Section I. Thoracic aortic aneurysm What is a thoracic aortic aneurysm? An aortic aneurysm is not a real tumor, but a localized or multiple outward expansion or bulging of the aorta due to various reasons, which is called “aneurysm-like”. An aneurysm is defined as a dilatation or bulge of the aortic diameter greater than 50% of the normal diameter of the artery. Thoracic aortic aneurysm refers to the aortic aneurysm from the aortic sinus, ascending aorta, aortic arch, descending aorta to the diaphragm level. Atherosclerosis is common over the age of 50, and is the first cause abroad; 2. Cystic mesangial necrosis or degenerative degeneration is common in young and middle-aged males, mostly in the aortic root, often accompanied by aortic valve insufficiency, and is the first cause in China; 3. Syphilis is a late complication of syphilitic arteritis, often arising 15-20 years after infection, and was the first cause before 1940; 6, congenital aneurysms are often associated with aortic constriction, ductus arteriosus, and diastematous malformation. According to the pathological anatomy, there are three types of aortic aneurysms: 1. true aortic aneurysms, which are formed by the pathological enlargement or protrusion of the aortic wall and the whole aortic wall. 2. Pseudoaneurysm refers to a tear or puncture in the wall of the aorta, and the blood flows out from the puncture and is wrapped in the adjacent tissue of the aorta to form a hematoma, mostly due to trauma. 3.Sealed aneurysm is also called aortic endothelial dissection. It is caused by a local tear of the intima and the strong impact of blood, which leads to the expansion of the intima and the formation of two chambers in the aorta. It can be divided into DeBakey type I, II and III according to the extent of entrapment. The natural course and prognosis of thoracic aortic aneurysms are generally sinister and have a poor prognosis. However, there are differences depending on the etiology, and the prognosis is significantly improved by surgical treatment. Clinical manifestations Symptoms: Pain: often the main symptom of aneurysm Compression symptoms: hoarseness, dyspnea, dysphagia Cardiac insufficiency and angina: often associated with aortic valve insufficiency Signs: Thoracic malformation Aneurysm compressing superior vena cava and innominate vein Facial and neck swelling, bruising One side vocal cord paralysis Cardiac signs Honor syndrome Diagnosis Clinical manifestations and signs can provide clues; UCG, CT+, CT+, MRI+ angiography 3-D imaging, MRI+contrast to confirm the diagnosis. Treatment 1. Ascending aortic aneurysm (1) Pouch-shaped: arterioplasty (2) Spindle-shaped aneurysm: artificial vessel replacement (3) Root aneurysm: Bentall, Wheat, Cabrol procedures Artificial vessel replacement Button Bentall procedure Classic Wheat procedure Modified Wheat procedure 2. Aortic arch aneurysm Deep hypothermic stop circulation 3. Descending aortic aneurysm Left heart diversion 4. Aortic stenting: Talent, applied clinically in 1996, more than 5000 cases since then. Advantages: low surgical mortality rate, 9.5~11%; less trauma, less complications, shorter hospital stay and faster recovery. Disadvantages: expensive. Indications: ① Aneurysm neck >1.0~1.5cm ②Landing Zone ③Aneurysm diameter <6cm ④Femoral artery diameter >8mm (24F catheter) Treatment effect Surgical treatment is better than non-surgical treatment Section 2 Aortic dissection Definition Aortic dissection is a rupture of the intima of the aorta caused by various reasons and the formation of an intramural hematoma between the intima and the middle and outer layers. Aortic dissection It forms a “double barrel aorta” or aneurysmal dilatation of the aorta. The incidence and natural course of the disease is 5-10 per million people; 90% of untreated coarctation aneurysms die within a year. Etiology 1. Hypertension and atherosclerosis, which is the leading cause in Europe and the United States (90%). 2. Cystic necrosis of the middle layer of the artery and Marfan’s syndrome, the first cause in China (92%). 3.Other. 1.Tear site: Ascending aorta 67%. Descending aorta 26%. Arch 5%. Abdomen 2%. The main factors causing endothelial tears: (1) Pathological changes in the middle layer of the aorta (underlying). (2) Aortic motion due to cardiac pulsation. (3) Impact of the left ventricular ejection on the arterial wall. Type I: Aortic dissection begins in the ascending aorta or the arch, and the dissection extends as far as the descending aorta or even to the femoral artery; or the dissection is located in the descending aorta and reverses to the ascending aorta; Type II: Aortic dissection with hematoma limited to the ascending aorta or the arch; Type III: Aortic dissection begins far from the opening of the left subclavian artery and extends downward to the diaphragm. Type III: Aortic dissection begins far from the opening of the left subclavian artery and does not extend downward beyond the diaphragm as type IIIa, and beyond the diaphragm as type IIIb. Miller’s Stanford typing according to surgical needs: Type A: Debakey type I + Debakey type II Type B: Debakey type III Clinical manifestations 1, pain: 90%; 10% painless. 2, hoarseness, dyspnea 3, heart failure, often with aortic valve closure insufficiency According to the need for surgery Miller’s Stanford staging: Type A: Debakey type I + Debakey type II Type B: Debakey type III Clinical manifestations 1, pain: 90%; 10% painless. 2.Heartiness and dyspnea. 3, Heart failure, often with aortic valve closure insufficiency. 4, stripping affecting the root aorta (Adamkiewiecz- artery): paralysis. 5, abdominal pain, intestinal necrosis. 6, Renal failure: oliguria, anuria. 7, sudden lower limb paralysis, Diagnosis Typical history + hypertension + aortic valve insufficiency or corresponding signs X-ray: widening of the mediastinum UCG: visible tear endothelial piece and true and false lumen blood flow CT: visible true and false lumen MRI: can confirm the diagnosis of the rupture site, the extent and type of tear Aortography and DSA: in the case of combined coronary artery disease Among them, the diagnostic rate of UCG + MRI can reach nearly 100%. Differential diagnosis 1.myocardial infarction 2.acute pulmonary embolism 3.acute abdomen 4.mediastinal tumor 5.cerebrovascular accident Treatment Principles of acute aortic coarctation aneurysm Once the aortic coarctation aneurysm is diagnosed, immediately admit to ICU, monitor blood pressure, heart rate, central venous pressure, urine volume, sedation, analgesia, hypotension, heart rate control, once the vital signs are stable, immediately complete UCG and MRI examination, and make good preoperative examination and preparation. Preoperative examination and preparation. Indications for medical treatment: acute Debakey type III without complications, chronic Debakey type III without complications, (no significant growth, true cavity enlargement) Debakey type I, Debakey type II with contraindications to surgery. Indications for surgical treatment: acute aortic coarctation aneurysms (Debakey type I, Debakey type II), Debakey type III with rupture precursors, signs and symptoms of invasion of vital organs (heart, kidneys, abdomen, lower limbs…) that continue to develop. Contraindications 1. cerebral complications. 2, rupture haemorrhage, shock. Surgical approach 1, Debakey type I and Debakey type II: surgical results (1-year survival rate 70-90%, 5-year survival rate 55-80%) are significantly better than conservative treatment ( 1-year survival rate 10%, 5-year survival rate <3%). 2.Debakey type III: the effect of medical and surgical treatment was similar in the near term (<1 year) and in the long term (5 years), with survival rates of 70-90% with surgery and 20-30% with conservative treatment.