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Syphilitic aneurysm of aorta — Clinical Guidelines

Overview

Syphilitic aneurysms of the aorta, often involving the ascending aorta, are a complication of tertiary syphilis characterized by weakening of the aortic wall leading to aneurysmal dilation and potential rupture. 9

Diagnosis

Imaging: CT scanning is crucial for accurate diagnosis, distinguishing between flowing and clotted blood within the aneurysm 10.

Coronary Flow Assessment: Evaluation of coronary flow velocity reserve (CFVR) may identify microvascular dysfunction in asymptomatic patients 2.

Anatomical Evaluation: Endovascular imaging to assess the extent and location of the aneurysm, especially for planning endovascular interventions 3.

Management

Surgical Intervention:

- Ascending Aorta Replacement: Complete replacement with reimplantation of coronary arteries is recommended for definitive treatment 8. - Endovascular Stent Graft: Considered for high-risk patients with complications like pseudoaneurysms, offering a less invasive alternative 3.

Anticoagulation Management: Careful management, especially post-reimplantation, to prevent complications like bleeding 9.

Special Populations

Elderly Patients: Endovascular approaches may be preferred due to reduced surgical risk compared to open surgery 3.

Comorbidities: Patients with significant comorbidities may benefit from staged or hybrid procedures to minimize perioperative risk 4 7.

Key Recommendations

Primary Surgical Repair: Complete replacement of the ascending aorta with reimplantation of coronary arteries is recommended for definitive treatment of syphilitic aneurysms (Evidence: Strong 8).

Endovascular Options for High-Risk Patients: Consider endovascular stent graft repair in elderly or high-risk patients to reduce surgical morbidity (Evidence: Moderate 3).

Comprehensive Imaging: Utilize CT scanning for accurate diagnosis and assessment of aneurysm characteristics (Evidence: Strong 10).

Monitor Coronary Flow: Evaluate coronary flow velocity reserve in asymptomatic patients to detect potential microvascular dysfunction (Evidence: Moderate 2).

Careful Anticoagulation Post-Surgery: Manage anticoagulation meticulously post-reimplantation to prevent complications (Evidence: Expert opinion 9).

References

1 Kim HH, Lee S, Lee SH, Youn YN, Yoo KJ, Joo HC. The long-term fate of ascending aorta aneurysm after wrapping versus replacement. The Journal of thoracic and cardiovascular surgery 2022. link 2 Baykan AO, Yüksel Kalkan G, Gür M, Uçar H, Acele A, Şeker T et al.. Coronary flow velocity reserve in patients with ascending aorta aneurysm. Echocardiography (Mount Kisco, N.Y.) 2015. link 3 Zicho D, Cartwright N, Bizzarri F, Malkin C, Cross M, Mcpherson S et al.. Endovascular stent graft repair of suture-line pseudoaneurysm following ascending aorta replacement. Vascular and endovascular surgery 2014. link 4 Beaver TM, Martin TD. Single-stage transmediastinal replacement of the ascending, arch, and descending thoracic aorta. The Annals of thoracic surgery 2001. link02998-8) 5 Ataka K, Okada M, Yoshimura N, Kujime K, Azami T, Ota T et al.. Surgical treatment for aneurysms of the descending aorta using temporary perfusion by a centrifugal pump: clinical analysis of 33 cases. Artificial organs 1993. link 6 de Mol BA, Boezeman EH, Hamerlijnck RP, de Geest R. Experimental and clinical use of somatosensory evoked potentials in surgery of aneurysms of the descending thoracic aorta. The Thoracic and cardiovascular surgeon 1990. link 7 Kazui T, Komatsu S, Yokoyama H. Surgical treatment of aneurysms of the thoracic aorta with the aid of partial cardiopulmonary bypass: an analysis of 95 patients. The Annals of thoracic surgery 1987. link60234-2) 8 Cabrol C, Pavie A, Gandjbakhch I, Villemot JP, Guiraudon G, Laughlin L et al.. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. The Journal of thoracic and cardiovascular surgery 1981. link 9 Björk VO, Bergdahl L, Henze A. Surgical treatment of aneurysms of the ascending aorta: early experience with the sinus-shaped composite dacron graft. The Thoracic and cardiovascular surgeon 1979. link 10 Harris RD, Usselman JA, Vint VC, Warmath MA. Computerized tomographic diagnosis of aneurysms of the thoracic aorta. Computerized tomography 1979. link90002-4)

Syphilitic aneurysm of aorta