Thoracic Aneurysm Treatment & Management

Updated: Feb 05, 2020
  • Author: Bret P Nelson, MD; Chief Editor: Erik D Schraga, MD  more...
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Treatment

Prehospital Care

In patients with symptoms suggestive of thoracic aortic aneurysm (TAA), prehospital care should consist of ensuring adequate airway and ventilation, providing oxygen via a nonrebreather mask, placing two 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 two 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, congestive heart failure (CHF), or pulmonary embolus.

Provide aggressive blood pressure control. Beta-blockers and nitrates are commonly used. [9]

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

Patients with TAA who are symptomatic should only be transferred via advanced life support (ALS) system if the sending facility is unable to provide appropriate operative care.

Unstable patients with TAA usually require medical or surgical ICU admission for careful hemodynamic monitoring.

Patients who are symptomatic require admission, as do those in whom a final diagnosis is uncertain.

Some patients with complicating conditions, such as Marfan syndrome or another cardiovascular disease, may require admission for medical stabilization and for more urgent surgical repair, even if they are asymptomatic at presentation.

Indications for surgical repair include the following: [10]

  • Rupture

  • Acute dissection (ascending requires urgent intervention, whereas descending is managed medically or surgically, if vascular complications arise)

  • Symptomatic states, including pain, mediastinal organ compression, or aortic insufficiency severe enough to cause CHF or a dilated hypokinetic left ventricle

  • Rapid aneurysm growth rate

  • Absolute size (5.5 cm for ascending aortic aneurysm, 6.0 cm for descending aortic aneurysm; in patients with Marfan syndrome, 5.0 cm for ascending aortic aneurysm, 6.0 cm for descending aortic aneurysm)

Surgical and other interventional options for TAA repair include the following: [9]

  • Open approaches using cardiopulmonary bypass, hypothermia, and grafting

  • Endovascular stent grafting may be an option when TAA is limited to the descending aorta.

  • Complications of repair include paraplegia, renal failure, and intraoperative mortality.

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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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