Disease of the Great Vessel

Author: Fawwaz Shaw, MD
Institution: University of Washington
Date Reviewed: February 2014
Learning Domain: Adult Cardiac Surgery
Learning Objective: Understand the imaging techniques and measurements associated with aortic aneurysmal disease
PowerPoint File: Disease of the Great Vessel

 

Discussion Points

  • Best Imaging Modalities for Aneurysmal disease
  • Indications for Aneurysm resection with congenitally Bicuspid Aortic Valve Disease
    • Evolving Concepts
  • Which Operation to Perform ?
    • Bentall
    • AVR alone 
    • AVR with Ascending Aortic
    • Aortic Wrap?

 

Basic Definitions

  • Fusiform- symmetric enlargement 
  • Saccular- appears as an out pouching
  • Pseudoaneurysm – does not include all 3 layers
  • Aortic root-extends from the aortic annulus to the STJ. Includes the SoV and valve leaflets
  • STJ-point where the SoV end and the tubular aorta begins
  • Asc Ao- extends to the origin of the brachiocephalic artery
  • Arch-extends from brachiocephalic artery to left subclavian artery.

 

Which imaging modality?

  • CTA 
    • least operator dependent
    • provides most objective findings 
    • 3 scans (non enhanced, contrasted and delayed)
    • shorter time     
    • advanced post processing allows for precise measurements (Multiplanar reconstructions)
  • MR: 
    • Prone to artifacts
    • operator dependent     
    • longer scanning times 
    • not always accessible
  • Echo: 
    • Operator dependent 
    • TEE is invasive 
    • avoids contrasted media and radiation exposure 
    • portable
    • provides functional data 
    • difficult to image arch
    • 97-100% sensitivity and specificity at experienced centers

 

When to operate?

  • Symptomatic
  • 5.5 cm Ascending for non Marfan’s
  • 5 cm for Familial disorders or Marfan’s
  • 6.5 cm Descending for non Marfan’s
  • 6 cm Descending for Marfan’s

 

When does it rupture/dissect?

  • Elefteriades (2002):
  • Larger the aorta, the faster it grows.
  • “Hinge points”: Ascending aorta – 6 cm,  31% of patients would have ruptured or dissected. Descending aorta – 7cm, 43% of patients would have ruptured or dissected.
  • 10.8% yearly risk of death with ascending aneurysm >6 cm.

 

Learning Points

  • Aneurysm: Size >50% of normal aortic diameter.
  • Can be fusiform or saccular.
  • Incidence of aneurysm rupture is related to size.
  • Multiple imaging modalities exist to evaluate the aorta each with their individual benefits.
  • Treatment strategies with Bicuspid Aortic valve and Enlarged Ascending Aorta evolving