Thoracic Aortic Aneurysm Clinical Presentation

Updated: Jul 19, 2016
  • Author: Elaine Tseng, MD; Chief Editor: Mary C Mancini, MD, PhD, MMM  more...
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Presentation

History and Physical Examination

Most patients with aortic aneurysms are asymptomatic at the time of discovery. Thoracic aortic aneurysms (TAAs) are usually found incidentally after chest radiographs or other imaging studies. Abdominal aortic aneurysms (AAAs) may be discovered incidentally during imaging studies or a routine physical examination as a pulsatile abdominal mass.

The most common complication of AAAs is rupture with life-threatening hemorrhage manifesting as pain and hypotension. The triad of abdominal pain, hypotension, and a pulsatile abdominal mass is diagnostic of a ruptured AAA, and emergency operation is warranted without delay for imaging studies.

Patients with a variant of AAA may present with fever and a painful aneurysm with or without an obstructive uropathy. These patients may have an inflammatory aneurysm that can be treated with surgical repair.

Other presentations of AAA include lower-extremity ischemia, duodenal obstruction, ureteral obstruction, erosion into adjacent vertebral bodies, aortoenteric fistula (ie, gastrointestinal [GI] bleeding), and aortocaval fistula (caused by spontaneous rupture of aneurysm into the adjacent inferior vena cava [IVC]). Patients with aortocaval fistula present with abdominal pain, venous hypertension (ie, leg edema), hematuria, and high-output cardiac failure.

Patients with TAAs are often asymptomatic. Most patients are hypertensive but remain relatively asymptomatic until the aneurysm expands. Their most common presenting symptom is pain. Pain may be acute, implying impending rupture or dissection, or chronic, from compression or distention. The location of pain may indicate the area of aortic involvement, but this is not always the case. Ascending aortic aneurysms tend to cause anterior chest pain, whereas arch aneurysms more likely cause pain radiating to the neck. Descending thoracic aneurysms more likely cause back pain localized between the scapulae. When located at the level of the diaphragmatic hiatus, the pain occurs in the mid back and epigastric region.

Large ascending aortic aneurysms may cause superior vena cava obstruction manifesting as distended neck veins. Ascending aortic aneurysms also may develop aortic insufficiency, with widened pulse pressure or a diastolic murmur, and heart failure. Arch aneurysms may cause hoarseness, which results from stretching of the recurrent laryngeal nerves. Descending thoracic aneurysms and thoracoabdominal aneurysms may compress the trachea or bronchus and cause dyspnea, stridor, wheezing, or cough. Compression of the esophagus results in dysphagia.

Erosion into surrounding structures may result in hemoptysis, hematemesis, or GI bleeding. Erosion into the spine may cause back pain or instability. Spinal cord compression or thrombosis of spinal arteries may result in neurologic symptoms of paraparesis or paraplegia. Descending thoracic aneurysms may thrombose or embolize clot and atheromatous debris distally to visceral, renal, or lower extremities.

Patients who present with ecchymoses and petechiae may be particularly challenging because these signs probably indicate disseminated intravascular coagulation (DIC). The risk of significant perioperative bleeding is extremely high, and large amounts of blood and blood products must be available for resuscitative transfusion.

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Complications

The most common complications of TAAs are acute rupture and dissection. Some patients present with tender or painful nonruptured aneurysms. Although debate continues, these patients are thought to be at increased risk for rupture and should undergo surgical repair on an emergency basis.

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