Diseases of the aorta are the 14th leading cause of death in the United States. This complex group of diseases (aneurysms, dissections, and occlusive disease) affects multiple vascular beds, from the aortic valve to the terminal aorta and iliac arteries. Because of this fact, the clinical management of aortic diseases is performed by a variety of healthcare providers.
The incidence and prevalence of aortic disease are increasing as society ages and contributing risk factors go untreated. Thus, these diseases are not rare and, if they are left untreated, patients with aortic disease die. In addition, there are no proven specific or targeted drug therapies to treat aortic disease.
Universal are a significantly higher prevalence in men and a graded increased prevalence with advancing age. The inciting events that lead to aortic disease are not well understood; however, some common themes include: (1) proteolytic derangements in the aortic wall, (2) transmural vessel wall inflammation, (3) immune responses, including a strong genetic link, and (4) altered biomechanical wall stresses along the length of the aorta.
Unfortunately, aortic disease is often clinically silent until patients present with catastrophic aortic rupture or malperfusion of end organs, such as the intestines or kidneys. Alternatively, aortic disease may be discovered serendipitously when healthcare providers perform tests for other disease processes. Discovery of aortic disease before aortic rupture is critical, as there is a huge disparity in mortality rates between patients who undergo aortic repair in the elective setting and those who undergo repair in an emergency setting.
Until recently, the treatment of aortic disease was primarily surgical, involving large incisions with the potential for excessive blood loss, life-threatening perioperative complications, and death. Although open aortic repair is effective and durable for treating aneurysms and dissections and preventing aortic rupture, the associated excessive mortality rates, as well as an overall strong trend in surgery toward minimally invasive techniques, led to a process in which a covered stent graft could be delivered endoluminally, effectively sealing off an aneurysm or dissection, preventing aortic rupture, and decreasing associated mortality. Subsequent years have witnessed a tremendous surge in the number of endovascular aortic repairs performed with significant technological improvements in stent graft design. The use of endovascular technology in the treatment of abdominal and thoracic aorta pathology lowers short-term mortality and morbidity rates. However, this comes at an increased cost due to the expensive nature of the stent grafts, as well as the lifelong follow-up with serial computed tomography scans that patients with endografts must undergo.
Articles in the “Aortic Disease” series will be published monthly over the next 10 months. Most of the articles in this series will focus on the clinical care of patients with aortic disease, with articles on repair of the ascending aorta and aortic arch, open and endovascular repair of thoracic aortic aneurysms, and treatment of thoracoabdominal aortic aneurysms with fenestrated and multibranched endografts, as well as the management of patients with small abdominal aortic aneurysms. Other articles will focus more on disease processes, such as Marfan’s disease and aortic dissections. The articles in this series should serve as an up-to-date review for the clinician who provides care for this complex group of patients.