Author + information
- Received May 28, 2009
- Revision received August 24, 2009
- Accepted August 31, 2009
- Published online March 2, 2010.
- ↵⁎Reprint requests and correspondence:
Dr. John A. Elefteriades, Cardiac Surgery, Yale University School of Medicine, Boardman 2, 333 Cedar Street, New Haven, Connecticut 06510
This paper addresses clinical controversies and uncertainties regarding thoracic aortic aneurysm and its treatment. 1) Estimating true aortic size is confounded by obliquity, asymmetry, and noncorresponding sites: both echocardiography and computed tomography/magnetic resonance imaging are necessary for complete assessment. 2) Epidemiology of thoracic aortic aneurysm. There has been a bona fide increase in incidence of aortic aneurysm making aneurysm disease the 18th most common cause of death. 3) Aortic growth rate. Although a virulentdisease, thoracic aortic aneurysm is an indolentprocess. The thoracic aorta grows slowly—0.1 cm/year. 4) Evidence-based intervention criteria. It is imperative to extirpate the thoracic aorta before rupture or dissection occurs; surgery at 5.0- to 5.5-cm diameter will prevent most adverse natural events. Symptomatic (painful) aneurysms must be resected regardless of size. 5) Development of nonsize criteria. Mechanical properties of the aorta deteriorate at the same 6 cm at which dissection occurs; elastic properties of the aorta may soon become useful intervention criteria. 6) Medical treatment of aortic aneurysm. Medical treatment is of unproven value, even beta-blockers and angiotensin-receptor blockers. 7) A genetic disease. Even non-Marfan aneurysms have a strong genetic basis. 8) Need for biomarkers. Virulent but silent, TAA cries out for a biomarker that can predict the onset of adverse events. Pathophysiologic understanding has led to identification of promising biomarkers, especially metalloproteinases. 9) Endovascular therapy for aneurysms. Endovascular therapy has burgeoned, despite the fact that the EVAR-2, DREAM, and INSTEAD trials showed no benefit at mid-term over medical or conventional surgical therapy. We must avoid “irrational exuberance.” 10) Inciting events for acute aortic dissection. Recent evidence shows that dissections are preceded by a specific severe exertional or emotional event. 11) “Silver lining” of aortic disease. Proximal aortic root disease seems to protect against arteriosclerosis.
- Received May 28, 2009.
- Revision received August 24, 2009.
- Accepted August 31, 2009.
- American College of Cardiology Foundation
- Estimating True Aortic Size (and Reconciling Discrepant Reports) Can Be Difficult
- Thoracic Aortic Aneurysm Is Increasing in Frequency
- The Dilated Thoracic Aorta Grows Slowly, in an Indolent Fashion
- Evidence-Based Size Criteria for Replacement of the Dilated Aorta Are Now Available
- Dissections Can and Do Occasionally Occur at Small Aortic Sizes
- Nonsize Engineering Criteria Are Evolving
- Drug Therapy for Thoracic Aortic Disease Is Largely Unproven
- Thoracic Aortic Aneurysm Is a Genetic Disease
- Genetic Testing for Clinical Purposes Is Still Controversial
- Biomarkers for Thoracic Aortic Aneurysm May Be on the Horizon
- Stent Therapy for Degenerative Aneurysms Is Burgeoning, But it May Be “The Emperor's New Clothes”
- The Date and Time That Acute Aortic Dissection Occurs Is NotRandom
- A Silver Lining in the Cloud of Aneurysm Disease
- Advances in Diagnosis and Treatment Envisioned for the Near Future