MEDizzy - A 68-year-old man with a history of coronary artery disease

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Disorders of the Cardiovascular System

A 68-year-old man with a history of coronary artery disease is seen in his primary care clinic for complaint of cough with sputum production. His care provider is concerned about pneumonia, so a chest radiograph is ordered. On the chest radiograph, the aorta appears tortuous with a widened mediastinum. A contrast-enhanced CT of the chest confirms the presence of a descending thoracic aortic aneurysm measuring 4 cm with no evidence of dissection. What is the most appropriate management of this patient?

ExplanationDescending aortic aneurysms are most commonly associated with atherosclerosis. The average growth rate is approximately 0.1–0.2 cm yearly. The risk of rupture and subsequent management are related to the size of the aneurysm as well as symptoms related to the aneurysm. However, most thoracic aortic aneurysms are asymptomatic. When symptoms do occur, they are frequently related to mechanical complications of the aneurysm causing compression of adjacent structures. This includes the trachea and esophagus, and symptoms can include cough, chest pain, hoarseness, and dysphagia. The risk of rupture is approximately 2–3% yearly for aneurysms less than 4 cm and increases to 7% per year once the size is greater than 6 cm. Management of descending aortic aneurysms includes blood pressure control. Beta blockers are recommended because they decrease the contractility of the heart and thus decrease aortic wall stress, potentially slowing aneurysmal growth. Individuals with thoracic aortic aneurysms should be monitored with chest imaging at least yearly, or more frequently if new symptoms develop. This can include CT angiography, MRI, or transesophageal echocardiography. Operative repair is indicated if the aneurysm expands by more than 1 cm in a year or reaches a diameter of more than 5.5–6.0 cm. Endovascular stenting for the treatment of thoracic aortic aneurysms is a relatively new procedure with limited long-term results available. The largest study to date included more than 400 patients with a variety of indications for thoracic endovascular stents. In 249 patients, the indication for stent was thoracic aortic aneurysm. This study showed an initial success rate of 87.1%, with a 30-day mortality rate of 10%. However, if the procedure was done emergently, the mortality rate at 30 days was 28%. At 1 year, data were available on only 96 of the original 249 patients with degenerative thoracic aneurysms. In these individuals, 80% continued to have satisfactory outcomes with stenting and 14% showed growth of the aneurysm (LJ Leurs, J Vasc Surg 40:670, 2004). Ongoing studies with long-term follow-up are needed before endovascular stenting can be recommended for the treatment of thoracic aortic aneurysms, although in individuals who are not candidates for surgery, stenting should be considered.