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Ann Thorac Surg 1999;67:1922-1926
© 1999 The Society of Thoracic Surgeons
a Section of Cardiothoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
b Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
Address reprint requests to Dr Elefteriades, Section of Cardiothoracic Surgery, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510
e-mail: john_elefteriades{at}QM.yale.edu
Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.
Background. Evidence regarding the behavior of thoracic aortic aneurysm (TAA) is limited. This study reviews our ongoing efforts to understand the factors influencing aortic growth rates and the complications of rupture and dissection in order to define scientifically sound criteria for surgical intervention.
Methods. Data from 370 patients with TAA treated at Yale University School of Medicine from January 1985 to June 1997 were analyzed. This computerized data base included 1063 imaging studies (magnetic resonance imaging, computed tomography, and echocardiography).
Results. The mean size of the thoracic aorta in these patients at initial presentation was 5.2 cm (range 3.5–10). The mean growth rate was 0.10 cm/year. Median size at the time of rupture or dissection was 5.9 cm for ascending 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 
6.0 cm increased the probability of these devastating complications by 25.2% for ascending aneurysms (p = 0.006 compared with aneurysms 4.0–4.9 cm). For descending aneurysms 7.0 cm, risk of dissection or rupture was increased by 37.3% (p = 0.031).
Conclusions. If the median size at time of dissection or rupture had been used as the indication for intervention, half the patients would have suffered a devastating complication before surgery. 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 this operation can be performed with relatively low mortality. For aneurysms of the descending aorta, where perioperative complications are greater and the median size at the time of complication is larger, we recommend intervention at 6.5 cm.
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