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With each heartbeat, blood is ejected into the aorta generating multiple mechanical forces including pressure, radial stress and longitudinal stress. These forces increase aortic wall tension potentially leading to the development of aortic dissections and aortic aneurysms that may require surgical or endovascular repair.
The aorta ascends in the anterior mediastinum, curves backward into the aortic arch from which emanate the great vessels of the head and the upper extremities, descends into the posterior mediastinum and beyond the diaphragm continues into the abdomen providing blood to the spinal cord, gut, kidneys, ultimately dividing to deliver blood to the lower extremities (Figure 9–1).
Diseases that interfere with the delivery of blood to the tissues (e.g., aortic dissections, atherosclerosis, and emboli) place patients at great risk for organ ischemia. Other disease conditions (e.g., aneurysms) weaken the wall of the aorta and often result in aortic rupture and sudden death. Many patients with aortic disease present emergently secondary to acute dissection, aneurysm rupture, or following traumatic aortic injury. Others, with long-standing aortic aneurysms, present for elective surgical or, increasingly common, for endovascular repair.
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DISEASES OF THE ASCENDING THORACIC AORTA
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Patients with ascending thoracic aortic aneurysms present either acutely or electively (Figure 9–2). Crushing chest pain often heralds acute presentations. Some of these acute patients never undergo surgery as they develop lethal complications such as coronary ischemia, pericardial effusion and tamponade, or intrathoracic bleeding. In most cases, patients will present emergently for repair following diagnosis in the emergency room. Acute, contained ascending aortic aneurysm ruptures require immediate surgical correction. Radiographic (MRI, CT) and ultrasound ...