IR Playbook pp 197-207 | Cite as

Abdominal and Thoracic Aortic Aneurysms

  • Andy Lee
  • Michael D. DakeEmail author


The management of aortic aneurysms has evolved over the last 15 years from open surgical repair as the standard therapy to endovascular stent-graft placement as the treatment of choice in anatomically suitable patients. This chapter introduces the basic pathophysiology, clinical symptoms, and indications for repair of both abdominal (AAA) and thoracic aortic aneurysms (TAA) and describes the conventional approaches of conservative medical management and open surgical repair for these lesions. The concept and rationale supporting endovascular AAA repair (EVAR) and TAA repair (TEVAR) are presented. The importance of pre-procedure planning is emphasized, and a detailed “How To” section explains the technical steps of the procedures. The most common risks and complications of EVAR and TEVAR are reviewed, and tips to avoid these adverse events are provided.


Abdominal aortic aneurysm (AAA) Thoracic aortic aneurysm (TAA) Endovascular management EVAR TEVAR Crawford classification 


  1. 1.
    Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on reporting standards for arterial aneurysms, Ad Hoc committee on reporting standards, Society for vascular surgery and North American chapter, International society for cardiovascular surgery. J Vasc Surg. 1991;13:452.CrossRefPubMedGoogle Scholar
  2. 2.
    Brown PM, Pattenden R, Vernooy C, Zelt DT, Gutelius JR. Selective management of abdominal aortic aneurysms in a prospective measurement program. J Vasc Surg. 1996;23(2):213–20.CrossRefPubMedGoogle Scholar
  3. 3.
    Bown MJ, Sutton AJ, Bell PR, Sayers RDA. Meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg. 2002;89:714.CrossRefPubMedGoogle Scholar
  4. 4.
    Hoornweg LL, Storm-Versloot MN, Ubbink DT, Koelemay MJ, Legemate DA, Balm R. Meta-analysis on mortality of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2008;35:558.CrossRefPubMedGoogle Scholar
  5. 5.
    Parkinson F, Ferguson S, Lewis P, Williams IM, Twine CP. South East Wales vascular network. Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair. J Vasc Surg. 2015;61(6):1606–12. Epub 2015 Feb 7. Review.CrossRefPubMedGoogle Scholar
  6. 6.
    Karrowni W, Dughman S, Hajj GP, Miller FJ Jr. Statin therapy reduces growth of abdominal aortic aneurysms. J Investig Med. 2011;59(8):1239–43.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Golledge J, Muller J, Daugherty A, Norman P. Abdominal aortic aneurysm: pathogenesis and implications for management. Arterioscler Thromb Vasc Biol. 2006;26(12):2605–13. Epub 2006 Sep 14. Review.CrossRefPubMedGoogle Scholar
  8. 8.
    Kotze CW, Ahmed IG. “Etiology, pathogenesis and pathophysiology of aortic aneurysms.” Etiology and pathogenesis of aortic aneurysms, and aneurysm rupture edited by Reinhart Grundmann, Intech, 2011, 1–22.
  9. 9.
    Xu J, Shi GP. Vascular wall extracellular matrix proteins and vascular diseases. Biochem Biophys Acta. 2014;1842(11):2106–19. Epub 2014 Jul 18.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. 2005;111(6):816–28.CrossRefPubMedGoogle Scholar
  11. 11.
    Lee AM, Chaikof EL. Is the abdominal aortic aneurysm rupture rate decreasing? Adv Surg. 2013;47:271–86.CrossRefPubMedGoogle Scholar
  12. 12.
    Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. Society for vascular surgery. The care of patients with an abdominal aortic aneurysm: the society for vascular surgery practice guidelines. J Vasc Surg. 2009;50(4 Suppl):S2–49.CrossRefPubMedGoogle Scholar
  13. 13.
    Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117(14):1883–9.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Evans GH, Stansby G, Hamilton G. Suggested standards for reporting on arterial aneurysms. J Vasc Surg. 1992;15(2):456.CrossRefPubMedGoogle Scholar
  15. 15.
    Fillinger M. Who should we operate on and how do we decide: predicting rupture and survival in patients with aortic aneurysm. Semin Vasc Surg. 2007;20(2):121–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Darling RC. Ruptured arteriosclerotic abdominal aortic aneurysms. A pathologic and clinical study. Am J Surg. 1970;119(4):397–401.CrossRefPubMedGoogle Scholar
  17. 17.
    Lall P, Gloviczki P, Agarwal G, Duncan AA, Kalra M, Hoskin T, et al. Comparison of EVAR and open repair in patients with small abdominal aortic aneurysms: can we predict results of the PIVOTAL trial? J Vasc Surg. 2009;49(1):52–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Cao P, De Rango P, Verzini F, Parlani G, Romano L, Cieri E, CAESAR Trial Group. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomised trial. Eur J Vasc Endovasc Surg. 2011;41(1):13–25.CrossRefPubMedGoogle Scholar
  19. 19.
    Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database Syst Rev. 2012;3:CD001835.PubMedCentralGoogle Scholar
  20. 20.
    UK Small Aneurysm Trial Participants. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet. 1998;352:1649.CrossRefGoogle Scholar
  21. 21.
    Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1437.CrossRefPubMedGoogle Scholar
  22. 22.
    Ouriel K, Clair DG, Kent KC, Zarins CK. Positive impact of endovascular options for treating aneurysms early (PIVOTAL) investigators. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg. 2010;51:1081.CrossRefPubMedGoogle Scholar
  23. 23.
    United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med. 2010;362:1872.CrossRefGoogle Scholar
  24. 24.
    Brewster DC, Cronenwett JL, Hallett JW Jr, Johnston KW, Krupski WC, Matsumura JS, Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the joint council of the American association for vascular surgery and society for vascular surgery. J Vasc Surg. 2003;37(5):1106–17.CrossRefPubMedGoogle Scholar
  25. 25.
    Chang JB, Stein TA, Liu JP, Dunn ME. Risk factors associated with rapid growth of small abdominal aortic aneurysms. Surgery. 1997;121(2):117–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Brown LC, Powell JT, UK Small Aneurysm Trial Participants. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. Ann Surg. 1999;230(3):289–96.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Lederle FA. Should abdominal aortic aneurysm be managed differently in women? Scand J Surg. 2008;97(2):125–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Crawford ES, Cohen ES. Aortic aneurysm: a multifocal disease. Presidential address. Arch Surg. 1982;117(11):1393–400.CrossRefPubMedGoogle Scholar
  29. 29.
    Elefteriades JA. Indications for aortic replacement. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S5–9.; discussion S45-51. Scholar
  30. 30.
    von Allmen RS, Anjum A, Powell JT. Incidence of descending aortic pathology and evaluation of the impact of thoracic endovascular aortic repair: a population-based study in England and Wales from 1999 to 2010. Eur J Vasc Endovasc Surg. 2013;45(2):154–9. Epub 2012 Dec 29.CrossRefGoogle Scholar
  31. 31.
    Acosta S, Ogren M, Bengtsson H, Bergqvist D, Lindblad B, Zdanowski Z. Increasing incidence of ruptured abdominal aortic aneurysm: a population-based study. J Vasc Surg. 2006;44(2):237–43.CrossRefPubMedGoogle Scholar
  32. 32.
    Tsamis A, Krawiec JT, Vorp DA. Elastin and collagen fibre microstructure of the human aorta in aging and disease: a review. J R Soc Interface. 2013;10:20121004.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Safi HJ, Winnerkvist A, Miller CC 3rd, Iliopoulos DC, Reardon MJ, Espada R, Baldwin JC. Effect of extended cross-clamp time during thoracoabdominal aortic aneurysm repair. Ann Thorac Surg. 1998;66(4):1204–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Elefteriades JA, Farkas EA. Thoracic aortic aneurysm clinically pertinent controversies and uncertainties. J Am Coll Cardiol. 2010;55(9):841–57. Scholar
  35. 35.
    Davies RR, Gallo A, Coady MA, Tellides G, Botta DM, Burke B, et al. Novel measurement of relative aortic size predicts rupture of thoracic aortic aneurysms. Ann Thorac Surg. 2006;81:169.CrossRefPubMedGoogle Scholar
  36. 36.
    Davies RR, Goldstein LJ, Coady MA, Tittle SL, Rizzo JA, Kopf GS, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73:17.CrossRefPubMedGoogle Scholar
  37. 37.
    Coady MA, Rizzo JA, Hammond GL, Mandapati D, Darr U, Kopf GS, et al. What is the appropriate size criterion for resection of thoracic aortic aneurysms? J Thorac Cardiovasc Surg. 1997;113:476.CrossRefPubMedGoogle Scholar
  38. 38.
    Hiratzka LF, Creager MA, et al. Surgery for aortic dilatation in patients with bicuspid aortic valves: A statement of clarification from the American college of cardiology/american heart association task force on clinical practice guidelines. J Am Coll Cardiol. 2016;133:680. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease Representative Members*.Google Scholar
  39. 39.
    Lobato AC, Puech-Leão P. Predictive factors for rupture of thoracoabdominal aortic aneurysm. J Vasc Surg. 1998;27:446.CrossRefPubMedGoogle Scholar
  40. 40.
    Tambyraja AL, Murie JA, Chalmers RT. Prediction of outcome after abdominal aortic aneurysm rupture. J Vasc Surg. 2008;47(1):222–30. Epub 2007 Oct 24.CrossRefPubMedGoogle Scholar
  41. 41.
    Dueck AD, Kucey DS, Johnston KW, Alter D, Laupacis A. Survival after ruptured abdominal aortic aneurysm: effect of patient, surgeon, and hospital factors. J Vasc Surg. 2004;39:1253–60.CrossRefPubMedGoogle Scholar
  42. 42.
    Lovricevic I, Despot I, DeSyo D, et al. Ruptured abdominal aortic aneurysms–Ten-year experience: review of results and prognostic factors. Acta Clin Croat. 2000;39:33–9.Google Scholar
  43. 43.
    Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with result after five months. AMA Arch Surg. 1952;64(3):405–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Lam CR, Aram HH. Resection of the descending thoracic aorta for aneurysm; a report of the use of a homograft in a case and an experimental study. Ann Surg. 1951;134(4):743–52.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Mastroroberto P, Chello M. Emergency thoracoabdominal aortic aneurysm repair: clinical outcome. J Thorac Cardiovasc Surg. 1999;118(3):477–81. discussion 481-2.CrossRefPubMedGoogle Scholar
  46. 46.
    Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991;5(6):491–9.CrossRefGoogle Scholar
  47. 47.
    Schermerhorn ML, Bensley RP, Giles KA, Hurks R, Oʼmalley AJ, Cotterill P, et al. Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study. Ann Surg. 2012;256(4):651–8.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Giles KA, Hamdan AD, Pomposelli FB, Wyers MC, Dahlberg SE, Schermerhorn ML. Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms. J Endovasc Ther. 2009;16(5):554–64.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331(26):1729–34.CrossRefPubMedGoogle Scholar
  50. 50.
    Walsh SR, Tang TY, Sadat U, Naik J, Gaunt ME, Boyle JR, et al. Endovascular stenting versus open surgery for thoracic aortic disease: systematic review and meta-analysis of perioperative results. J Vasc Surg. 2008;47:1094.CrossRefPubMedGoogle Scholar
  51. 51.
    Cheng D, Martin J, Shennib H, Dunning J, Muneretto C, Schueler S, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010;55:986.CrossRefPubMedGoogle Scholar
  52. 52.
    Bavaria JE, Appoo JJ, Makaroun MS, Verter J, ZF Y, Mitchell RS, Gore TAG Investigators. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369.CrossRefPubMedGoogle Scholar
  53. 53.
    Ellozy SH, Carroccio A, Minor M, Jacobs T, Chae K, Cha A, et al. Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned. J Vasc Surg. 2003;38(4):676–83.CrossRefPubMedGoogle Scholar
  54. 54.
    Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg RJ, et al. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation. 2011;123(24):2848–55. Epub 2011 Apr 10. Erratum in: Circulation. 2012 Jan 17;125(2):e266.CrossRefPubMedGoogle Scholar
  55. 55.
    Malkawi AH, Hinchliffe RJ, Holt PJ, Loftus IM, Thompson MM. Percutaneous access for endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 2010;39(6):676–82. Epub 2010 Feb 24.CrossRefPubMedGoogle Scholar
  56. 56.
    Surowiec SM, Davies MG, Fegley AJ, Tanski WJ, Pamoukian VN, Sternbach Y, et al. Relationship of proximal fixation to postoperative renal dysfunction in patients with normal serum creatinine concentration. J Vasc Surg. 2004;39(4):804–10.CrossRefPubMedGoogle Scholar
  57. 57.
    Mills JL, Duong ST, Leon LR Jr, Goshima KR, Ihnat DM, Wendel CS, et al. Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate. J Vasc Surg. 2008;47(6):1141–9. Scholar
  58. 58.
    Zettervall SL, Ultee KH, Soden PA, Deery SE, Shean KE, Pothof AB, et al. Predictors of renal dysfunction after endovascular and open repair of abdominal aortic aneurysms. J Vasc Surg. 2017;65(4):991–6. Epub 2016 Sep 26.CrossRefPubMedGoogle Scholar
  59. 59.
    Messé SR, Bavaria JE, Mullen M, Cheung AT, Davis R, Augoustides JG, et al. Neurologic outcomes from high risk descending thoracic and thoracoabdominal aortic operations in the era of endovascular repair. Neurocrit Care. 2008;9(3):344–51. Scholar
  60. 60.
    Cambria RP, Clouse WD, Davison JK, Dunn PF, Corey M, Dorer D. Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval. Ann Surg. 2002;236:471.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    McGarvey ML, Cheung AT, Szeto W, Messe SR. Management of neurologic complications of thoracic aortic surgery. J Clin Neurophysiol. 2007;24:336.PubMedGoogle Scholar
  62. 62.
    Cheung AT, Weiss SJ, McGarvey ML, Stecker MM, Hogan MS, et al. Interventions for reversing delayed-onset postoperative paraplegia after thoracic aortic reconstruction. Ann Thorac Surg. 2002;74:413.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Vascular SurgeryBeth Israel Deaconess Medical CenterBostonUSA
  2. 2.Department of Cardiothoracic SurgeryStanford University Medical CenterStanfordUSA

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