterial blood gas determinations.

Patients with a history of coronary artery disease or those older than 40 years should undergo cardiac catheterization.

Previous
Next

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.

Previous
 
 
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, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, 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

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: Nothing to disclose.

Additional Contributors

Benson B Roe, MD 

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, Society of University Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

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

References
  1. Estes JE Jr. Abdominal aortic aneurysm: A study of 102 cases. Circulation. 1950. 2:258.

  2. Gross RE, Hurwitt ES, Bill AH Jr. Preliminary observations on the use of human arterial grafts in the treatment of certain cardiovascular defects. N Engl J Med. 1948. 239:578.

  3. LAM CR, ARAM HH. Resection of the descending thoracic aorta for aneurysm; a report of the use of a homograft in a case and an experimental study. Ann Surg. 1951 Oct. 134(4):743-52. [Medline]. [Full Text].

  4. Cooley DA, De Bakey ME. Resection of entire ascending aorta in fusiform aneurysm using cardiac bypass. J Am Med Assoc. 1956 Nov 17. 162(12):1158-9. [Medline].

  5. De Bakey ME, Crawford ES, Cooley DA, Morris GC Jr. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet. 1957 Dec. 105(6):657-64. [Medline].

  6. Deterling RA, Bhonslay SB. An evaluation of synthetic materials and fabrics suitable for blood vessel replacement. Surgery. 1955 Jul. 38(1):71-91. [Medline].

  7. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968 Jul. 23(4):338-9. [Medline]. [Full Text].

  8. Ross DN. Homograft replacement of the aortic valve. Lancet. 1962 Sep 8. 2:487.

  9. Barratt-Boyes BG. Homograft aortic valve replacement in aortic incompetence and stenosis. Thorax. 1964 Mar. 19:131-50. [Medline]. [Full Text].

  10. Sievers HH, Podszus G, Lange PE, Bürsch JH, Bernhard A. Replacement of the aortic root by free implantation of a stentless aortic porcine bioprosthesis in a patient with aneurysm of the sinuses of Valsalva. Thorac Cardiovasc Surg. 1985 Dec. 33(6):360-1. [Medline].

  11. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994 Dec 29. 331(26):1729-34. [Medline].

  12. US Food and Drug Administration (FDA). FDA Approves First-of-Kind Device to Treat Descending Thoracic Aneurysms. FDA Web site. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2005/ucm108424.htm. Accessed: October 5, 2009.

  13. Culliford AT, Ayvaliotis B, Shemin R, et al. Aneurysms of the ascending aorta and transverse arch: surgical experience in 80 patients. J Thorac Cardiovasc Surg. 1982 May. 83(5):701-10. [Medline].

  14. Cabrol C, Gandjbakhc I, Pavie A. Surgical treatment of ascending aortic pathology. J Card Surg. 1988 Sep. 3(3):167-80. [Medline].

  15. Donaldson RM, Ross DN. Composite graft replacement for the treatment of aneurysms of the ascending aorta associated with aortic valvular disease. Circulation. 1982 Aug. 66(2 Pt 2):I116-21. [Medline].

  16. Crawford ES, Saleh SA. Transverse aortic arch aneurysm: improved results of treatment employing new modifications of aortic reconstruction and hypothermic cerebral circulatory arrest. Ann Surg. 1981 Aug. 194(2):180-8. [Medline]. [Full Text].

  17. Crawford ES, Saleh SA, Schuessler JS. Treatment of aneurysm of transverse aortic arch. J Thorac Cardiovasc Surg. 1979 Sep. 78(3):383-93. [Medline].

  18. Colombi P, Rossi C, Porrini AM, Pellegrini A. Aneurysms involving the aortic arch. Report on thirteen surgically treated patients. Thorac Cardiovasc Surg. 1983 Aug. 31(4):234-8. [Medline].

  19. Ergin MA, Spielvogel D, Apaydin A, et al. Surgical treatment of the dilated ascending aorta: when and how?. Ann Thorac Surg. 1999 Jun. 67(6):1834-9; discussion 1853-6. [Medline].

  20. Galloway AC, Colvin SB, LaMendola CL, et al. Ten-year operative experience with 165 aneurysms of the ascending aorta and aortic arch. Circulation. 1989 Sep. 80(3 Pt 1):I249-56. [Medline].

  21. Donahoo JS, Brawley RK, Gott VL. The heparin-coated vascular shunt for thoracic aortic and great vessel procedures: a ten-year experience. Ann Thorac Surg. 1977 Jun. 23(6):507-13. [Medline].

  22. Livesay JJ, Cooley DA, Ventemiglia RA, et al. Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia. Ann Thorac Surg. 1985 Jan. 39(1):37-46. [Medline].

  23. Crawford ES, Snyder DM, Cho GC, Roehm JO Jr. Progress in treatment of thoracoabdominal and abdominal aortic aneurysms involving celiac, superior mesenteric, and renal arteries. Ann Surg. 1978 Sep. 188(3):404-22. [Medline]. [Full Text].

  24. Kitamura S, Onishi K, Nakano S, et al. Early and late results of the Bentall operation for annulo-aortic ectasia. J Cardiovasc Surg (Torino). 1983 Jan-Feb. 24(1):5-12. [Medline].

  25. Makaroun MS, Dillavou ED, Kee ST, Sicard G, Chaikof E, Bavaria J, et al. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J Vasc Surg. 2005 Jan. 41(1):1-9. [Medline].

  26. Fattori R, Nienaber CA, Rousseau H, Beregi JP, Heijmen R, Grabenwoger M, et al. Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg. 2006 Aug. 132(2):332-9. [Medline].

  27. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007 Feb. 133(2):369-77. [Medline].

  28. R. Scott Mitchell, Michel S. Makaroun, Gregario Sicard. A comparative trial of open versus stent graft repair of descending thoracic aneurysms. AATS 2005 Meeting Abstract. 2005.

  29. Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP,. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008 May. 47(5):912-8. [Medline].

  30. Greenberg RK, Lu Q, Roselli EE, Svensson LG, Moon MC, Hernandez AV. Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation. 2008 Aug 19. 118(8):808-17. [Medline].

  31. Cambria RP, Crawford RS, Cho JS, Bavaria J, Farber M, Lee WA. A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta. J Vasc Surg. 2009 Dec. 50(6):1255-64.e1-4. [Medline].

  32. Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, et al. Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms. Circulation. 2010 Jun 29. 121(25):2718-23. [Medline].

  33. Antoniou GA, El Sakka K, Hamady M, Wolfe JH. Hybrid treatment of complex aortic arch disease with supra-aortic debranching and endovascular stent graft repair. Eur J Vasc Endovasc Surg. 2010 Jun. 39(6):683-90. [Medline].

  34. Bavaria J, Milewski RK, Baker J, Moeller P, Szeto W, Pochettino A. Classic hybrid evolving approach to distal arch aneurysms: toward the zone zero solution. J Thorac Cardiovasc Surg. 2010 Dec. 140(6 Suppl):S77-80; discussion S86-91. [Medline].

  35. Lee WA, Daniels MJ, Beaver TM, Klodell CT, Raghinaru DE, Hess PJ Jr. Late outcomes of a single-center experience of 400 consecutive thoracic endovascular aortic repairs. Circulation. 2011 Jun 28. 123(25):2938-45. [Medline].

  36. Mendoza DD, Kochar M, Devereux RB, et al. Impact of image analysis methodology on diagnostic and surgical classification of patients with thoracic aortic aneurysms. Ann Thorac Surg. 2011 Sep. 92(3):904-12. [Medline].

  37. Davies RR, Gallo A, Coady MA, Tellides G, Botta DM, Burke B. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 2006 Jan. 81(1):169-77. [Medline].

  38. Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg. 2002 Nov. 74(5):S1877-80; discussion S1892-8. [Medline].

  39. Coady MA, Rizzo JA, Hammond GL, Mandapati D, Darr U, Kopf GS, et al. What is the appropriate size criterion for resection of thoracic aortic aneurysms?. J Thorac Cardiovasc Surg. 1997 Mar. 113(3):476-91; discussion 489-91. [Medline].

  40. Davies RR, Gallo A, Coady MA, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 2006 Jan. 81:169-77. [Medline].

  41. Svensson LG, Kouchoukos NT, Miller DC, Bavaria JE, Coselli JS, Curi MA. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008 Jan. 85(1 Suppl):S1-41. [Medline].

  42. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, ... Circulation. 2010 Apr 6. 121(13):e266-369. [Medline].

  43. Fergusson DA, Hebert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008 May 29. 358(22):2319-31. [Medline].

  44. Criado FJ, Abul-Khoudoud OR, Domer GS, McKendrick C, Zuzga M, Clark NS. Endovascular repair of the thoracic aorta: lessons learned. Ann Thorac Surg. 2005 Sep. 80(3):857-63; discussion 863. [Medline].

  45. Zipfel B, Hammerschmidt R, Krabatsch T, Buz S, Weng Y, Hetzer R. Stent-grafting of the thoracic aorta by the cardiothoracic surgeon. Ann Thorac Surg. 2007 Feb. 83(2):441-8; discussion 448-9. [Medline].

  46. Leurs LJ, Bell R, Degrieck Y, Thomas S, Hobo R, Lundbom J. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries. J Vasc Surg. 2004 Oct. 40(4):670-9; discussion 679-80. [Medline].

  47. Ergin MA, Spielvogel D, Apaydin A, Lansman SL, McCullough JN, Galla JD, et al. Surgical treatment of the dilated ascending aorta: when and how?. Ann Thorac Surg. 1999 Jun. 67(6):1834-9; discussion 1853-6. [Medline].

  48. Patel ND, Williams JA, Barreiro CJ, Bethea BT, Fitton TP, Dietz HC. Valve-sparing aortic root replacement: early experience with the De Paulis Valsalva graft in 51 patients. Ann Thorac Surg. 2006 Aug. 82(2):548-53. [Medline].

  49. Cabrol C, Pavie A, Mesnildrey P, Gandjbakhch I, Laughlin L, Bors V, et al. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg. 1986 Jan. 91(1):17-25. [Medline].

  50. Kouchoukos NT, Marshall WG Jr, Wedige-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg. 1986 Oct. 92(4):691-705. [Medline].

  51. LeMaire SA, Green SY, Sharma K, Cheung CK, Sameri A, Tsai PI, et al. Aortic root replacement with stentless porcine xenografts: early and late outcomes in 132 patients. Ann Thorac Surg. 2009 Feb. 87(2):503-12; discussion 512-3. [Medline].

  52. Ross D. Replacement of the aortic valve with a pulmonary autograft: the "switch" operation. Ann Thorac Surg. 1991 Dec. 52(6):1346-50. [Medline].

  53. US Food and Drug Administration (FDA). Zenith® TX2® Thoracic TAA Endovascular Graft with the H&LB One-Shot™ Introduction System - P070016. FDA Web site. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm074075.htm. Accessed: October 5, 2009.

  54. US Food and Drug Administration (FDA). Talent™ Thoracic Stent Graft System - P070007. FDA Web site. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm074063.htm. Accessed: October 5, 2009.

  55. Sweet MP, Hiramoto JS, Park KH, Reilly LM, Chuter TA. A standardized multi-branched thoracoabdominal stent-graft for endovascular aneurysm repair. J Endovasc Ther. 2009 Jun. 16(3):359-64. [Medline].

  56. Reilly LM, Chuter TA. Reversal of fortune: induced endoleak to resolve neurological deficit after endovascular repair of thoracoabdominal aortic aneurysm. J Endovasc Ther. 2010 Feb. 17(1):21-9. [Medline].

  57. Ullery BW, Cheung AT, Fairman RM, Jackson BM, Woo EY, Bavaria J, et al. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg. 2011 Sep. 54(3):677-84. [Medline].

  58. Criado FJ, Barnatan MF, Rizk Y, Clark NS, Wang CF. Technical strategies to expand stent-graft applicability in the aortic arch and proximal descending thoracic aorta. J Endovasc Ther. 2002 Jun. 9 Suppl 2:II32-8. [Medline].

  59. Schoder M, Lammer J, Czerny M. Endovascular aortic arch repair: hopes and certainties. Eur J Vasc Endovasc Surg. 2009 Sep. 38(3):255-61. [Medline].

  60. Jackson BM, Woo EY, Bavaria JE, Fairman RM. Gender analysis of the pivotal results of the Medtronic Talent Thoracic Stent Graft System (VALOR) trial. J Vasc Surg. 2011 Aug. 54(2):358-363.e1. [Medline].

 
Previous
Next
 
Chest radiograph showing widening of the superior mediastinum.
Computed tomography scan depicting a descending thoracic aortic aneurysm with mural thrombus at the level of the left atrium.
Ascending aortogram showing ascending aortic aneurysm. The patient also underwent computed tomography scanning.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.