Thoracic Aneurysm Treatment & Management

  • Author: Bret P Nelson, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Sep 1, 2011
 

Prehospital Care

  • In patients with symptoms suggestive of thoracic aortic aneurysm (TAA), prehospital care should consist of ensuring adequate airway and breathing, providing oxygen via a nonrebreather mask, placing 2 large-bore intravenous lines, and providing continuous cardiac monitoring.
  • Patients who are unstable (often those with a ruptured aneurysm or dissection) may require airway protection, mechanical ventilation, and aggressive fluid resuscitation. Timely communication between prehospital care providers and the receiving hospital is important in ensuring that the proper resources are available and brought to bear rapidly.
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Emergency Department Care

  • Initial stabilization includes the following:
    • Placing 2 large-bore intravenous lines, administering 100% oxygen, and providing a cardiac monitor
    • Monitoring urine output
  • Consider alternate diagnoses. Until the diagnosis of thoracic aortic aneurysm (TAA) is established, be vigilant for other causes of symptoms, such as myocardial infarction (MI), aortic insufficiency, CHF, or pulmonary embolus.
  • Provide aggressive blood pressure control. Beta-blockers and nitrates are commonly used.[3]
  • For patients who are hemodynamically unstable, provide the following:
    • Aggressive fluid resuscitation (including blood products)
    • Placing an arterial line in the right radial artery (or in the left radial artery, if the systolic blood pressure on the left is higher), especially in patients who may have dissection or in those who are receiving intravenous nitroprusside and/or esmolol
    • Correction of coagulopathy
    • Immediate surgical consultation
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Consultations

  • Immediately consult with a cardiac surgeon (for ascending aorta or arch) or with a vascular surgeon (for descending aorta) for patients who are hemodynamically unstable or for patients with symptoms of a thoracic aneurysm. Anesthesia and operating room personnel need to be contacted in cases where emergent operative procedures are indicated.
  • Consult with a vascular surgeon or a cardiac surgeon and a radiologist to determine the optimal studies for assessing the anatomy of the thoracic aneurysm.
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Contributor Information and Disclosures
Author

Bret P Nelson, MD  Associate Professor of Emergency Medicine, Director of Emergency Ultrasound, Department of Emergency Medicine, Mount Sinai School of Medicine

Bret P Nelson, MD is a member of the following medical societies: American College of Emergency Physicians, American Institute of Ultrasound in Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Theodore I Benzer, MD, PhD  Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Eric M Isselbacher, MD  Associate Professor of Medicine, Harvard Medical School; Associate Director, Massachusetts General Hospital Heart Center; Co-Director, Thoracic Aortic Center, Massachusetts General Hospital

Eric M Isselbacher, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

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

Gary Setnik, MD  Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. Feb 15 2005;111(6):816-28. [Medline].

  2. Clouse WD, Hallett JW Jr, Schaff HV. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA. Dec 9 1998;280(22):1926-9. [Medline].

  3. Ince H, Nienaber CA. Etiology, pathogenesis and management of thoracic aortic aneurysm. Nat Clin Pract Cardiovasc Med. Aug 2007;4(8):418-27. [Medline].

  4. Coady MA, Rizzo JA, Elefteriades JA. Developing surgical intervention criteria for thoracic aortic aneurysms. Cardiol Clin. Nov 1999;17(4):827-39. [Medline].

  5. Coady MA, Rizzo JA, Goldstein LJ, Elefteriades JA. Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections. Cardiol Clin. Nov 1999;17(4):615-35; vii. [Medline].

  6. Barbant SD, Eisenberg MJ, Schiller NB. The diagnostic value of imaging techniques for aortic dissection. Am Heart J. Aug 1992;124(2):541-3. [Medline].

  7. Bickerstaff LK, Pairolero PC, Hollier LH, et al. Thoracic aortic aneurysms: a population-based study. Surgery. Dec 1982;92(6):1103-8. [Medline].

  8. Crawford ES, Cohen ES. Aortic aneurysm: a multifocal disease. Presidential address. Arch Surg. Nov 1982;117(11):1393-400. [Medline].

  9. Dapunt OE, Galla JD, Sadeghi AM, et al. The natural history of thoracic aortic aneurysms. J Thorac Cardiovasc Surg. May 1994;107(5):1323-32; discussion 1332-3. [Medline].

  10. Fuster V, Andrews P. Medical treatment of the aorta. I. Cardiol Clin. Nov 1999;17(4):697-715, viii. [Medline].

  11. Glade GJ, Vahl AC, Wisselink W, et al. Mid-term survival and costs of treatment of patients with descending thoracic aortic aneurysms; endovascular vs. open repair: a case-control study. Eur J Vasc Endovasc Surg. Jan 2005;29(1):28-34. [Medline].

  12. Guo DC, Papke CL, He R, Milewicz DM. Pathogenesis of thoracic and abdominal aortic aneurysms. Ann N Y Acad Sci. Nov 2006;1085:339-52. [Medline].

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

  14. Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg. Jan 1985;89(1):50-4. [Medline].

  15. Safi HJ, Miller CC. Thoracic vasculature. In: Townsend CM, Beauchamp DR, Evers MB, et al, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia, Pa: WB Saunders Co; 2001.

 
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Descending thoracic aortic aneurysm with mural thrombus at the level of the left atrium.
 
 
 
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