Clinical and subclinical characteristics on thoracic aortic aneurysm patients treated by endovascular repair
Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
CLINICAL AND SUBCLINICAL CHARACTERISTICS ON
THORACIC AORTIC ANEURYSM PATIENTS TREATED
BY ENDOVASCULAR REPAIR
Lam Trieu Phat1, Tran Quyet Tien1, Nguyen Truong Giang1
SUMMARY
Objectives: To describe some clinical and subclinical characteristics of patients with thoracic
aortic aneurysms (TAA) before endovascular repair. Subjects and methods: A descriptive
study on clinical and subclinical features in 80 patients with TAA treated endovascular
interventions under the guidance of a DSA or C-arm machine at Cho Ray Hospital, from August
2013 to September 2018. Results: The average age of the study population was 64.71 11.58.
Men accounted for the majority with 62 patients (77.50%). The most common medical history
was hypertension (76.25%) and smoking (63.75%), while diabetes was less than 20%.
Preoperative tests were mostly within the normal range. The incidence of fusiform aortic
aneurysms was lower than that of the saccular aortic aneurysms (38.75% vs. 61.25%, respectively).
The average diameter of the TAA was 64.16 mm; its length was 97.92 mm. The mean proximal
diameter was 32.00 mm, the mean distal diameter was 26.51 mm. Arterial access size was
almost suitable for the endovascular. Conclusion: The average age of TAA patients was over
60 years old, common in men. The common risk factors associated with TAA were hypertension
and smoking. The saccular aortic aneurysm was dominant.
* Keywords: Clinical and subclinical features; Thoracic aortic aneurysm; Endovascular repair.
INTRODUCTION
old in people with a family history of aortic
disease [3]. Currently, in the world, in
developed countries, endovascular repair
to treat thoracic aortic aneurysm has been
performed many times and is the preferred
treatment method compared to conventional
open surgery. In Vietnam, many large
The aortic aneurysm is the second
most common disease of the aorta after
atherosclerosis. In global treatment
guidelines, aortic aneurysm is divided
into the thoracic aortic aneurysm and
abdominal aortic aneurysm because of
differences in screening, diagnosis, and
treatment strategy [2]. The mean age of
detection of aortic disease was 64.3 years
old in the normal population and 56.8 years
medical
establishments
implement
endovascular repair to treat TAA. This
study aims to: Describe some clinical and
subclinical characteristics of patients with
TAA before endovascular repair.
1Cho Ray Hospital
2Vietnam Military Medical University
Corresponding author: Lam Trieu Phat ([email protected])
Date received: 05/4/2021
Date accepted: 07/6/2021
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
SUBJECTS AND METHODS
1. Subjects
In which, p is the success rate, d is the
marginal error, Z(1-α/2) is the probability
of the normal distribution at the error
probability α.
Patients with TAA were treated by
endovascular under the guidance of DSA
or C-arm at Cho Ray Hospital from
August 2013 to September 2018.
- The probability of error α = 0.05 then
* Selection criteria:
Z(1-α/2) = 1.96.
- The patients diagnosed with a thoracic
aortic aneurysm were indicated for
endovascular repair according to the
guidelines of the European Heart
Association (2014) [2].
- According to Grace Wang et al, the
mortality rate of the TEVAR program in
patients with TAA was about 1.9 to 3.1%,
an average of 2.5% [11]. So we chose
p = 0.025.
- Thoracic aortic aneurysm treated by
endovascular.
- d: Accuracy (or permissible error),
choose d = 0.04.
- Aortic arch debranching surgery and
later endovascular repair.
From the above formula, we calculate
n = 58.5. Thus, the minimum sample size
for the study was 59 patients. In fact, we
studied 80 patients.
* Exclusion criteria:
- Combined aortic root aneurysm or
ascending aortic aneurysm.
* Research indicators:
- Combined heart surgery: Heart valve
surgery, coronary artery bypass surgery.
- Age: The average age and distributed
by age groups (under 50, 50 - 59, 60 - 69,
70 - 79 and from 80 years old and over).
- The femoral and pelvic artery morphology
is not suitable for endovascular repair.
- Gender: Male, female, male/female
ratio.
- Combined abdominal aortic aneurysm.
- Malignancy or severe medical disease
with a survival prognosis of fewer than
2 years.
-
Medical history: Hypertension,
diabetes mellitus, coronary artery disease
with or without stenting, chronic renal
failure, stroke, smoking, dyslipidemia,
family history of arterial disease.
- Allergy to radiocontrast.
- Combined aortic dissection.
- Subclinical tests: Plain chest radiograph,
2. Methods
electrocardiogram,
echocardiogram,
* Study design: Descriptive study on
clinical and subclinical characteristics of
patients with thoracic aortic aneurysm.
ultrasound of carotid artery.
- Measureparameters of aneurysms on
thoracic computed tomography: The
shape of an aneurysm (fusiform or
saccular); the largest diameter of the
aneurysm, the proximal and distal
* Sample size:
The sample size is calculated using
the following formula:
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
diameter of the aneurysm (mm); the artery diameter (mm); external iliac artery
length of the aneurysm (mm); The diameter (mm); common femoral artery
distance from the aneurysm to the diameter (mm).
arteries such as left subclavian artery, left
common carotid artery, brachiocephalic
trunk, celiac trunk (mm); common iliac
* Statistical analysis: Collected data
were entered and processed on the
biomedical statistical software SPSS 22.0.
RESULTS
35
30
25
20
15
10
5
31
19
16
7
7
0
< 50
50 - 59
60 - 69
70 - 79
≥ 80
Age group
Figure 1: Distribution of patients by age group.
The average age of the study group was 64.71
11.58 years; the youngest
31 years old and the oldest 87 years old. When distributing patients into different age
groups, we found that the age group 60 - 69 accounted for the highest proportion
(38.75%), the 70 - 79 age group explained for 23.75%, and the age group under 50 years
and the elderly group over 80 years old had an equal percentage of 8.75 (7 patients
each group).
18, 22.50%
Male
Female
62, 77.50%
Figure 2: Distribution of patients by sex.
Regarding the sex distribution, in the study group, men accounted for the majority
compared to women, the ratio of male/female was 3.4/1.
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Table 1: Medical history and cardiovascular risk factors (n = 80).
Medical history and cardiovascular risk factors
Number (n)
Rate (%)
76.25
12.50
6.25
Hypertension
61
10
5
Diabetes
Coronary artery disease with stenting
Dyslipidemia
49
1
61.25
1.25
Chronic renal failure
Smoking
51
63.75
Stroke history
4
2
0
5.00
2.50
0
Chronic obstructive pulmonary disease
Family history of aortic disease
Among cardiovascular risk factors, hypertension accounted for the highest rate of
76.25% (61 patients), the second-highest rate of smoking was present in 51 patients
(63.75%), dyslipidemia ranked the third with 61.25% of cases. The rate of diabetic
patients was 12.50%. Coronary artery disease with stenting occupied 6.25% of cases.
Other risk factors such as a history of stroke, chronic obstructive pulmonary disease,
carotid stenosis, and a family history of an aortic aneurysm were low.
Bulging aorta on chest X ray
[]
Yes
No
[]
Figure 3: The proportion of bulging aorta on chest X-ray.
There were 46 patients with signs of the bulging aorta on the plain chest X-ray,
accounting for 57.50%; and 42.50% of patients did not have this sign.
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Table 2: Characteristics of the ECG, echocardiogram and carotid ultrasound.
Characteristics
Value
Echocardiogram
Mean ejection fraction (%)
Abnormal hypoactivity (n, %)
ECG
65.07 7.29
2 (2.5)
Heart rhythm
- Sinus rhythm (n, %)
- Atrial fibrillation (n, %)
77 (96.25)
3 (3.75)
Myocardial ischemia (n, %)
7 (8.75)
- On the cardiac ultrasound parameters, the average ejection fraction reached
65.07%, the rate of patients with abnormal hypoactivity in cardiac ultrasound was
only 2.5%.
- On the electrocardiogram, only 3.75% of patients had atrial fibrillation,
the remaining 96.25% were sinus rhythm. 91.25% of patients showed no sign of
myocardial ischemia.
Table 3: Characteristics of the superior thoracic aortic aneurysm on computed
tomography.
Characteristics
n (%)
Aneurysm shape
- Fusiform
31 (38.75)
49 (61.25)
- Saccular
Thrombosis in the wall of an aneurysm
- Yes
- No
62 (77.50)
18 (22.50)
Calcification in an aneurysm
- Yes
- No
3 (3.75)
77 (96.25)
The rate of the saccular aneurysm was more than that of the fusiform aneurysm.
Most of the aneurysms had thrombosis in the wall, with the rate of thrombosis on CT-scans
up to 77.50% of cases. 3.75% had calcification into the aneurysm.
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Table 4: Dimensional characteristics of the aneurysm and important interventional areas.
Characteristics
Value
The average largest diameter of the aneurysm (mm)
The length of the aneurysm (mm)
64.16 15.48 (38.0 - 113.0)
97.92 65.53 (26.80 - 339.0)
27.63 45.41 (0.0 - 175.60)
40.20 47.87 (0.0 - 196.10)
50.82 48.30 (0.0 - 210.20)
141.26 74.93 (5.0 - 256.0)
32.00 4.60 (21.50 - 40.00)
26.51 4.69 (14.00 - 39.00)
The distance from the aneurysm to the left subclavian artery (mm)
The distance from the aneurysm to the left common carotid artery (mm)
The distance from the aneurysm to the brachiocephalic trunk (mm)
The distance from the aneurysm to the celiac trunk (mm)
The proximal diameter of the aneurysm (mm)
The distal diameter of the aneurysm (mm)
- The average largest diameter of the TAA in men over 65 years old can detect
aneurysm of the patients was 64.16 mm. and promptly treat this dangerous
The length of the aneurysm was 97.92 mm. disease. The methods used to screen for
thoracic aneurysms were plain chest
- The distances from the aneurysm
radiographs, thoracic echocardiography,
to the branches of the aortic arch were
and transesophageal echocardiography if
27.63 mm, 40.20 mm and 50.82 mm,
indicated.
respectively.
In terms of the medical history and
cardiovascular risk factors, hypertension
was high (76.25%), smoking was also an
important risk factor in 63.75% of the
cases. However, type II diabetes
accounted for only 12.50%. Unlike other
cardiovascular risk factors, type II
diabetes does not increase the risk of
aortic aneurysms. In 2019, D’Cruz et al.
conducted a study on evaluating the
correlation of diabetes and TAA, which
included 5 cohort studies and 5 case-
control studies with more than 1 million
patients selected for analysis. The
analysis results of all 10 studies showed
an inverse correlation between diabetes
-
The proximal diameter of the
aneurysm was 32.00 mm. The distal
diameter of the aneurysm was 26.51 mm.
DISCUSSION
The average age of our patient group
was 64.71 11.58 years old, of which the
most common age group was from 60 to
69 years old (38.75%). Male was
predominant with male/female ratio of
3.4/1. In the study by Wang et al. in
Taiwan, the mean age was 73.3; 78.8% of
patients aged ≥ 65 years, and 75.6% of
patients were male [10]. With age
analysis and male/female ratio, we found
that TAA usually occurs in the age group
over 60, most frequently in the age group mellitus and TAA (OR = 0.77; 95%CI:
65 to 70 years and in men 3 to 5 times 0.61 - 0.98). Through this study, the
higher than women. With the above
analysis data, the initiation of screening
authors concluded that there was an
inverse correlation between diabetes
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
mellitus and thoracic aneurysms. In other can be difficult to use to eliminate aortic
words, diabetes has the potential to aneurysms. In 2004, Von Kodolitsch et al.
did research on evaluating the role of
chest radiographs in the diagnosis of
acute aortic syndrome. There were 216
patients (143 men, 73 women) recruited
in the study. Patients had a plain chest X-
ray because of suspected acute aortic
syndrome, with the gold standard for
evaluation of CT-scan. The results
showed that the plain chest radiograph
had 64% sensitivity and 86% specificity
for aortic disease. Particularly for the
aortic aneurysm, the sensitivity of the
plain chest radiograph was 61%. The
authors concluded that plain thoracic
radiograph limited value in the diagnosis
of the acute aortic syndrome, in particular
lesions involving the ascending thoracic
aorta, and recommended replacement of
plain chest radiograph by CT-scan to
evaluate more accurately [9].
protect patients from aneurysms [1].
In contrast to diabetes, smoking was
considered one of the important risk
factors for aortic aneurysms. Landenhed
et al. conducted a cohort study on
evaluating risk factors for aortic disease in
a population, including thoracic aortic
aneurysm. The study was performed on
30,412 subjects in Sweden, with a follow-
up period of 20 years. The authors
assessed the incidence of aortic disease,
including TAA, and its correlation with risk
factors. The results showed that the
incidence of the TAA was 9 per 100,000
people-year (95%CI: 6.8 - 12.6). This
study showed that smoking increases the
risk of developing TAA (HR = 2.2; 95%CI:
1.2 - 4.0), hypertension also increases the
risk of developing TAA (HR = 2.2; 95%CI:
1.2 - 4.0), but it was lower than smoking in
this study (HR = 1.46; 95%CI: 0.73 - 2.95)
[5].
To assess cardiovascular disease
associated with aortic aneurysms, we used
echocardiography and electrocardiograms.
Since coronary artery disease and aortic
disease have many common cardiovascular
risk factors, screening for coronary artery
disease is essential. In our patient group,
the rate of abnormal hypoactivity of
cardiac wall was only 2.50%, the rest had
good contractile heart, with a mean
ejection fraction of 65.07%. On the
electrocardiogram, only 3.75% of patients
had atrial fibrillation and 96.25% of
patients with sinus rhythm; 8.75% of
patients showed signs of myocardial
In addition to the above important
medical history, other medical histories in
our study showed that the patient’s risk
was quite low, with only 1 case of chronic
renal failure, 5 cases of coronary artery
disease with stenting, 4 patients of stroke.
Therefore, our patient group had a
relatively low risk compared with the
mean risk in patients with TAA.
On a plain thoracic X-ray, the sign of a
bulging aorta arch or enlarged aortic arch
is a sign of a thoracic aortic aneurysm.
The proportion of patients with enlarged anemia on the electrocardiogram and
aortic arch in our study was 57.50%. This 91.25% had no symptoms of myocardial
showed that the specificity of this sign on anemia. Thus, with the above data, our
plain chest radiograph was not high and subjects had fewer clear signs of ischemic
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
heart disease. However, in 2007, Ferro et near the origin of the visceral artery.
al.’s report on the incidence and risk According to the study by Shang et al.,
factors of coronary artery disease out of 322 sac aneurysms, 68.1% were in
associated with aortic disease showed the descending thoracic aorta, 24.2% in
inconsistent results. 95 asymptomatic
patients with ischemic heart disease (66
the abdominal aorta, 7.1% in the arch,
and 0.6% in the ascending thoracic
aneurysm [7]. In our study, there were
49 patients with saccular aneurysms,
accounting for 61.25%, more dominant
men, 33 women, mean age 63
11.8)
were evaluated. The patients will have a
coronary angiogram and aortic CT-scan
to check for the presence of these two than fusiform aneurysms. This is consistent
diseases. The results showed that the with the above authors because we
rate of asymptomatic coronary artery evaluate the group of patients with TAA,
stenosis in patients with aortic disease
was 63.1%, of which the rate of coronary
artery disease associated with thoracic
aortic disease was 70%. The two most
important risk factors were smoking and
dyslipidemia. The authors concluded that
coronary artery disease had a high
incidence in patients with aortic disease,
and recommended careful coronary artery
screening in this group of patients [4].
so the saccular aneurysm is more common.
Average length of aneurysm in our
study was 97.92 mm if adding the
proximal and distal regions (minimum 20
mm per region). The average required
intravascular graft length was 138 mm.
The thoracic aortic endovascular grafts
used in our study had a minimum length
of 150 mm, so with the above-average
length, normally just one graft can be
used to achieve the purpose to isolate the
aneurysm with hypovolemic areas with
The aneurysm shape is one of the
important factors influencing treatment
strategy and prognosis. The aortic long enough distance to ensure that
aneurysm is divided into two main groups there were no intravascular leakage
of shapes: Fusiform and saccular complications for the patient. However,
there were also cases with the length of
the large aneurysm, which need to place
many grafting tubes, or the proximal neck
and distal neck diameters of the aneurysm
were much different, so it needs to place
the grafting abide by technique from the
bottom up. This technique is performed by
placing a smaller size graft in the bottom
place first, then placing the larger size
within the smaller graft. In this procedure,
the hypovolemic areas with a diameter
difference of more than 6 mm to 8 mm
can be successfully interfered with by the
endovascular repair method.
aneurysms. Fusiform aortic aneurysms
are primarily caused by connective tissue
disease or atherosclerosis. In contrast,
the saccular aortic aneurysm has many
different causes: Advanced infection or
previous infection, inflammatory diseases
such as tuberculosis, syphilis, degeneration,
and progression of a trans-arterial ulcer of
aorta, a medical history of aortic injury,
Behcet's disease, and Takayasu's disease…
[6]. In terms of frequency of occurrence,
the location of the saccular aneurysm is
most commonly found in the small
curvature of the arch of the aorta and
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
In our study, the average distance from < 10% (n = 85), 10 - 20% (n = 188),
the aneurysm to the main arteries of the > 20% (n = 64). The results showed that
aortic arch was: Left subclavian artery aneurysm diameter (32.6 mm vs. 31.3 mm
(27.63 mm), the left common carotid artery and 28.2 mm, p < 0.001) and aneurysm
(40.20 mm), and the brachiocephalic length in group I (69 mm vs. 58 mm and
trunk (50.82 mm). Thus, with the above- 52 mm, p = 0.035) were larger than that
average distances, the proximal and distal of the other two groups [8].
landing zones were ensured without the
CONCLUSION
need to aortic arch debranching surgery.
However, 43 patients in the study underwent
aortic arch debranching surgery. Considering
the median number, the distance from the
aneurysm to the main arteries of the
aortic arch were: 0 mm of the left
subclavian artery; the left common carotid
artery (19.1 mm); the brachiocephalic
trunk (30 mm). In this case, the median in
the case of the objective evaluation was
more than the mean because in some
cases, the distance from the aneurysm
was much larger than the others and
interfered with the mean.
The average age of the study population
was 64.71 11.58. Men accounted for the
majority with 62 patients (77.50%). The most
common medical history was hypertension
(76.25%) and smoking (63.75%), and
diabetes was less than 20%. Preoperative
tests were mostly within the normal range.
The incidence of fusiform aneurysms was
lower than that of the saccular aneurysm
(38.75% and 61.25%) of the aorta. The
average diameter of the aneurysm was
64.16 mm; its length was 97.92 mm. The
mean proximal diameter was 32.00 mm
and the mean distal diameter was
26.51 mm. Arterial access size of the
study group was almost suitable for the
endovascular.
The mean diameters of the proximal
and distal landing zones were 32.00 mm
and 26.51 mm, respectively, which were
within the current permissible limits for the
types of stent grafts used in the research.
With TAA, the recommended oversizing
of landing zones was 10 to 20%. This rate
of the oversizing of endovascular repair in
the treatment of TAA has been reported
by several authors. Tolenaar et al.
performed a meta-study to evaluate the
effect of oversizing on the outcome of
TEVAR in patients with TAA. The study
included four clinical trials with 377 patients
(222 male patients, mean age of 72 years).
The average oversizing rate was 14.6%.
Patients were divided into three groups
based on the rate of oversizing:
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