68

Anemia

Anemia
Erythropoietic System, Diseases of the

Aneurysm
Abnormal dilation of any vascular structure with the risk
of rupture.
Stroke, Interventional Radiology

Aneurysm, Aortic and Thoracic

R OBERT M ORGAN
St Georges NHS Trust, Blackshaw Road,
London, UK
robert.morgan@stgeorges.nhs.uk

Synonyms

syndrome, are of the fusiform type. Saccular aneurysms

refer to aneurysms where there is localized dilatation,
which is often confined to one side of the aortic wall.
Thoracic aneurysms are associated with hypertension,
coronary artery disease, and abdominal aortic aneurysms.
The main causes of TAA are atherosclerosis, hypertension, Marfans syndrome, EhlersDanlos syndrome,
and syphilis, mycotic aneurysms and connective tissue
disorders, e.g., ankylosing spondylitis, rheumatoid arthritis, Reiters disease, systemic lupus erythematosus.
The most frequent site of a TAA is the descending
aorta. In most patients, atherosclerosis is the underlying
cause of descending aortic and aortic arch aneurysms.
Aneurysms of the ascending aorta are often due to
cystic medial degeneration. These commonly start at
the aortic root and extend distally into the ascending
aorta. Ascending aortic aneurysms are commonly seen in
patients with Marfans syndrome, although in the
majority of patients atheroma is also the underlying
cause. False aneurysms are usually the result of previous
trauma that was not diagnosed at the time of the injury.
Such aneurysms usually occur around the aortic isthmus
just beyond the origin of the left subclavian artery. They
often involve the inferior surface of the aortic arch as it
becomes the descending aorta and a saccular configuration is not uncommon. Mycotic aneurysms are almost
all due to bacterial infection and in most cases are also
false aneurysms. Aneurysms of the descending aorta
may extend into the abdomen and are referred to as
thoracoabdominal aortic aneurysms.

Thoracic aneurysm; thoracic aortic aneurysm

Clinical Presentation
Definition
Aneurysmal enlargement of the thoracic aorta is
normally defined as permanent dilatation to at least
150% of normal size.

Pathogenesis/Histopathology
Similar to abdominal aortic aneurysms, the majority of
thoracic aortic aneurysms (TAAs) are caused by
atherosclerosis. Aneurysmal dilation may involve only a
portion of the thoracic aorta or the entire aorta may be
aneurysmal. TAAs can be classified by site, morphology,
and etiology. True aneurysms involve all the layers of the
aortic wall, while false aneurysms are essentially contained
ruptures and involve just the outer layers of the wall,
usually only the adventitia, surrounded by fibrosis related
to a previous hematoma. The majority of aneurysms,
including those due to atherosclerosis and Marfans

Aneurysms of the thoracic aorta are a disease of increasing

age and occur in males three times as commonly as in
females. They occur in 1:1,000 of the population.
Thoracic aneurysms are usually discovered by chance
on a routine chest radiograph. Clinical presentations
include substernal, back or shoulder pain, superior
vena cava syndrome (due to compression of the SVC),
dysphagia (due to esophageal compression), dyspnea,
stridor (due to airway compression), and hoarseness (due
to laryngeal nerve compression). Although TAAs may
present because of pressure effects on adjacent structures
as described, the main problem is rupture, which is
usually catastrophic and fatal. Around half of patients die
from the actual rupture, and coexisting medical disease
accounts for the rest. Natural history studies of patients
with untreated TAA estimate mortality rates of 50% after
5 years and 70% after 10 years. Eighty percent of thoracic
aneurysms detected at autopsy have ruptured. The risk of
rupture increases with aneurysm size and most aneurysms
rupture when they reach 10 cm in diameter (1).

Aneurysm, Aortic and Thoracic

Imaging of TAA
TAAs are the most common cause of a mediastinal
mass on chest radiography. Other chest radiographic
findings include a widened tortuous aorta and curvilinear
peripheral calcifications within the mediastinal mass.
The main modalities used to image the thoracic aorta
are computed tomography (CT) and magnetic resonance
imaging (MRI)/magnetic resonance angiography (MRA).
Most radiologists prefer CT to MR, although the relative
advantages of MR with respect to the non-use of ionizing radiation and iodinated contrast media are obvious.
Both axial images and multiplanar (MIP) reconstructions are necessary for an adequate assessment of the
thoracic aorta.
The normal diameters of the thoracic aorta are:
Aortic root
Ascending aorta 1 cm proximal to arch
Proximal descending aorta
Distal descending aorta

36 mm
35 mm
26 mm
24 mm

Transesophageal echocardiography is used as a supplementary technique in some patients, mainly those who
have aneurysmal aortic dissections, so as to locate the
main proximal fenestration when this is not clear from
either the CT or MR images.
The size criteria for treatment of TAAs vary widely
from center to center, which is often due to the individual
interventionalists enthusiasm, ability, and experience in
treating TAAs. Most operators would consider treating
fusiform aneurysms if they were 6 cm or larger. Because of
the relative paucity of data on the rupture rates of saccular
aneurysms, these types of aneurysms are often treated
when they are smaller than 6 cm.

Diagnosis
Thoracic aneurysms are diagnosed by imaging. In the
majority of patients, thoracic aneurysms are discovered as
a chance finding on chest radiographs that have been
obtained for other clinical indications. Patients presenting
with symptoms referable to the aneurysm undergo chest
radiography at first, followed by either CT or MRI to
evaluate the identity of mediastinal enlargement seen on
the chest x-ray.

Interventional Radiology Treatment

Since the early 1990s, many patients with aneurysms of
the descending aorta and some patients with aneurysms

69

involving the aortic arch have been treated by the

insertion of stent grafts into the aorta via small
arteriotomies in the femoral arteries.
The aim of therapy is to exclude the aneurysm sac
from the circulation to prevent further growth and
rupture. This is achieved by placing one or more stent
grafts in the aorta extending from the normal-caliber
proximal aorta through the aneurysm to the normalcaliber aorta inferiorly. Short aneurysms may only require
a single device; more extensive aneurysms may require
several overlapping devices (2).
While it is difficult to envisage aneurysms of the
ascending aorta being treated in this way in the near
future, with increasing physician experience and advances
in stent graft technology, it is predicted that most patients
with nonascending TAA will be treated by endografts
within a few years.

Stent Graft Designs

All stent grafts for use in the thoracic aorta consist of
a metallic mesh (the stent) made up of either nitinol or
stainless steel with a covering material (the graft)
consisting of either polyester, polytetrafluoroethylene
(PTFE), or dacron along the length of the stent. The
graft material is affixed to the stent either by multiple
small sutures or by enclosing the stent between two layers
of graft material. All stent grafts are of the self-expanding
type and are mounted on a delivery system whose function
is to advance the stent in a compressed state from the site of
access into the vascular system, usually the femoral arteries,
to the desired site of deployment. The stent graft is
compressed on the delivery system by a covering outer
sheath. When the outer sheath is retracted, the stent graft
is released and expands to its predetermined diameter by
its own radial force.
Several types of stent graft for use in the thoracic aorta
are currently available. The main types are the Valiant
endograft (Medtronic, Santa Rosa, CA) (Fig. 1), the Gore
TAG endograft (WM Gore, Flagstaff, AZ), and the Zenith
TX2 endograft (William Cook, Bjaeverskov, Denmark).
The devices are available in a range of lengths and
diameters. The range of diameters is from 22 mm to
46 mm and lengths vary from 100 mm to 200 mm.

Inclusion Criteria for Endografting

Suitability for treatment with a stent graft depends on the
presence of proximal (upper) and distal (lower) landing
zones of the normal-caliber aorta to place the ends of the
devices so that an effective seal can be achieved between
the stent graft and the aortic wall. The diameter criteria

70

Aneurysm, Aortic and Thoracic

Aneurysm, Aortic and Thoracic. Figure 2 A patient with a

65-mm diameter aneurysm of the descending thoracic
aorta.
Aneurysm, Aortic and Thoracic. Figure 1
endograft.

A Valiant

Stent Graft Insertion Procedure

for suitable landing zones are decided by the available
sizes of endografts. In general, devices should be oversized
by 1020% in relation to the landing zones to provide an
adequate seal. In practice, the maximum diameter for a
landing zone is 42 mm and the minimum landing zone
diameter is 18 mm. The landing zones should be at least
20 mm in length.
When aneurysms are close to or involve the aortic arch,
it is possible to extend the length of the proximal landing
zone by intentionally covering the left subclavian artery
with the stent graft. If this maneuver is still not likely to
produce a landing zone of adequate length, the landing
zone can be elongated by elective bypass of the left common
carotid artery to the right common carotid artery. It is even
possible to treat patients with aneurysms of the mid-aortic
arch, by elective bypass of the left common carotid and
innominate arteries to the mid-ascending aorta before
insertion of an endograft. If aneurysms extend into the
upper abdomen, the distal landing zone length can be
increased, if necessary, by bypass of one or more of the
celiac, superior mesenteric, and renal arteries.
The access arteries (iliac and femoral) should be
assessed for their ability to convey a stent graft delivery
system. If they are too diseased or tortuous to accept
passage of devices from a femoral arteriotomy, stents
can be introduced via other access arteries (often using
a surgical prosthetic conduit) including the common
iliac arteries, the abdominal aorta, the axillary arteries,
the subclavian arteries, or even the common carotid
arteries.

The devices are inserted as a combined procedure by an

interventional radiologist and a vascular surgeon. The
procedure is performed with the patient under general or
regional anesthesia, although stents can also be inserted
with the aid of local anesthesia alone. A diagnostic flush
catheter is placed in the proximal aorta via a brachial
artery or the contralateral femoral artery. Femoral
arteriotomy is performed, and an exchange length extra
stiff guidewire (e.g., Lunderquist wire, William Cook) is
advanced so that the tip is placed in the low ascending
aorta. The stent graft delivery system is advanced over
the guidewire to the desired site of deployment. Accurate
positioning is achieved by serial aortography. When the
correct position is achieved, the stent graft is released.
The stent graft should be molded by balloon dilatation to
achieve its full diameter and to eliminate folds in the
device (Figs. 2 and 3).

Results of Endografting
The technical success rates of stent grafting with immediate
exclusion of the aneurysm sac are 81100%. Mortality rates
are 210% for elective procedures and increase to 28% for
emergency procedures. These results are better than the
mortality rates reported in most surgical series, which are
around 1525%. Morbidity after endovascular repair is
substantially less than for open surgery. In most cases,
patients are discharged from hospital a few days after the

Aneurysm, Artery, Iliac

71

References
1.

2.

3.
4.

Ogilvie BC. The thoracic aorta. In: Grainger RG, Allison DJ, Adam A,
Dixon AK (eds) Diagnostic Radiology A textbook of medical
imaging. Churchill Livingstone, pp 953956
Dake MD, Miller DC, Mitchell RS et al (1998) The first generation
of endovascular stent-grafts for patients with aneurysms of the
descending thoracic aorta. J Thorac Cardiovasc Surg 116:689703
Black JH, Cambria RP (2006) Current results of open surgical repair
of descending thoracic aortic aneurysms. J Vasc Surg 43 Suppl A:611
Ouriel K, Greenberg RK (2003) Endovascular treatment of thoracic
aortic aneurysms. J Card Surg 18:455463

Aneurysm, Artery, Iliac

T ONY N ICHOLSON
Leeds Teaching Hospitals NHS Trust
Leeds, UK
Tony.Nicholson@leedsth.nhs.uk
Aneurysm, Aortic and Thoracic. Figure 3 The aneurysm
has been treated by the insertion of endografts into the
thoracic aorta.

procedure and in many cases they are not required to spend

time on the intensive care unit (3,4).
Similar to abdominal aortic aneurysm stent-grafting,
endoleaks are a problem with endovascular therapy for
thoracic aneurysms. The most common endoleak is an
attachment site (or type 1) endoleak. These may occur
immediately or during follow-up and should be treated
with additional overlapping devices. Type 3 leaks (between
adjacent devices or through disrupted grafts) may occur
and should also be treated with additional devices. Type 2
leaks from intercostals vessels supplying blood retrogradely into the aneurysm sac occur but are uncommon as
are other types of leak. The paraplegia rates are 12% and
are much lower than open surgery. The treatment of
acute paraplegia following thoracic stenting is immediate
catheter drainage of cerebrospinal fluid. Stroke is a more
common complication occurring at least twice as
commonly as paraplegia in most series.
The development of endografting revolutionized the
diagnosis and treatment of TAAs. Many patients with lifethreatening aneurysms of the descending aorta and aortic
arch who would hitherto have been refused surgery are
now treated with high success rates and low mortality and
morbidity at most large hospitals. Further research into
combined endografting and surgery, and the development
of fenestrated and branched endografts, may in the future
enable the majority of TAAs in all locations to be treated
without the need for a thoracotomy and cardiopulmonary
bypass.

Definition
Iliac aneurysms are pulsatile swellings of the iliac arteries
in the pelvis. An actual size definition is difficult and
an artery is usually said to be aneurysmal when it is
more than 50% larger than its counterpart but this is a
gray area.

Characteristics
Ninety percent are caused by atherosclerosis where a
marked decrease in aortic elastin, an increase in collagen
production and degradation, inflammatory changes, and
imbalances of matrix metalloproteinases and their inhibitors have been noted in pathologic studies. Ten percent are
mycotic, syphilitic, traumatic, iatrogenic, congenital (due to
persistence of the sciatic artery), or vasculitic. Genetic
predisposition plays some role, especially in disorders such
as Marfan disease and type IV Ehlers-Danlos syndrome.
Familial clustering of cases also have been documented.
They are found in 16% of patients with abdominal
aortic aneurysms (1). Isolated iliac artery aneurysms are
rare, being found in only 2% of patients (2) but rupture
has a high mortality rate. Eighty-nine percent occur in the
common iliac artery, 10% in the internal iliac artery, and
only 1% in the external iliac artery.
Clinical risk factors that predispose individuals to
these degenerative changes in the arterial wall include
smoking, advanced age, male sex, chronic obstructive
pulmonary disease (COPD), hypertension, and family
history.