The Practice Pulse August 2017
Management of Aortic Aneurysms
A thoracic aortic aneurysm, or abnormal bulge in a weakened wall of the aorta in the chest area, can cause a variety of symptoms and often life-threatening complications. Thoracic aortic aneurysms can involve any area of the aorta in the chest including the aortic root, ascending, arch, and descending aorta.
Thoracic aortic aneurysms affect about 15,000 people in the United States each year, and are the 13th leading cause of death. The decision on how to best treat a thoracic aneurysm or the aorta depends on its size and rate of its growth, location, overall assessment of functional capacity and health status. The risk of rupture increases when the aneurysm is larger than about twice the normal diameter of a healthy aorta, but can vary with the size of the patient.
We often consider the absolute size of the aneurysm, but then also consider its ratio to the patients’ normal aortic size in a different location. For example, an aneurysm of 5.0 cm would be worthy of further consideration and investigation particularly if the normal aorta in a different anatomic area was only 2.5 cm. Furthermore we also consider the size as indexed to body surface area at a rate of 2.5 cm/m2. In the same example of an aortic aneurysm at 5.0 cm would garner different levels of concern for a patient at 1.7 m2 vs a patient with a BSA of 2.4 m2.
Like many things in medicine it is important to individualize the plan to the patient while also following the general consensus guidelines for the disease process. Family history becomes a critical part of this individualization of the plan. A patient with a first degree relative that has suffered an aortic catastrophe may be considered for earlier intervention, as will those with known issues with connective tissue disorders.
Medical Management vs Surgical Correction?
Consideration of surgical repair is given with thoracic aneurysms at 5.5 cm but may be considered earlier for familial disorders such as Marfan syndrome, presence of symptoms (chest, back pain), aneurysm growth > 1 cm/year and/or signs of aortic dissection. Patients with any of these situations or family history of aortic catastrophe will be considered earlier for intervention.
The decision to proceed with surgical intervention vs ongoing medical management of the aneurysm can be difficult because of the multifactorial decision process. It is ideal to involve a surgical specialist in the treatment of aortic pathology in the decision process. It is only through careful evaluation of the patient and complete analysis of the risks of surgical intervention in comparison to the risks of rupture or dissection with medical management that an individualized care plan can be developed. The actual surgical repair can be either open surgery or minimally invasive endovascular repair depending on the exact location and anatomy of the abnormal aorta.
Medical management is considered for patients who are felt to have a lower risk of rupture or dissection than the risk of surgery. These recommendations include strict blood pressure and heart control (systolic blood pressure <120, HR 60-80) and risk factor modification including smoking cessation, cholesterol control and dietary reform if indicated. A CT scan remains the gold standard for monitoring the growth of aneurysms and will be ordered on a routine basis to determine the stability unless specific patient characteristics mandate an alternative form of aneurysm surveillance.
At The Florida Heart and Lung Institute we strive to develop care plans that cater to the individual needs of each patient and are able to offer complex aortic surgical repair if indicated. We also have a large cohort of patients we follow with ongoing medical management and longitudinal surveillance of their aortic aneurysm.
Charles T. Klodell, MD
The Latest Murmurs
Welcome Dr. Zeyl!
The Florida Heart & Lung Institute at North Florida Regional Medical Center is pleased to welcome new faculty member Dr. Thomas Zeyl, M.D. to the Cardiothoracic Surgery division. Thomas Zeyl, M.D., has held a longtime interest in cardiothoracic surgery, a passion that has grown over the years. Now, Dr. Zeyl will help transform lives at North Florida Regional Medical Center. He recently joined the Florida Heart and Lung Institute in partnership with Dr. Charles T.Klodell.
Through his training, Dr. Zeyl developed a special interest in aortic surgeries, including the surgical treatment of aortic aneurysms and aortic dissections. Dr. Zeyl also has expertise in the diagnosis and treatment of lung cancer, coronary artery disease and valvular abnormalities.
Dr. Zeyl came to NFRMC after completing his cardiothoracic surgery residency at the University of Florida in Gainesville, FL followed by two years of being an Attending Cardiothoracic Surgeon in Tennessee. He is certified by the American Board of Surgery and has advanced trauma life support and advanced cardiac life support certificates.
“We’re excited to have Dr. Zeyl join our practice and contribute his skill set to the extraordinary team of caregivers who are making a positive difference in patients’ lives every day,” said Dr. Charles Klodell the Surgical Director of the cardiovascular surgical service line at North Florida Regional Medical Center. “Dr. Zeyl will play an integral role in the strength of our diverse cardiovascular program and reinforce that superior care is available close to home. He is an outstanding addition to the team at the Florida Heart and Lung Institute and North Florida Regional Medical Center.”
Charles T. Klodell, MD
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For insights, answers to questions, or to share commentary contact: Aubrey Hall, NP and Publisher of The Practice Pulse, at Aubrey.email@example.com
Florida Heart and Lung Institute