Acute Aortic Disease.. - Index of

320 Hackmann et al.
Patients with Chronic Aortic Dissection
Similar to patients with small asymptomatic aneurysms, patients with chronic
descending aortic dissection receive nonoperative management (i.e., anti-impulse
therapy and imaging surveillance) until symptoms or significant aortic expansion
occur. Unfortunately, the current pharmacologic approach has limited efficacy.
Aneurysm expansion occurs in 43% to 81% of patients receiving nonoperative
management of chronic descending aortic dissection, and fatal rupture occurs in
up to 23% (87,129–132). Patients who ultimately require surgical treatment
undergo extensive aortic replacement, an operation that carries substantial morbidity
and mortality. Enhancements in pharmacologic treatment could improve
the prognosis of chronic dissection.
Patients with Predisposing Conditions
Many patients are born with disorders that predispose them to aortic dilatation and
aortic dissection. Patients with these conditions, including MFS, Ehlers–Danlos
syndrome type IV, Loeys-Dietz syndrome, and congenital bicuspid aortic valve,
often develop aortic complications at an early age (4,70,133). In addition, the
rates of rupture are higher in patients with these syndromes. Suppressive medical
therapy before aneurysm formation might dramatically alter the course for patients
with known matrix defects.
Similarly, the risk for developing aortic aneurysms and dissections is high
in some families. About 15% of patients diagnosed with AAAs have a first-degree
relative who had an AAA (134). Mutations causing familial predisposition to
TAAs and dissection have been described in several families (69,135,136). Young
patients with a known family history of aortic aneurysms or dissection are screened
aggressively so that aneurysms can be detected and treated before rupture. Longterm
suppressive therapy may reduce the incidence of aneurysms and decrease the
risk of dissection or rupture in these families.
Patients Undergoing Nonaortic Operations
Patients with aortic aneurysms who undergo nonaortic operations, such as cardiac,
abdominal, and orthopedic procedures, are at risk of postoperative aneurysm
rupture (137). Several retrospective or autopsy studies have suggested a 2% to 3%
risk of aneurysm rupture in the months after any major surgery. Postoperative
suppressive therapy may decrease this risk.
Patients Who Have Had Open or Endovascular Aortic Repair
Both open and endovascular repairs have limited durability. During open repair,
the prosthetic graft is sutured to aorta that is prone to continued deterioration,
resulting in new adjacent aneurysms or anastomotic pseudoaneurysms. The durability
of endovascular repair relies on the ability of the stent graft to maintain an