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v
Introduction
Informa Healthcare has developed various series of beautifully produced books in
different branches of medicine. These series have facilitated the integration of
rapidly advancing information for both the clinical specialist and the researcher.
John A. Elefteriades, MD has written and edited a much-needed, practical,
and timely book, Acute Aortic Disease. This complex clinical set of cardiovascular
problems is approached methodically, with beautifully illustrated sections on
diagnosis, imaging, biology, and treatment. Dr. Elefteriades has coauthored many
of the chapters, which provides the text with unparalleled cohesion and uniformity.
As a clinical cardiologist, I will keep this book open and on my office desk, not
perched on my bookshelf, because of the practical information it provides to assist
me in patient care.
The Editor has recruited the world’s leading experts in epidemiology,
pathophysiology, imaging, medical therapy, and surgery to approach this subject
with depth and special insight. The textbook summarizes the present state-of-the-
art and looks toward future advances in molecular diagnosis, gene therapy, and
even more sophisticated diagnostic modalities.
My goal as Editor-in-Chief of the Fundamental and Clinical Cardiology
Series is to assemble the talents of world-renowned authorities to discuss virtually
every area of cardiovascular medicine. I feel we have achieved this objective with
Acute Aortic Disease. Future contributions to this series will include books on
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molecular biology, interventional cardiology, and clinical management of such
problems as coronary artery disease, venous thromboembolism, peripheral vascular
disease, and cardiac arrhythmias.
Samuel Z. Goldhaber, MD
Professor of Medicine
Harvard Medical School
Staff Cardiologist
Brigham and Women’s Hospital
Boston, Massachusetts, U.S.A.
Editor-in-Chief
Fundamental and Clinical Cardiology Series
vi Introduction
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vii
Foreword
There is no disease more conducive to clinical humility than
aneurysm of the aorta.
The above quotation from Osler, the renowned physician, expresses the attitude
of the medical profession toward aortic aneurysms during the first half of the
20th century. In 1952, however, the advent of a curative surgical approach (1)
stimulated new interest in aortic diseases, and a more aggressive approach ensued.
As physicians began to realize the seriousness of aortic lesions and their high
morbidity and mortality, increasing attention was focused on the processes that
lead up to acute conditions. Also, as physicians began to appreciate the varied
etiology of aortic diseases, they gained a better understanding of the multiple
factors (wall stress, age-related degeneration, hypertension, inflammation, and
infection) that predispose to complications, mostly related to rupture.
Since the early years of aortic surgery, operative treatment has undergone
extensive changes, ranging from excision of sacciform lesions to imposition of
fabric or biologic grafts designed to restore the vascular continuity of all major
tributaries. Conventional aortic surgery, involving the use of cardiopulmonary
bypass and induced hypothermia, has yielded impressive results but is highly
invasive and necessitates prolonged recuperation. Newer approaches, entailing
intravascular placement of fabric-covered stents, promise to supplant the older
techniques. Anatomic locations that are hard to access, such as the ascending aorta
and proximal arch and the thoracoabdominal segments, may be more easily
repaired in hybrid suites, which allow surgeons and interventionalists to perform
combined repairs.
In addition, researchers are studying genetic factors and proposing preventive
measures for averting aortic diseases. With digitized and computerized techniques,
diagnoses are being made more precisely, more definitively, and less invasively
than with conventional aortography. These techniques allow better prognostic
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assessment and may help the physician decide on the best treatment after preven-
tive measures fail.
Because of this intense interest and progress, the management of aortic
diseases has a solid foundation. It will be interesting to see what new preventive
measures and treatment strategies lie ahead. Indeed, the present book may provide
the stimulus for future breakthroughs. I congratulate Dr. John Elefteriades on
producing such an excellent volume, which belongs on the shelves of all who deal
with aortic diseases.
Denton A. Cooley, MD
President and Surgeon-in-Chief
Texas Heart Institute
REFERENCE
1. Cooley DA, DeBakey ME. Surgical considerations of intrathoracic aneurysms of the
aorta and great vessels. Ann Surg 1952; 135:660–680.
viii Foreword
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ix
Preface
Over 100 years ago, the great physician Sir William Osler observed “there is no
condition more conducive to clinical humility than aneurysm of the aorta.” The
lithograph in Figure 1 illustrates the “electroshock therapy” applied in that era for
the treatment of large aortic aneurysms. Although we have made great progress
since that era, Osler’s observation regarding the challenge posed by aortic diseases
remains true to this day. The powerful potential for aortic aneurysm and related
Figure 1 In Osler’s time, electroshock therapy was employed to stop aneurysm progres-
sion and prevent rupture. Will our current therapies be looked at in another 100 years as
similarly archaic?
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disorders to injure or kill patients is expressed through a variety of acute aortic
conditions. It is on these conditions that this volume is focused.
Acute aortic disease has affected so many individuals of great intelligence,
creativity, and physical prowess (Fig. 2) that some authors have even speculated
that the propensity for aortic aneurysm or dissection is genetically associated with
intellectual or physical brilliance.
This volume is intended for cardiologists, emergency physicians, and
cardiac surgeons. Of course, this book is also appropriate for trainees in those
disciplines. We anticipate that it will also prove useful to a wide variety of other
professionals, including internists, vascular surgeons, radiologists, physician
associates, nurses, and students and residents in these various disciplines. The
book provides basic information for the novice as well as cutting-edge insight for
the expert.
This book takes up four perspectives to understanding aortic diseases: we
explore the underlying biology of aortic disease, the imaging of aortic aneurysms
and dissections, the appropriate means for diagnosis of these entities, and, of
course, the treatment, both medical and surgical, of acute aortic conditions. Via
these investigations, we will “read the playbook” of this virulent opponent that
constitutes the acute aortic condition. By reading the playbook, we aim to render
the professional better able to do battle with these conditions.
We make liberal use of illustrations of all types, including line drawings,
x-rays, and operative photographs, in order to emphasize the narrative observations
made in the text.
x Preface
Figure 2 (See color insert) Albert Einstein, Lucille Ball, Jonathan Larson (author of
“Rent”), Flo Hyman (Olympic volleyball player), George C. Scott, and John Ritter are just
a few among scores of brilliant people whose lives were cut short by acute aortic diseases.
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Some distinguishing features of this book, intended to engage the reader in
an almost interactive exchange with the author experts, include the Editor’s
Counterpoint (in which comments on the material are presented by each chapter
author) and the inclusion of a question and answer section at the end of most
chapters (Questions for the Author).
The aorta, we are finding, is “much more than a tube.” It is not simply a
passive conduit for carrying blood to important organs. Rather, it is an active
organ in its own right, even assisting the heart itself in propelling blood via its
elastic properties in the “game of catch” it plays with the left ventricle. These
organ-type functions of the aorta are explored in this book.
We place special emphasis on the difficult problem of diagnosing acute
aortic conditions on the front lines—in the office, in the emergency room, or in the
coronary care unit. Aside from their inherent virulence and complexity, these
conditions pose special challenges by virtue of their relative infrequency and
myriad clinical presentations. In many ways, for the internist, cardiologist, or
emergency physician on the front lines, looking for aortic dissections is like trying
to find a needle in a haystack. In fact, for every 100 patients presenting with chest
pain, 99 will have some cause other than aortic aneurysm and dissection. Also,
aortic dissection has been called “the great masquerader” because it can mimic
such a broad spectrum of diseases. Dissection can present with chest pain, back
pain, neck pain, abdominal distress, stroke-like symptoms, paraplegia, and vascular
insufficiency of the extremities. Our intent is that readers of this book will always
maintain an index of suspicion for aortic conditions and become better prepared
to recognize affected individuals among the vast number of disparate patients they
are called to evaluate.
The challenges of diagnosis and treatment in acute aortic conditions are such
that litigation abounds in this arena. In this book, we pay special attention to the
nature of lawsuits in aortic diseases and make special recommendations regarding
measures for their prevention. An entire chapter is devoted to this topic.
The biologic, radiologic, and medical and surgical sciences have indeed
made great strides since the observations of Osler regarding the challenge posed
by aortic diseases. This book intends to present those strides to the reader, so as to
better equip medical professionals to recognize and treat these disorders.
Through scientific advances, the balance of power is slowly changing vis-à-
vis aortic diseases, with a better outlook than ever before, for both physicians and
for the patients with whom they are entrusted, and progressively less danger from
the inherent aortic disease.
John A. Elefteriades
Preface xi
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xiii
Acknowledgments
The Editor expresses extreme gratitude to Sandra Beberman, who conceived and
commissioned this book. This is but one of many contributions she has made to
scientific education.
The Editor expresses thanks to Vanessa Sanchez and Ginny Faber for their
production and editorial contributions.
The Editor is grateful to the many chapter contributors, acknowledged inter-
national authorities in their respective fields, whose contributions constitute the
substance of this book. They have made time in their very busy lives to devote
attention to the generation of their exceptional manuscripts.
The Editor wishes to thank Ms. Marianne McCarthy, our Academic
Specialist in the Section of Cardiothoracic Surgery at Yale University, for her
tireless efforts on behalf of this book. Thanks also go to Suzanne Giannotti for her
administrative oversight that makes all our projects possible. Special thanks go to
Ms. Marianne Tranquilli, RN, for extraordinary contributions not only to this
book but also to all the functions of the Yale Center for Thoracic Aortic Disease.
Thanks are extended also to our current research staff—Amar Trivedi, Shannon
Widman, and Andrew Percy—for their review and scrutiny of the individual
chapters of this book. A special thank you goes out to the dozens of prior research
students and residents whose efforts are reflected in many chapters of this book,
including Dr. George Koullias, Dr. Gonzalo Albornoz, Dr. Remo Moomiaie, and
Dr. Ryan Davies, among others. Dr. John Rizzo, epidemiologist extraordinaire,
has been a vital component of the Yale Center since its very inception. My col-
league, Dr. Michael Coady, has contributed not only his clinical acumen and
skills, but also his considerable statistical and investigational talents, to all the
efforts of the Yale Center for Thoracic Aortic Disease. Appreciation is expressed
to Drs. Emily Farkas and Ali Shahriari for their manuscript review and their
contributions to Questions for the Authors.
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