Aortic Aneurysms - Abdominal Aortic Aneurysms (AAAs) ...

Aortic Aneurysms - Abdominal Aortic Aneurysms (AAAs) and Thoracic Aortic Aneurysms (TAAs) - Diagnosis and Management Summary

Abdominal Aortic Aneurysms (AAAs)

 • Etiology

     - Usually due to atherosclerotic disease

     - Risk factors: smoking, male sex, age, pre-existing atherosclerosis, obesity, HLD, HTN, FHx

 • Screening / Surveillance

     - ACC/AHA: One-time abd. ultrasound in all men >60 w/ FHx of AAA (IIC) and all men >65 that have ever smoked (IA)

     - USPSTF: One-time abd. ultrasound for men age 65-75 who have ever smoked (Grade B) and selective screening for male never smokers 65-75 (Grade C). Screening women not recommended.

     - Surveillance:

           3-3.4 cm: U/S q3y

           3.5-4.4 cm: U/S or CT q12mo

           4.5-5.4 cm: U/S or CT q6mo

 • Medical Treatment:

     - Smoking cessation (slows AAA growth by up to 25%)

     - Reduce BP in accordance with ACC/AHA standards

     - Meds: Statins (reduce all-cause mortality in pts s/p surgery); BBs (may slow expansion; IA for perioperative use); ACEi (controversial; may prevent rupture but may speed growth); low dose ASA (may slow growth); antibiotics (e.g., roxithromycin may reduce expansion rate, not mortality)

 • Surgical Treatment:

     - Men: >5.5cm OR growing at >0.5cm/yr OR symptomatic Women: >4.5-5cm (controversial)

     - Open repair (~4-6% 30 day mortality) vs. EVAR (only ~50% suitable, c/b endoleaks [continued blood flow into aneurysmal cavity, ~1% 30 day mortality]).

Thoracic Aortic Aneurysms (TAAs)

 • Etiology

      - Atherosclerotic: Majority of cases. Mostly in descending Ao. Risk factors: smoking, HLD, HTN

      - Structural/genetic: Mostly in root and ascending aorta. Causes: CTD disease (Marfan, Ehlers-Danlos, Loeys-Dietz), Turner, bicuspid AoV, trauma

      - Infectious: 3° syphilis, mycotic aneurysm (most common org: Staph spp., Salmonella spp.)

      - Inflammatory: GCA (~10% have TAA), Takayasu, RA, psoriasis, Behcet’s, Wegener’s, IgG4

 • Screening / Surveillance

      - General population: Not recommended

      - Indications: At time of dx of Marfan (IC), Turner (IC), Loeys-Dietz, Takayasu or GCA. 1st deg relatives of pt w/ TAA, dissection, bicuspid valve (IB/IC).

      - Surveillance: If aneurysm only, then same as AAA. If also with dissection, image at 1, 3, 6, & 12 months then annually. Image entire aorta (CT/MRI) if multiple aneurysms (~25% TAA will have AAA; ~25% AAA will have TAA).

 • Medical Treatment:

     - Reduce BP (<140/90 or <130/80 if DM or CKD; little actual evidence, IB)

     - BBs proven to decrease TAA growth in Marfan

     - ARBs slow aortic root aneurysm expansion in Marfan patients, likely via TGF-B inhibition

     - Statins LDL<70, some evidence

     - Smoking cessation; avoid straining

     - Stress test used to guide BP management (follow SBP response to stress)

 • Surgical Treatment:

     - Root/ascending TAAs: usually concomitant aortic valve replacement

     - Arch/descending TAAs: mostly open graft, (EVAR). Ischemic brain/spine injury most worrisome complication.

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