今日の臨床サポート

胸部大動脈瘤

著者: 木村直行1) 自治医科大学さいたま医療センター 心臓血管外科

著者: 安達秀雄2) 練馬光が丘病院循環器センター/自治医科大学

監修: 今井靖 自治医科大学 薬理学講座臨床薬理学部門・内科学講座循環器内科学部門

著者校正/監修レビュー済:2021/09/15
参考ガイドライン:
  1. 日本循環器学会, 日本心臓血管外科学会, 日本胸部外科学会, 日本血管外科学会大動脈瘤・大動脈解離診療ガイドライン(2020年改訂版)
  1. American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine(https://www.onlinejacc.org/content/55/14/1509):2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease
  1. European Society of Cardiology(https://academic.oup.com/eurheartj/article/35/41/2873/407693):2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult
患者向け説明資料

概要・推奨   

  1. 最大径55 mm未満(症状なし、紡錘状瘤、半年で5 mm以上の瘤径拡大なし、マルファン症候群を除く)の胸部・胸腹部大動脈瘤に対し、内科治療が推奨される。
  1. 内科治療に関しては、血圧値130/80 mmHg未満を目標として血圧管理を行う(推奨度1)。
  1. 最大径55 mm未満でも急速拡大(最大径5 mm/半年以上)を認める場合、侵襲的治療を考慮する(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
木村直行 : 特に申告事項無し[2021年]
安達秀雄 : 特に申告事項無し[2021年]
監修:今井靖 : 講演料(第一三共株式会社)[2021年]

改訂のポイント:
  1. 日本循環器学会/日本心臓血管外科学会/日本胸部外科学会/日本血管外科学会合同ガイドライン 2020年改訂版 大動脈瘤・大動脈解離診療ガイドラインに基づき、診療と治療推奨レベルに関しての改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
ポイント:
  1. 胸部大動脈瘤とは、胸部大動脈壁の一部が全周性または局所性に拡大(正常径の1.5倍)または突出した状態と定義され、大動脈が全体にわたって拡大したものを大動脈拡張症(aortomegaly)と称する。
  1. 破裂前の早期発見、早期治療が重要である。胸部X線検査後、疑わしい場合、単純・造影CT/MRIによる精査を行う。多くが破裂するまで無症状であるが、動脈硬化性瘤がほとんどなため、高齢、高血圧、高脂血症、喫煙、家族歴(マルファン症候群など)などの動脈硬化あるいは動脈瘤の危険因子から上記疾患を疑う。非解離性大動脈瘤の発症のピークは、男性は70代、女性は80代である。
 
分類:
  1. 形状的に、大動脈全周の拡張である紡錘状瘤と、一部局所的に突出した嚢状瘤に分類される。また、形態別に、真性瘤(非解離性瘤)、仮性瘤、解離性瘤に分類され、部位別に、上行大動脈瘤(大動脈基部拡大を含む)、弓部大動脈瘤、胸部下行大動脈瘤、胸腹部大動脈瘤に分類される。原因別には、動脈硬化性、変性、炎症性、感染性、外傷、先天性などに分類され、動脈硬化性がほとんどを占める。
 
 
胸部大動脈瘤の存在部位による分類

出典

 
胸腹部大動脈瘤の分類

Crawford分類

出典

 
  1. Ⅰ型:近位胸部下行大動脈から始まり腎動脈上で終わる。
  1. Ⅱ型:近位胸部下行大動脈から始まり腎動脈下で終わる。
  1. Ⅲ型:遠位胸部下行大動脈から始まる。
  1. Ⅳ型:横隔膜以下の腹部大動脈に限局するが、腹部大動脈のほとんどを巻き込んでいる。
問診・診察のポイント  
症状:
  1. 破裂するまで、ほとんどが無症状であるが、動脈の拡張により神経などを圧迫することにより症状を認めることがある。

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文献 

著者: Alexander J Fletcher, Maaz B J Syed, Timothy J Aitman, David E Newby, Niki L Walker
雑誌名: Circulation. 2020 May 12;141(19):1570-1587. doi: 10.1161/CIRCULATIONAHA.119.043756. Epub 2020 May 11.
Abstract/Text Inherited thoracic aortopathies denote a group of congenital conditions that predispose to disease of the thoracic aorta. Aortic wall weakness and abnormal aortic hemodynamic profiles predispose these patients to dilatation of the thoracic aorta, which is generally silent but can precipitate aortic dissection or rupture with devastating and often fatal consequences. Current strategies to assess the future risk of aortic dissection or rupture are based primarily on monitoring aortic diameter. However, diameter alone is a poor predictor of risk, with many patients experiencing dissection or rupture below current intervention thresholds. Developing tools that improve the risk assessment of those with aortopathy is internationally regarded as a research priority. A robust understanding of the molecular pathways that lead to aortic wall weakness is required to identify biomarkers and therapeutic targets that could improve patient management. Here, we summarize the current understanding of the genetically determined mechanisms underlying inherited aortopathies and critically appraise the available blood biomarkers, imaging techniques, and therapeutic targets that have shown promise for improving the management of patients with these important and potentially fatal conditions.

PMID 32392100  Circulation. 2020 May 12;141(19):1570-1587. doi: 10.116・・・
著者: Gonzalo Albornoz, Michael A Coady, Michele Roberts, Ryan R Davies, Maryann Tranquilli, John A Rizzo, John A Elefteriades
雑誌名: Ann Thorac Surg. 2006 Oct;82(4):1400-5. doi: 10.1016/j.athoracsur.2006.04.098.
Abstract/Text BACKGROUND: We examined the genetic nature and phenotypic features of thoracic aortic aneurysms (TAAs) and dissections in a large cohort of patients.
METHODS: Interviews were conducted with 520 patients with TAAs and their pedigrees were compiled to identify family members with aneurysms. Study patients were divided into three groups: 101 non-Marfan patients, in 88 pedigrees, had a family pattern for TAA (familial group), 369 had no family pattern (sporadic group), and 50 had Marfan syndrome (MFS). We determined incidence of familial clustering, age at presentation, rate of aneurysm growth, incidence of hypertension, correlation of aneurysm sites among kindred, and pedigree inheritance patterns.
RESULTS: An inherited pattern for TAA was present in 21.5% of non-MFS patients. The predominant inheritance pattern was autosomal dominant (76.9%), with varying degrees of penetrance and expressivity. The familial TAA group was significantly younger than the sporadic group (p < 0.0001), but not as young as the MFS group (p < 0.0001) (mean ages, 58.2 versus 65.7 versus 27.4 years). Among all 197 probands and kindred with aneurysm, 131 (66.5%) had TAA, 49 (24.9%) had abdominal aortic aneurysm (AAA), and 17 (8.6%) had cerebral or other aneurysms. Ascending aneurysm paired most commonly with ascending, and descending with abdominal. Abdominal aortic aneurysms (AAAs) and hypertension were more often associated with descending than with ascending TAAs (p < 0.001). Aortic growth rate was highest for the familial group (0.21 cm/y), intermediate for the sporadic group (0.16 cm/y), and lowest for the Marfan group (0.1 cm/y; p < 0.01).
CONCLUSIONS: TAAs are frequently familial diseases. The predominant mode of inheritance is autosomal dominant. Familial TAAs have a relatively early age of onset. Aneurysms in relatives may be seen in the thoracic aorta, the abdominal aorta, or the cerebral circulation. Screening of first-order relatives of probands with TAA is essential. Familial TAAs tend to grow at a higher rate, exemplifying a more aggressive clinical entity.

PMID 16996941  Ann Thorac Surg. 2006 Oct;82(4):1400-5. doi: 10.1016/j.・・・
著者: Bulat A Ziganshin, Panagiotis Theodoropoulos, Mohammad N Salloum, Khaled J Zaza, Maryann Tranquilli, Hamid R Mojibian, Neera K Dahl, Hai Fang, John A Rizzo, John A Elefteriades
雑誌名: J Am Heart Assoc. 2016 Jan 8;5(1). doi: 10.1161/JAHA.115.002248. Epub 2016 Jan 8.
Abstract/Text BACKGROUND: Thoracic aortic aneurysm is usually a clinically silent disease; timely detection is largely dependent upon identification of clinical markers of thoracic aortic disease (TAD); (bicuspid aortic valve, intracranial aortic aneurysm, bovine aortic arch, or positive family history). Recently, an association of simple renal cysts (SRC) with abdominal aortic aneurysm and aortic dissection was established. The aim of our study was to evaluate the prevalence of SRC in patients with TAD in order to assess whether the presence of SRC can be used as a predictor of TAD.
METHODS AND RESULTS: We evaluated the prevalence of SRC in 842 patients with TAD (64.0% males) treated at our institution from 2004 to 2013 and compared to a control group of patients (n=543; 56.2% males). Patients were divided into 4 groups: ascending aortic aneurysm (456; 54.2%); descending aortic aneurysm (86; 10.2%); type A aortic dissection (118; 14.0%); and type B aortic dissection (182; 21.6%). SRC were identified by abdominal computed tomography or magnetic resonance imaging of these patients. Prevalence of SRC is 37.5%, 57.0%, 44.1%, and 47.3% for patients with ascending aneurysm, descending aneurysm, type A dissection, and type B dissection, respectively. Prevalence of SRC in the control group was 15.3%. Prevalence of SRC was not significantly different between male and female aortic disease patients, despite reported general male predominance (2:1), which was also observed in our control group (1.7:1).
CONCLUSIONS: This study establishes an increased prevalence of SRC in patients with TAD. SRC can potentially be used as a marker for timely detection of patients at risk of TAD.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
PMID 26746998  J Am Heart Assoc. 2016 Jan 8;5(1). doi: 10.1161/JAHA.11・・・
著者: Julia Dumfarth, Alan S Chou, Bulat A Ziganshin, Rohan Bhandari, Sven Peterss, Maryann Tranquilli, Hamid Mojibian, Hai Fang, John A Rizzo, John A Elefteriades
雑誌名: J Thorac Cardiovasc Surg. 2015 Jun;149(6):1586-92. doi: 10.1016/j.jtcvs.2015.02.019. Epub 2015 Feb 14.
Abstract/Text OBJECTIVE: To examine the potential of aortic arch variants, specifically bovine aortic arch, isolated left vertebral artery, and aberrant right subclavian artery, as markers for thoracic aortic disease (TAD).
METHODS: We screened imaging data of 556 patients undergoing surgery due to TAD for presence of aortic arch variations. Demographic data were collected during chart review and compared with a historical control group of 4617 patients.
RESULTS: Out of 556 patients with TAD, 33.5% (186 patients) demonstrated anomalies of the aortic arch, compared with 18.2% in the control group (P < .001). Three hundred seventy (66.5%) had no anomaly of the aortic arch. Bovine aortic arch emerged as the most common anomalous branch pattern with a prevalence of 24.6% (n = 137). Thirty-five patients (6.3%) had an isolated left vertebral artery, and 10 patients (1.8%) had an aberrant right subclavian artery. When compared with the control group, all 3 arch variations showed significant higher prevalence in patients with TAD (P < .001). Patients with aortic aneurysms and anomalous branch patterns had hypertension less frequently (73.5% vs 81.8%; P = .048), but had a higher rate of bicuspid aortic valve (40.8% vs 30.6%; P = .042) when compared with patients with aneurysms but normal aortic arch anatomy. Patients with aortic branch variations were significantly younger (58.6 ± 13.7 years vs 62.4 ± 12.9 years; P = .002) and needed intervention for the aortic arch more frequently than patients with normal arch anatomy (46% vs 34.6%; P = .023).
CONCLUSIONS: Aortic arch variations are significantly more common in patients with TAD than in the general population. Atypical branching variants may warrant consideration as potential anatomic markers for future development of TAD.

Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
PMID 25802134  J Thorac Cardiovasc Surg. 2015 Jun;149(6):1586-92. doi:・・・
著者: Adam J Brownstein, Syed Usman Bin Mahmood, Ayman Saeyeldin, Camilo Velasquez Mejia, Mohammad A Zafar, Yupeng Li, John A Rizzo, Neera K Dahl, Young Erben, Bulat A Ziganshin, John A Elefteriades
雑誌名: Open Heart. 2019;6(1):e000862. doi: 10.1136/openhrt-2018-000862. Epub 2019 Jan 28.
Abstract/Text Objective: This study aimed to assess the prevalence of thoracic aortic disease (TAD) and abdominal aortic aneurysms (AAA) among patients with simple renal cyst (SRC) and bovine aortic arch (BAA).
Methods: Through a retrospective search for patients who underwent both chest and abdominal CT imaging at our institution from 2012 to 2016, we identified patients with SRC and BAA and propensity score matched them to those without these features by age, gender and presence of hypertension, hyperlipidaemia, diabetes and chronic kidney disease.
Results: Of a total of 35 498 patients, 6366 were found to have SRC. Compared with the matched population without SRC, individuals with SRC were significantly more likely to have TAD (10.1% vs 3.9%), ascending aortic aneurysm (8.0% vs 3.2%), descending aortic aneurysm (3.3% vs 0.9%), type A aortic dissection (0.6% vs 0.2%), type B aortic dissection (1.1% vs 0.3%) and AAA (7.9% vs 3.3%). The 920 patients identified with BAA were significantly more likely to have TAD (21.8% vs 4.5%), ascending aortic aneurysm (18.4% vs 3.2%), descending aortic aneurysm (6.5% vs 2.0%), type A aortic dissection (1.4% vs 0.4%) and type B aortic dissection (2.4% vs 0.7%) than the matched population without BAA. SRC and BAA were found to be significantly associated with the presence of TAD (OR=2.57 and 7.69, respectively) and AAA (OR=2.81 and 2.56, respectively) on multivariable analysis.
Conclusions: This study establishes a substantial increased prevalence of aortic disease among patients with SRC and BAA. SRC and BAA should be considered markers for aortic aneurysm development.

PMID 30774963  Open Heart. 2019;6(1):e000862. doi: 10.1136/openhrt-201・・・
著者: Dan Laukka, Emily Pan, Terhi Fordell, Kemal Alpay, Melissa Rahi, Jussi Hirvonen, Jaakko Rinne, Jarmo Gunn
雑誌名: J Vasc Surg. 2019 Dec;70(6):1801-1808. doi: 10.1016/j.jvs.2019.01.066. Epub 2019 Jul 18.
Abstract/Text OBJECTIVE: The prevalence of intracranial aneurysms (IAs) is higher in patients with aortic aneurysms. However, there are lack of studies investigating prevalence of thoracic aortic aneurysms (TAAs) in patients with IAs. The objective of this study was to evaluate the prevalence and risk factors for thoracic aortic dilatations (TADs) and TAAs in patients with IAs.
METHODS: We retrospectively reviewed data from 1777 patients with diagnosed IAs at our institution between 2006 and 2016. We included 411 patients with saccular IAs and available imaging studies (computed tomography or magnetic resonance imaging) of all thoracic aortic segments. TAD was defined according to age- and sex-matched normograms, and TAA as a diameter of greater than 4.0 cm.
RESULTS: A total of 83 patients (20%) had TAD or TAA. The prevalence of TADs and TAAs were 18% (n = 74) and 8% (n = 31) without significant difference between unruptured and ruptured IAs (P = .7). Of the 74 patients with TAD, 22 (30%) had multiple TADs and 66% of the TADs located in the aortic arch. Older age (odds ratio [OR], 1.04; P = .006), rheumatic disease (OR, 4.73; P = .009) and alcohol abuse (OR, 4.77; P = .01) were significant risk factors for TAD/TAA.
CONCLUSIONS: The prevalence of TADs and TAAs is considerably greater in patients with IAs compared with reports from the general population, suggesting that IAs might be associated with aortopathy and might share a similar pathogenetic background with TADs/TAAs. Especially patients with IAs and a history of rheumatic disease and/or alcohol abuse are at high risk for TADs/TAAs.

Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
PMID 31327605  J Vasc Surg. 2019 Dec;70(6):1801-1808. doi: 10.1016/j.j・・・
著者: Arttu Kurtelius, Nelli Väntti, Behnam Rezai Jahromi, Olli Tähtinen, Hannu Manninen, Juha Koskenvuo, Riikka Tulamo, Satu Kotikoski, Heidi Nurmonen, Olli-Pekka Kämäräinen, Terhi Huttunen, Jukka Huttunen, Mikael von Und Zu Fraunberg, Timo Koivisto, Juha E Jääskeläinen, Antti E Lindgren
雑誌名: J Am Heart Assoc. 2019 Sep 17;8(18):e013277. doi: 10.1161/JAHA.119.013277. Epub 2019 Sep 5.
Abstract/Text Background Varying degrees of co-occurrence of intracranial aneurysms (IA) and aortic aneurysms (AA) have been reported. We sought to compare the risk for AA in fusiform intracranial aneurysms (fIA) and saccular intracranial aneurysms (sIA) disease and evaluate possible genetic connection between the fIA disease and AAs. Additionally, the characteristics and aneurysms of the fIA and sIA patients were compared. Methods and Results The Kuopio Intracranial Aneurysm Database includes all 4253 sIA and 125 fIA patients from its Eastern Finnish catchment population, and 13 009 matched population controls and 18 455 first-degree relatives to the IA patients were identified, and the Finnish national registers were used to identify the individuals with AA. A total of 33 fIA patients were studied using an exomic gene panel of 37 genes associated with AAs. Seventeen (14.4%) fIA patients and 48 (1.2%) sIA patients had a diagnosis of AA. Both fIA and sIA patients had AAs significantly more often than their controls (1.2% and 0.5%) or relatives (0.9% and 0.3%). In a competing risks Cox regression model, the presence of fIA was the strongest risk factor for AA (subdistribution hazard ratio 7.6, 95% CI 3.9-14.9, P<0.0005). One likely pathogenic variant in COL5A2 and 3 variants of unknown significance were identified in MYH11, COL11A1, and FBN1 in 4 fIA patients. Conclusions The prevalence of AAs is increased slightly in sIA patients and significantly in fIA patients. fIA patients are older and have more comorbid diseases than sIA patients but this alone does not explain their clinically significant AA risk.

PMID 31538843  J Am Heart Assoc. 2019 Sep 17;8(18):e013277. doi: 10.11・・・
著者: Chien-Chang Lee, Meng-Tse Gabriel Lee, Yueh-Sheng Chen, Shih-Hao Lee, Yih-Sharng Chen, Shyr-Chyr Chen, Shan-Chwen Chang
雑誌名: JAMA Intern Med. 2015 Nov;175(11):1839-47. doi: 10.1001/jamainternmed.2015.5389.
Abstract/Text IMPORTANCE: Fluoroquinolones have been associated with collagen degradation, raising safety concerns related to more serious collagen disorders with use of these antibiotics, including aortic aneurysm and dissection.
OBJECTIVE: To examine the relationship between fluoroquinolone therapy and the risk of developing aortic aneurysm and dissection.
DESIGN, SETTING, AND PARTICIPANTS: We conducted a nested case-control analysis of 1477 case patients and 147 700 matched control cases from Taiwan's National Health Insurance Research Database (NHIRD) from among 1 million individuals longitudinally observed from January 2000 through December 2011. Cases patients were defined as those hospitalized for aortic aneurysm or dissection. One hundred control patients were matched for each case based on age and sex.
EXPOSURES: Current, past, or any prior-year use of fluoroquinolone. Current use was defined as a filled fluoroquinolone prescription within 60 days of the aortic aneurysm or dissection; past use refers to a filled fluoroquinolone prescription between 61 and 365 days prior to the aortic aneurysm; and any prior-year use refers to having a fluoroquinolone prescription filled for 3 or more days any time during the 1-year period before the aortic aneurysm or dissection.
MAIN OUTCOMES AND MEASURES: Risk of developing aortic aneurysm or dissection.
RESULTS: A total of 1477 individuals who experienced aortic aneurysm or dissection were matched to 147 700 controls. After propensity score adjustment, current use of fluoroquinolones was found to be associated with increased risk for aortic aneurysm or dissection (rate ratio [RR], 2.43; 95% CI, 1.83-3.22), as was past use, although this risk was attenuated (RR, 1.48; 95% CI, 1.18-1.86). Sensitivity analysis focusing on aortic aneurysm and dissection requiring surgery also demonstrated an increased risk associated with current fluoroquinolone use, but the increase was not statistically significant (propensity score-adjusted RR, 2.15; 95% CI, 0.97-4.60).
CONCLUSIONS AND RELEVANCE: Use of fluoroquinolones was associated with an increased risk of aortic aneurysm and dissection. While these were rare events, physicians should be aware of this possible drug safety risk associated with fluoroquinolone therapy.

PMID 26436523  JAMA Intern Med. 2015 Nov;175(11):1839-47. doi: 10.1001・・・
著者: P W Stather, D A Sidloff, N Dattani, V J Gokani, E Choke, R D Sayers, M J Bown
雑誌名: Br J Surg. 2014 Oct;101(11):1358-72. doi: 10.1002/bjs.9593. Epub 2014 Aug 18.
Abstract/Text BACKGROUND: Many studies have investigated the systemic and local expression of biomarkers in patients with abdominal aortic aneurysm (AAA). The natural history of AAA varies between patients, and predictors of the presence and diameter of AAA have not been determined consistently. The aim of this study was to perform a systematic review, meta-analysis and meta-regression of studies comparing biomarkers in patients with and without AAA, with the aim of summarizing the association of identified markers with both AAA presence and size.
METHODS AND RESULTS: Literature review identified 106 studies suitable for inclusion. Meta-analysis demonstrated a significant difference between matrix metalloproteinase (MMP) 9, tissue inhibitor of matrix metalloproteinase 1, interleukin (IL) 6, C-reactive protein (CRP), α1-antitrypsin, triglycerides, lipoprotein(a), apolipoprotein A and high-density lipoprotein in patients with and without AAA. Although meta-analysis was not possible for MMP-2 in aortic tissue, tumour necrosis factor α, osteoprotegerin, osteopontin, interferon γ, intercellular cell adhesion molecule 1 and vascular cell adhesion molecule 1, systematic review suggested an increase in these biomarkers in patients with AAA. Meta-regression analysis identified a significant positive linear correlation between aortic diameter and CRP level.
CONCLUSION: A wide variety of biomarkers are dysregulated in patients with AAA, but their clinical value is yet to be established. Future research should focus on the most relevant biomarkers of AAA, and how they could be used clinically.

© 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.
PMID 25131707  Br J Surg. 2014 Oct;101(11):1358-72. doi: 10.1002/bjs.9・・・
著者: Peiman Nazerian, Simone Vanni, Fulvio Morello, Matteo Castelli, Maddalena Ottaviani, Claudia Casula, Alessandra Petrioli, Maurizio Bartolucci, Stefano Grifoni
雑誌名: Acad Emerg Med. 2015 May;22(5):536-41. doi: 10.1111/acem.12650. Epub 2015 Apr 21.
Abstract/Text OBJECTIVES: The diagnostic performance of transthoracic focused cardiac ultrasound (FoCUS) performed by emergency physicians (EP) to estimate ascending aorta dimensions in the acute setting has not been prospectively studied. The diagnostic accuracy and the interobserver variability of EP-performed FoCUS were investigated to estimate thoracic aortic dilation and aneurysm compared with the results of computed tomography angiography (CTA).
METHODS: This was a prospective single-center cohort study of a convenience sample of patients who underwent CTA in the emergency department for suspected aortic pathology. FoCUS was performed before CTA, and the maximum ascending aorta diameter evaluated in parasternal long-axis view. Aorta diameter < 40 mm by visual estimation or by diameter measurement was considered normal. Measurements were recorded in all patients with aorta diameter ≥ 40 mm. Diagnostic accuracy of FoCUS for detection of aortic dilation (diameter ≥ 40 mm) and aneurysm (diameter ≥ 45 mm) were calculated considering the CTA result as reference standard. In a subgroup of patients, a second EP-sonographer performed FoCUS to evaluate interobserver agreement for the diagnosis of ascending aorta dilation.
RESULTS: A total of 140 patients were enrolled in the study. Ascending aorta dilation and aneurysm were detected with FoCUS in 50 (35.7%) and in 27 (17.8%) patients, respectively. Sensitivity and specificity of FoCUS were 78.6% (95% confidence interval [CI] = 65.6% to 88.4%) and 92.9% (95% CI = 85.1% to 97.3%), respectively, for ascending aorta dilation and 64.7% (95% CI = 46.5% to 80.2%) and 95.3% (95% CI = 89.3% to 98.4%), respectively, for ascending aorta aneurysm. Interobserver agreement of FoCUS was k = 0.82.
CONCLUSIONS: FoCUS performed by EP is specific for ascending aorta dilation and aneurysm when compared to CTA and appears a reproducible technique.

© 2015 by the Society for Academic Emergency Medicine.
PMID 25899650  Acad Emerg Med. 2015 May;22(5):536-41. doi: 10.1111/ace・・・
著者: Tomasz Plonek, Mikolaj Berezowski, Maciej Bochenek, Grzegorz Filip, Bartosz Rylski, Tal Golesworthy, Marek Jasinski
雑誌名: J Thorac Cardiovasc Surg. 2019 Feb;157(2):479-486. doi: 10.1016/j.jtcvs.2018.07.053. Epub 2018 Aug 2.
Abstract/Text OBJECTIVES: The aim of the study is to evaluate an optimal way to assess the dimensions of the aortic root and each of the sinuses of Valsalva and examine how a single measurement in 1 plane (echocardiography or 2-dimensional computed tomography) can underestimate the maximum dimension of the aortic root.
METHODS: Computed tomography and transthoracic echocardiography images of the aortic root and ascending aorta of 112 patients were analyzed. The minimum and maximum aortic root dimensions, the root perimeter, and the total area of all 3 sinuses of Valsalva were measured on a plane perpendicular to the long axis of the aorta using 3-dimensional multiplanar reconstruction. Moreover, the maximum root dimension was compared with the measurements obtained from the echocardiography and 2-dimensional computed tomography angiography measurements.
RESULTS: The difference in the measurements of the minimum and maximum root dimension was 5.4 ± 3.2 mm (range, 0-21 mm, P < .0001) and was significantly larger in patients with bicuspid aortic valves compared with those with tricuspid valves (6.3 ± 4 mm, range, 0-21 mm vs 4.9 ± 2.6 mm, range, 0-15 mm, P = .036). The maximum root dimension measured in 3-dimensional multiplanar reconstruction (49.1 ± 9.0 mm) differed significantly from the root dimension measured in transthoracic echocardiography in the parasternal long-axis view (44.8 ± 8.4 mm) and 2-dimensional computed tomography (axial plane: 45.5 ± 9.0 mm, coronal plane: 46.1 ± 8.8 mm, sagittal plane: 45.1 ± 8.9 mm) (P < .001).
CONCLUSIONS: The difference in the measurements of the minimum and maximum aortic root dimensions is significant and may exceed 20 mm, especially in patients with bicuspid aortic valves. Therefore, aortic root dimensions can be significantly underestimated with the measurement (echocardiography, computed tomography angiography) performed in only 1 plane.

Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
PMID 30227996  J Thorac Cardiovasc Surg. 2019 Feb;157(2):479-486. doi:・・・
著者: Mariana R DeFreitas, Leslie E Quint, Kuanwong Watcharotone, Bin Nan, Michael J Ranella, Joanna R Hider, Peter S Liu, David M Williams, Jonathan L Eliason, Himanshu J Patel
雑誌名: Int J Cardiovasc Imaging. 2016 Apr;32(4):647-53. doi: 10.1007/s10554-015-0807-7. Epub 2015 Nov 24.
Abstract/Text Aortic aneurysms are a significant cause of mortality, and the presence of multiple aneurysms may affect treatment plans. The purpose of this study was to determine the frequency of abdominal aortic aneurysms (AAAs) in patients with thoracic aortic aneurysms (TAAs) and to establish whether patient specific factors, such as gender and comorbidities, influenced the frequency of AAAs, thereby indicating if and when abdominal aortic evaluation is justified. Electronic medical records were reviewed from 1000 patients with a computed tomography (CT) angiogram of the chest and abdomen and a clinical diagnosis of TAA from Cardiac Surgery clinic between 2008 and 2013. 538 patients with history of aortic intervention, dissection, rupture or trauma were excluded. The frequency of AAAs among the 462 remaining patients was established, and statistical analysis was used to elucidate differences in frequency based on age, gender, comorbidities, and TAA location. Overall, 104 of 462 (22.5 %) patients with a TAA also had an AAA. There were significant differences in the frequency of AAA based on TAA location, age, and comorbidities. The following comorbidities showed positive associations with AAA using logistic regression analysis: age ≥65 (P < 0.0001; OR 30.1; CI 7.14-126.61), smoking history (P < 0.0001; OR 4.1; 2.35-7.30), and hypertension (P = 0.024; OR 2.1; CI 1.11-4.16). Aneurysms in the proximal/mid descending (P < 0.0001; OR 4.96; CI 2.32-10.61) and diaphragm level (P < 0.0001; OR 38.4; CI 14.71-100.15) of the aorta also showed a positive association with AAAs when adjusted for age and gender. AAA screening in patients with TAA is a reasonable, evidence-based option regardless of the TAA location, with the strongest support in patients >age 55, with systemic hypertension, a smoking history and/or a TAA in the descending thoracic aorta.

PMID 26602411  Int J Cardiovasc Imaging. 2016 Apr;32(4):647-53. doi: 1・・・
著者: Matthew Chapman, Leslie E Quint, Kuanwong Watcharotone, Bin Nan, Michael J Ranella, Mariana R DeFreitas, Joanna R Hider, Jonathan L Eliason, Himanshu J Patel
雑誌名: Int J Cardiovasc Imaging. 2017 Oct;33(10):1627-1635. doi: 10.1007/s10554-017-1178-z. Epub 2017 May 27.
Abstract/Text Approximately ¼ of patients with thoracic aortic aneurysms (TAAs) have concomitant abdominal aortic aneurysms (AAAs), thereby justifying the addition of an abdominal CT scan to a chest CT scan in patients with a newly diagnosed or suspected TAA. However, the prevalence of pelvic artery aneurysms (PAAs) in these patients is unknown. The purpose of this study was to determine the prevalence of PAAs in patients with TAAs and to assess what patient specific factors were associated with PAAs, thereby providing insight into the usefulness of pelvic imaging in TAA patients. Consecutive non-operated patients seen in Cardiac Surgery clinic between 2008 and 2013 with a TAA and a CT scan of the chest/abdomen/pelvis were included. Scans of 371 patients were evaluated for PAAs using threshold diameters of 20 and 15 mm for common iliac artery aneurysms (CIAs) and internal iliac artery aneurysms (IIAs), respectively, on 3D analysis. The prevalence of PAAs was determined and multiple logistic regression was used to identify associated risk factors. 41 of 371 (11.1%) patients with a TAA had at least one PAA. Factors showing positive associations with PAAs included increased age (p = 0.0004), male gender (p = 0.0007), descending TAA location (p = 0.0024) and presence of an AAA (p < 0.0001). The results of our study suggest that the addition of pelvic imaging for PAA screening in patients undergoing an initial CT scan of the chest and abdomen for a TAA is valuable, particularly in patients with the following demographics: age ≥65, male gender, descending TAA location, and/or known AAA.

PMID 28551718  Int J Cardiovasc Imaging. 2017 Oct;33(10):1627-1635. do・・・
著者: M A Coady, R R Davies, M Roberts, L J Goldstein, M J Rogalski, J A Rizzo, G L Hammond, G S Kopf, J A Elefteriades
雑誌名: Arch Surg. 1999 Apr;134(4):361-7.
Abstract/Text HYPOTHESIS: To provide evidence that genetic factors contribute to the development of thoracic aortic aneurysms (TAA) by demonstrating familial patterns of the disease.
DESIGN: Retrospective review.
SETTING: University hospital.
PATIENTS AND METHODS: We sought to identify familial patterns of TAA from a database of 598 patients evaluated or treated for TAA at the Yale Center for Thoracic Aortic Disease, New Haven, Conn, from January 1985 to August 1998. Of the 598 patients, 45 patients had a diagnosis of Marfan syndrome and 553 patients had no known history of any collagen vascular disorder. Of the 553 patients in the latter category, 398 patients had confirmed TAA, 66 had TAA with concomitant aortic dissections, and 89 had aortic dissections. From the group of 464 patients with TAA with or without concomitant aortic dissections, 2 interviewers attempted to contact 150 randomly selected patients for telephone screening to determine the presence of familial patterns of aortic disease. Fifteen of these patients were lost to follow-up. Complete medical and family histories of the remaining 135 patients (85 men, 50 women) were reviewed. Of the 135 individuals screened, 26 (18 men, 8 women) (19.3%) were found to belong to multiplex pedigrees. These 26 patients with familial nonsyndromic TAA were compared with the remaining 109 patients with sporadic TAA and the 45 patients with Marfan syndrome-associated TAA.
MAIN OUTCOME MEASURES: Groups were examined for statistical differences in age and aortic size at the time of diagnosis, growth rates of TAA, and rates of concomitant diseases. Nonsyndromic family pedigrees were analyzed and potential modes of inheritance were determined.
RESULTS: The mean age at presentation for patients with familial nonsyndromic TAA (56.8 years) was significantly younger than the mean age of presentation in sporadic cases (64.3 years, P< or =.03), and significantly older than that of patients with Marfan syndrome (24.8 years, P< or =.001). Patients with a family history of aortic aneurysms had faster growth rates (0.22 cm/y) compared with patients with sporadic TAA (0.03 cm/y) (P< or =.001) and patients with Marfan syndrome (0.10 cm/y) (P< or =.04). Familial nonsyndromic TAA in patients with a concomitant aortic dissection had a growth rate of 0.33 cm/y, which was greater than that of patients with sporadic TAA (0.10 cm/y) and patients with Marfan syndrome (0.08 cm/y) with associated aortic dissection. This growth of 0.33 cm/y was significantly faster than the overall growth rate estimate of aneurysms in patients with aortic dissection (0.14 cm/y) (P< or =.05). Ten pedigrees (38.5%) showed direct father to son transmission, consistent with an autosomal dominant mode of inheritance. Six family pedigrees (23.1%) suggested an autosomal dominant or X-linked mode of inheritance. Seven pedigrees (26.9%) suggested a recessive mode of inheritance; 2 an autosomal recessive mode, and 5 an X-linked recessive or autosomal recessive mode. The remaining 3 pedigrees displayed more complex modes of inheritance.
CONCLUSIONS: This study supports the role of genetic factors influencing familial aggregation of TAA. Thoracic aortic aneurysms in association with multiplex pedigrees represent a new risk factor for aneurysm growth. Pedigree analysis suggests genetic heterogeneity. The primary mode of inheritance seems to be autosomal dominant, but X-linked dominant and recessive modes are also evident.

PMID 10199307  Arch Surg. 1999 Apr;134(4):361-7.
著者: Eric K Shang, Derek P Nathan, Shanna R Sprinkle, Sarah C Vigmostad, Ronald M Fairman, Joseph E Bavaria, Robert C Gorman, Joseph H Gorman, Krishnan B Chandran, Benjamin M Jackson
雑誌名: Ann Thorac Surg. 2013 Feb;95(2):593-8. doi: 10.1016/j.athoracsur.2012.10.025. Epub 2012 Dec 13.
Abstract/Text BACKGROUND: Aortic diseases, including aortic aneurysms, are the 12th leading cause of death in the United States. The incidence of descending thoracic aortic aneurysms is estimated at 10.4 per 100,000 patient-years. Growing evidence suggests that stress measurements derived from structural analysis of aortic geometries predict clinical outcomes better than diameter alone.
METHODS: Twenty-five patients undergoing clinical and radiologic surveillance for thoracic aortic aneurysms were retrospectively identified. Custom MATLAB algorithms were employed to extract aortic wall and intraluminal thrombus geometry from computed tomography angiography scans. The resulting reconstructions were loaded with 120 mm Hg of pressure using finite element analysis. Relationships among peak wall stress, aneurysm growth, and clinical outcome were examined.
RESULTS: The average patient age was 71.6 ± 10.0 years, and average follow-up time was 17.5 ± 9 months (range, 6 to 43). The mean initial aneurysm diameter was 47.8 ± 8.0 mm, and the final diameter was 52.1 ± 10.0 mm. Mean aneurysm growth rate was 2.9 ± 2.4 mm per year. A stronger correlation (r = 0.894) was found between peak wall stress and aneurysm growth rate than between maximal aortic diameter and growth rate (r = 0.531). Aneurysms undergoing surgical intervention had higher peak wall stresses than aneurysms undergoing continued surveillance (300 ± 75 kPa versus 229 ± 47 kPa, p = 0.01).
CONCLUSIONS: Computational peak wall stress in thoracic aortic aneurysms was found to be strongly correlated with aneurysm expansion rate. Aneurysms requiring surgical intervention had significantly higher peak wall stresses. Peak wall stress may better predict clinical outcome than maximal aneurysmal diameter, and therefore may guide clinical decision-making.

Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
PMID 23245445  Ann Thorac Surg. 2013 Feb;95(2):593-8. doi: 10.1016/j.a・・・
著者: Subodh Verma, Samuel C Siu
雑誌名: N Engl J Med. 2014 May 15;370(20):1920-9. doi: 10.1056/NEJMra1207059.
Abstract/Text
PMID 24827036  N Engl J Med. 2014 May 15;370(20):1920-9. doi: 10.1056/・・・
著者: Ryan R Davies, Ryan K Kaple, Divakar Mandapati, Amy Gallo, Donald M Botta, John A Elefteriades, Michael A Coady
雑誌名: Ann Thorac Surg. 2007 Apr;83(4):1338-44. doi: 10.1016/j.athoracsur.2006.10.074.
Abstract/Text BACKGROUND: Patients with bicuspid aortic valve (BAV) are at risk for valvular disease and ascending aortic aneurysms and dissections. Although others have investigated the need for concomitant repair, the natural history of aortic disease has not been addressed.
METHODS: A review of our institutional clinical database identified 514 patients (326 male, 188 female) with unrepaired ascending aortic aneurysms followed from 1985 to 2005. Seventy patients (13.4%) diagnosed with BAV form group A; the remaining 445 patients form group B. Growth rates and risk factors for complications were assessed.
RESULTS: Patients in group A had a lower incidence of hypertension (p = 0.0185), carotid artery disease, and stroke (p = 0.0184), and presented at an earlier age (49.0 versus 64.2 years, p < 0.0001). Group A also had a higher rate of aortic growth (0.19 versus 0.13 cm/year, p = 0.0102). The incidence of rupture and dissection were similar. Overall survival was better among patients with BAV (p < 0.0001). Among patients with BAV, those with aortic stenosis had a higher risk of rupture, dissection, or death before operative repair than did those with normally functioning valves (odds ratio 10.475, 95% confidence interval: 1.153 to 95.155).
CONCLUSIONS: Aortic stenosis presents a significant added risk for patients with aneurysmal disease in the face of BAV. Despite faster rates of growth, however, patients with BAV have similar rates of aortic rupture, dissection, and death and improved long-term survival. Contributing to this finding may be the lower incidence of comorbidities, the younger age at presentation, and the more attentive follow-up with earlier operative repair.

PMID 17383337  Ann Thorac Surg. 2007 Apr;83(4):1338-44. doi: 10.1016/j・・・
著者: Giovanni La Canna, Eleonora Ficarra, Elefteria Tsagalau, Matilde Nardi, Antonella Morandini, Alaide Chieffo, Francesco Maisano, Ottavio Alfieri
雑誌名: Am J Cardiol. 2006 Jul 15;98(2):249-53. doi: 10.1016/j.amjcard.2006.01.096. Epub 2006 Jun 6.
Abstract/Text Dilation of the ascending aorta (AA), which is disproportionate to associated valvular lesions, is a relatively well-recognized phenomenon in patients with a bicuspid aortic valve (BAV). The aim of this study was to evaluate the rate of changes in the AA dimensions and the outcome in patients with AA dilation and BAVs compared with patients with AA dilation and tricuspid aortic valves (TAVs). Serial transesophageal echocardiograms (>12 months apart) were performed in 113 consecutive patients (BAV, n=27 and TAV, n=86) with AA diameters of >or=40 and
PMID 16828602  Am J Cardiol. 2006 Jul 15;98(2):249-53. doi: 10.1016/j.・・・
著者: L K Bickerstaff, P C Pairolero, L H Hollier, L J Melton, H J Van Peenen, K J Cherry, J W Joyce, J T Lie
雑誌名: Surgery. 1982 Dec;92(6):1103-8.
Abstract/Text Thoracic aortic aneurysms were detected in 72 residents (44 women and 28 men) in a stable midwestern community over a 30-year period, for an age- and sex-adjusted incidence of 5.9 new aneurysms per 100,000 person-years. The incidence was equal in both sexes and decreased slightly over the 30 years. Ages ranged from 47 to 93 years (median 65 years for men and 77 years for women). The ascending aorta was involved in 37 patients, the aortic arch in 8, and the descending aorta in 27. Pathologic examination was performed in 51 patients. The cause was aortic dissection in 27 patients (53%), atherosclerosis in 15 (29%), aortitis in 4 (8%), cystic medial necrosis in 3 (6%), and syphilis in 2 (4%). All autopsied patients had pathologic evidence of significant hypertension. Eleven patients (25%) had concomitant abdominal aortic aneurysms. Rupture occurred in 53 patients (74%) and 50 died. Thirty-seven of these patients had no prior diagnosis of aneurysm. The median interval between diagnosis and rupture in the 16 remaining patients was 2 years (range 1 month to 16 years). Ninety-five percent of aortic dissections ruptured and 51% of nondissecting aneurysms ruptured. The actuarial 5-year survival for all 72 patients was 13%; for patients with aortic dissection, 7% and for patients without dissection, 19.2%.

PMID 7147188  Surgery. 1982 Dec;92(6):1103-8.
著者: John A Elefteriades
雑誌名: J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S5-9; discussion S45-51. doi: 10.1016/j.jtcvs.2010.10.001.
Abstract/Text This monograph reviews currently accepted criteria for extirpation of the aneurysmal thoracic aorta. Presence of symptoms suffices to justify resection regardless of size. For asymptomatic patients, resection of the ascending aorta at 5 to 5.5 cm is warranted. The descending aorta can be watched until slightly larger sizes (ie, 5.5-6 cm). Marfan disease or bicuspid aortic valve encourages resection in the smaller region of these size ranges. A nomogram permits adjustment of intervention criteria for extremes of body size. A recently computerized aortic risk calculator automatically applies exponential equations for determination of yearly risk of rupture or dissection for individual patients (available at: http://aorta.yale.edu). Evolving modalities to enhance decision making include positron emission tomography imaging of aneurysm metabolic activity, measurement of mechanical properties of the aorta by echocardiography, and assessment of the biomolecular state of the aneurysm with the "RNA Signature" test.

Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
PMID 21092797  J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S5-9; d・・・
著者: E S Crawford, R W DeNatale
雑誌名: J Vasc Surg. 1986 Apr;3(4):578-82.
Abstract/Text Thoracoabdominal operation was not performed in 94 patients with thoracoabdominal aortic aneurysms during a 25-year period because of refusal by patients (eight patients), associated disease or age (64 patients), small size of aneurysm (five patients), and staging of operations in which another operation was performed instead of aneurysm resection (17 patients). The cause of aneurysm was chronic dissection in 23 patients and nondissection in 71. Most of the patients entered the study during the past 5 years and follow-up information is complete for all of them. Twenty-four percent of the patients were alive at 2 years, calculated by the Kaplan-Meier method, and half of the deaths were due to aneurysm rupture. In contrast, among our 604 patients treated surgically, 70% were alive at 2 years and 59% at 5 years. This study suggests that the natural course of the disease is favorably altered by surgical treatment.

PMID 3959256  J Vasc Surg. 1986 Apr;3(4):578-82.
著者: Ryan R Davies, Lee J Goldstein, Michael A Coady, Shawn L Tittle, John A Rizzo, Gary S Kopf, John A Elefteriades
雑誌名: Ann Thorac Surg. 2002 Jan;73(1):17-27; discussion 27-8.
Abstract/Text BACKGROUND: Prior work has clarified the cumulative, lifetime risk of rupture or dissection based on the size of thoracic aneurysms. Ability to estimate simply the yearly rate of rupture or dissection would greatly enhance clinical decision making for specific patients. Calculation of such a rate requires robust data.
METHODS: Data on 721 patients (446 male, 275 female; median age, 65.8 years; range, 8 to 95 years) with thoracic aortic disease was prospectively entered into a computerized database over 9 years. Three thousand one hundred fifteen imaging studies were available on these patients. Five hundred seventy met inclusion criteria in terms of length of follow-up and form the basis for the survival analysis. Three hundred four patients were dissection-free at presentation; their natural history was followed for rupture, dissection, and death. Patients were excluded from analysis once operation occurred.
RESULTS: Five-year survival in patients not operated on was 54% at 5 years. Ninety-two hard end points were realized in serial follow-up, including 55 deaths, 13 ruptures, and 24 dissections. Aortic size was a very strong predictor of rupture, dissection, and mortality. For aneurysms greater than 6 cm in diameter, rupture occurred at 3.7% per year, rupture or dissection at 6.9% per year, death at 11.8%, and death, rupture, or dissection at 15.6% per year. At size greater than 6.0 cm, the odds ratio for rupture was increased 27-fold (p = 0.0023). The aorta grew at a mean of 0.10 cm per year. Elective, preemptive surgical repair restored life expectancy to normal.
CONCLUSIONS: This study indicates that (1) thoracic aneurysm is a lethal disease; (2) aneurysm size has a profound impact on rupture, dissection, and death; (3) for counseling purposes, the patient with an aneurysm exceeding 6 cm can expect a yearly rate of rupture or dissection of at least 6.9% and a death rate of 11.8%; and (4) elective surgical repair restores survival to near normal. This analysis strongly supports careful radiologic follow-up and elective, preemptive surgical intervention for the otherwise lethal condition of large thoracic aortic aneurysm.

PMID 11834007  Ann Thorac Surg. 2002 Jan;73(1):17-27; discussion 27-8.・・・
著者: M A Coady, J A Rizzo, G L Hammond, D Mandapati, U Darr, G S Kopf, J A Elefteriades
雑誌名: J Thorac Cardiovasc Surg. 1997 Mar;113(3):476-91; discussion 489-91. doi: 10.1016/S0022-5223(97)70360-X.
Abstract/Text Although many articles have described techniques for resection of thoracic aortic aneurysms, limited information on the natural history of this disorder is available to aid in defining criteria for surgical intervention. Data on 230 patients with thoracic aortic aneurysms treated at Yale University School of Medicine from 1985 to 1996 were analyzed. This computerized database included 714 imaging studies (magnetic resonance imaging, computed tomography, echocardiography). Mean size of the thoracic aorta in these patients at initial presentation was 5.2 cm (range 3.5 to 10 cm). The mean growth rate was 0.12 cm/yr. Overall survivals at 1 and 5 years were 85% and 64%, respectively. Patients having aortic dissection had lower survival (83% 1 year; 46% 5 year) than the cohort without dissection (89% 1 year; 71% 5 year). One hundred thirty-six patients underwent surgery for their thoracic aortic aneurysms. For elective operations, the mortality was 9.0%; for emergency operations, 21.7%. Median size at time of rupture or dissection was 6.0 cm for ascending aneurysms and 7.2 cm for descending aneurysms. The incidence of dissection or rupture increased with aneurysm size. Multivariable regression analysis to isolate risk factors for acute dissection or rupture revealed that size larger than 6.0 cm increased the probability by 32.1 percentage points for ascending aneurysms (p = 0.005). For descending aneurysms, this probability increased by 43.0 percentage points at a size greater than 7.0 cm (p = 0.006). If the median size at the time of dissection or rupture were used as the intervention criterion, half of the patients would suffer a devastating complication before the operation. Accordingly, a criterion lower than the median is appropriate. We recommend 5.5 cm as an acceptable size for elective resection of ascending aortic aneurysms, because resection can be performed with relatively low mortality. For aneurysms of the descending aorta, in which perioperative complications are greater and the median size at the time of complications is larger, we recommend intervention at 6.5 cm.

PMID 9081092  J Thorac Cardiovasc Surg. 1997 Mar;113(3):476-91; discu・・・
著者: Olivier Milleron, Florence Arnoult, Jacques Ropers, Philippe Aegerter, Delphine Detaint, Gabriel Delorme, David Attias, Florence Tubach, Sophie Dupuis-Girod, Henry Plauchu, Martine Barthelet, Francois Sassolas, Nicolas Pangaud, Sophie Naudion, Julie Thomas-Chabaneix, Yves Dulac, Thomas Edouard, Jean-Eric Wolf, Laurence Faivre, Sylvie Odent, Adeline Basquin, Gilbert Habib, Patrick Collignon, Catherine Boileau, Guillaume Jondeau
雑誌名: Eur Heart J. 2015 Aug 21;36(32):2160-6. doi: 10.1093/eurheartj/ehv151. Epub 2015 May 2.
Abstract/Text AIMS: To evaluate the benefit of adding Losartan to baseline therapy in patients with Marfan syndrome (MFS).
METHODS AND RESULTS: A double-blind, randomized, multi-centre, placebo-controlled, add on trial comparing Losartan (50 mg when <50 kg, 100 mg otherwise) vs. placebo in patients with MFS according to Ghent criteria, age >10 years old, and receiving standard therapy. 303 patients, mean age 29.9 years old, were randomized. The two groups were similar at baseline, 86% receiving β-blocker therapy. The median follow-up was 3.5 years. The evolution of aortic diameter at the level of the sinuses of Valsalva was not modified by the adjunction of Losartan, with a mean increase in aortic diameter at the level of the sinuses of Valsalva of 0.44 mm/year (s.e. = 0.07) (-0.043 z/year, s.e. = 0.04) in patients receiving Losartan and 0.51 mm/year (s.e. = 0.06) (-0.01 z/year, s.e. = 0.03) in those receiving placebo (P = 0.36 for the comparison on slopes in millimeter per year and P = 0.69 for the comparison on slopes on z-scores). Patients receiving Losartan had a slight but significant decrease in systolic and diastolic blood pressure throughout the study (5 mmHg). During the study period, aortic surgery was performed in 28 patients (15 Losartan, 13 placebo), death occurred in 3 patients [0 Losartan, 3 placebo, sudden death (1) suicide (1) oesophagus cancer (1)].
CONCLUSION: Losartan was able to decrease blood pressure in patients with MFS but not to limit aortic dilatation during a 3-year period in patients >10 years old. β-Blocker therapy alone should therefore remain the standard first line therapy in these patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.
PMID 25935877  Eur Heart J. 2015 Aug 21;36(32):2160-6. doi: 10.1093/eu・・・
著者: Eugene Sun Yim
雑誌名: Sports Med. 2013 Aug;43(8):721-32. doi: 10.1007/s40279-013-0057-6.
Abstract/Text Two professional athletes in the U.S. National Basketball Association required surgery for aortic root dilation in 2012. These cases have attracted attention in sports medicine to the importance of aortic root disease in athletes. In addition to aortic root dilation, other forms of aortic disease include anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome. In this review, electronic database literature searches were performed using the terms "aortic root" and "athletes." The literature search produced 122 manuscripts. Of these, 22 were on aortic root dilation, 21 on anomalous coronary arteries, 12 on bicuspid aortic valves, and 8 on Marfan's syndrome. Aortic root dilation is a condition involving pathologic dilation of the aortic root, which can lead to life-threatening sequelae. Prevalence of the condition among athletes and higher risk athletes in particular sports needs to be better delineated. Normative parameters for aortic root diameter in the general population are proportionate to anthropomorphic variables, but this has not been validated for athletes at the extremes of anthropomorphic indices. Although echocardiography is the favored screening modality, computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are also used for diagnosis and surgical planning. Medical management has utilized beta-blockers, with more recent use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and statins. Indications for surgery are based on comorbidities, degree of dilation, and rate of progression. Management decisions for aortic root dilation in athletes are nuanced and will benefit from the development of evidence-based guidelines. Anomalous coronary artery is another form of aortic disease with relevance in athletes. Diagnosis has traditionally been through cardiac catheterization, but more recently has included evaluation with echocardiography, multislice CT, and MRI. Athletes with this condition should be restricted from participation in competitive sports, but can be cleared for participation 6 months after surgical repair. Bicuspid aortic valve is another form of aortic root disease with significance in athletes. Although echocardiography has traditionally been used for diagnosis, CT and MRI have proven more sensitive and specific. Management of bicuspid aortic valve consists of surveillance through echocardiography, medical therapy with beta-blockers and ARBs, and surgery. Guidelines for sports participation are based on the presence of aortic stenosis, aortic regurgitation, and aortic root dilation. Marfan's syndrome is a genetic disorder with a number of cardiac manifestations including aortic root dilation, aneurysm, and dissection. Medical management involves beta-blockers and ARBs. Thresholds for surgical management differ from the general population. With regard to sports participation, the most important consideration is early detection. Athletes with the stigmata of Marfan's syndrome or with family history should be tested. Further research should determine whether more aggressive screening is warranted in sports with taller athletes. Athletes with Marfan's syndrome should be restricted from activities involving collision and heavy contact, avoid isometric exercise, and only participate in activities with low intensity, low dynamic, and low static components. In summary, many forms of aortic root disease afflict athletes and need to be appreciated by sports medicine practitioners because of their potential to lead to tragic but preventable deaths in an otherwise healthy population.

PMID 23674060  Sports Med. 2013 Aug;43(8):721-32. doi: 10.1007/s40279-・・・
著者: Loren F Hiratzka, George L Bakris, Joshua A Beckman, Robert M Bersin, Vincent F Carr, Donald E Casey, Kim A Eagle, Luke K Hermann, Eric M Isselbacher, Ella A Kazerooni, Nicholas T Kouchoukos, Bruce W Lytle, Dianna M Milewicz, David L Reich, Souvik Sen, Julie A Shinn, Lars G Svensson, David M Williams, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, Society for Vascular Medicine
雑誌名: Circulation. 2010 Apr 6;121(13):e266-369. doi: 10.1161/CIR.0b013e3181d4739e. Epub 2010 Mar 16.
Abstract/Text
PMID 20233780  Circulation. 2010 Apr 6;121(13):e266-369. doi: 10.1161/・・・
著者: Raimund Erbel, Victor Aboyans, Catherine Boileau, Eduardo Bossone, Roberto Di Bartolomeo, Holger Eggebrecht, Arturo Evangelista, Volkmar Falk, Herbert Frank, Oliver Gaemperli, Martin Grabenwöger, Axel Haverich, Bernard Iung, Athanasios John Manolis, Folkert Meijboom, Christoph A Nienaber, Marco Roffi, Hervé Rousseau, Udo Sechtem, Per Anton Sirnes, Regula S von Allmen, Christiaan J M Vrints, ESC Committee for Practice Guidelines
雑誌名: Eur Heart J. 2014 Nov 1;35(41):2873-926. doi: 10.1093/eurheartj/ehu281. Epub 2014 Aug 29.
Abstract/Text
PMID 25173340  Eur Heart J. 2014 Nov 1;35(41):2873-926. doi: 10.1093/e・・・
著者: Ryan R Davies, Amy Gallo, Michael A Coady, George Tellides, Donald M Botta, Brendan Burke, Marcus P Coe, Gary S Kopf, John A Elefteriades
雑誌名: Ann Thorac Surg. 2006 Jan;81(1):169-77. doi: 10.1016/j.athoracsur.2005.06.026.
Abstract/Text BACKGROUND: Optimal operative decision making in thoracic aortic aneurysms requires accurate information on the risk of complications during expectant management. Cumulative and yearly risks of rupture, dissection, and death before operative repair increase with increasing aortic size, but previous work has not addressed the impact of relative aortic size on complication rates.
METHODS: Our institutional database contains data on 805 patients followed up serially with thoracic aortic aneurysms. Body surface area information was obtained on 410 patients (257 male, 153 female). We calculated a new measure of relative aortic size, the "aortic size index," and examined its ability to predict complications in these patients.
RESULTS: Increasing aortic size index was a significant predictor of increasing rates of rupture (p = 0.0014) as well as the combined endpoint of rupture, death, or dissection (p < 0.0001). Using aortic size index, patients were stratified into three risk groups: less than 2.75 cm/m2 are at low risk (approximately 4% per year), 2.75 to 4.24 cm/m2 are at moderate risk (approximately 8% per year), and those above 4.25 cm/m2 are at high risk (approximately 20% per year).
CONCLUSIONS: This study confirms that (1) thoracic aortic aneurysm is a lethal disease, (2) relative aortic size is more important than absolute aortic size in predicting complications, and (3) a novel measurement of relative aortic size allows for the stratification of patients into three levels of risk, enabling appropriate surgical decision-making.

PMID 16368358  Ann Thorac Surg. 2006 Jan;81(1):169-77. doi: 10.1016/j.・・・
著者: Noboru Motomura, Hiroaki Miyata, Hiroyuki Tsukihara, Shinichi Takamoto, Japan Cardiovascular Surgery Database Organization
雑誌名: Circulation. 2008 Sep 30;118(14 Suppl):S153-9. doi: 10.1161/CIRCULATIONAHA.107.756684.
Abstract/Text BACKGROUND: The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery.
METHODS AND RESULTS: The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%; ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively.
CONCLUSIONS: This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.

PMID 18824747  Circulation. 2008 Sep 30;118(14 Suppl):S153-9. doi: 10.・・・
著者: Joseph S Coselli, Scott A LeMaire, Ourania Preventza, Kim I de la Cruz, Denton A Cooley, Matt D Price, Alan P Stolz, Susan Y Green, Courtney N Arredondo, Todd K Rosengart
雑誌名: J Thorac Cardiovasc Surg. 2016 May;151(5):1323-38. doi: 10.1016/j.jtcvs.2015.12.050. Epub 2016 Jan 14.
Abstract/Text OBJECTIVE: Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes.
METHODS: We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 [59-73] years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes.
RESULTS: There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P < .0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years.
CONCLUSIONS: Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.

Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
PMID 26898979  J Thorac Cardiovasc Surg. 2016 May;151(5):1323-38. doi:・・・
著者: Joseph V Lombardi, G Chad Hughes, Jehangir J Appoo, Joseph E Bavaria, Adam W Beck, Richard P Cambria, Kristofer Charlton-Ouw, Mohammad H Eslami, Karen M Kim, Bradley G Leshnower, Thomas Maldonado, T Brett Reece, Grace J Wang
雑誌名: Ann Thorac Surg. 2020 Mar;109(3):959-981. doi: 10.1016/j.athoracsur.2019.10.005. Epub 2020 Jan 27.
Abstract/Text This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.

Copyright © 2020 The Society of Thoracic Surgeons and the Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
PMID 32000979  Ann Thorac Surg. 2020 Mar;109(3):959-981. doi: 10.1016/・・・
著者: Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Hideyuki Shimizu, Morihito Okada, Akira Tangoku, Yuichiro Doki, Shunsuke Endo, Hirotsugu Fukuda, Yasutaka Hirata, Hisashi Iwata, Junjiro Kobayashi, Hiraku Kumamaru, Hiroaki Miyata, Noboru Motomura, Shoji Natsugoe, Soji Ozawa, Yoshikatsu Saiki, Aya Saito, Hisashi Saji, Yukio Sato, Tsuyoshi Taketani, Kazuo Tanemoto, Wataru Tatsuishi, Yasushi Toh, Hiroyuki Tsukihara, Masayuki Watanabe, Hiroyuki Yamamoto, Kohei Yokoi, Yutaka Okita
雑誌名: Gen Thorac Cardiovasc Surg. 2020 Apr;68(4):414-449. doi: 10.1007/s11748-020-01298-2.
Abstract/Text
PMID 32140991  Gen Thorac Cardiovasc Surg. 2020 Apr;68(4):414-449. doi・・・

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