Risk of rupture or dissection in descending thoracic aortic aneurysm.
BACKGROUND
Current practice guidelines recommend surgical repair of large thoracic aortic aneurysms to prevent fatal aortic dissection or rupture, but limited natural history data exist to support clinical criteria for timely intervention.


RESULTS
Of 3247 patients with thoracic aortic aneurysm registered in our institutional Thoracic Aortic Center Database, we identified and reviewed 257 nonsyndromic patients (age, 72.4±10.5 years; 143 female) with descending thoracic or thoracoabdominal aortic aneurysm without a history of aortic dissection in whom surgical intervention was not undertaken. The primary end point was a composite of aortic dissection/rupture and sudden death. Baseline mean maximal aortic diameter was 52.4±10.8 mm, with 103 patients having diameters ≥55 mm. During a median follow-up of 25.1 months (quartiles 1-3, 8.3-56.4 months), definite and possible aortic events occurred in 19 (7.4%) and 31 (12.1%) patients, respectively. On multivariable analyses, maximal aortic diameter at baseline emerged as the only significant predictor of aortic events (hazard ratio=1.12; 95% confidence interval, 1.08-1.15). Estimated rates of definite aortic events within 1 year were 5.5%, 7.2%, and 9.3% for aortic diameters of 50, 55, and 60 mm, respectively. Receiver-operating characteristic curves for discriminating aortic events were higher for indexed aortic sizes referenced by body size (area under the curve=0.832-0.889) but not significantly different from absolute maximal aortic diameter (area under the curve=0.805).


CONCLUSIONS
Aortic size was the principal factor related to aortic events in unrepaired descending thoracic or thoracoabdominal aortic aneurysm. Although the risk of aortic events started to increase with a diameter >5.0 to 5.5 cm, it is uncertain whether repair of thoracic aortic aneurysms in this range leads to overall benefit, and the threshold for repair requires further evaluation.
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.).
Joon Bum
JB
Kim
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.).
Kibeom
K
Kim
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.).
Mark E
ME
Lindsay
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.).
Thomas
T
MacGillivray
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.).
Eric M
EM
Isselbacher
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.).
Richard P
RP
Cambria
From Division of Cardiac Surgery (J.B.K., T.M., T.M.S.), Thoracic Aortic Center (J.B.K., K.K., T.M., E.M.I., R.P.C., T.M.S.), Cardiology Division (M.E.L., E.M.I.), Pediatric Cardiology (M.E.L.), and Vascular and Endovascular Surgery (R.P.C.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (J.B.K., M.E.L.). tsundt@partners.org.
Thoralf M
TM
Sundt
D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery; D001013:Aorta, Thoracic / Q000648:ultrastructure*; D017545:Aortic Aneurysm, Thoracic / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery; D001018:Aortic Diseases / Q000453:epidemiology; D001019:Aortic Rupture / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery; D050197:Atherosclerosis / Q000453:epidemiology; D016208:Databases, Factual; D003645:Death, Sudden / Q000453:epidemiology / Q000209:etiology; D003920:Diabetes Mellitus / Q000453:epidemiology; D004108:Dilatation, Pathologic / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006949:Hyperlipidemias / Q000453:epidemiology; D006973:Hypertension / Q000453:epidemiology; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D012372:ROC Curve; D012306:Risk; D012907:Smoking / Q000453:epidemiology
aneurysm; aorta; prognosis; risk factors; surgery