Thoracic aortopathy - especially aneurysm, dissection, and rupture - is responsible for significant morbidity and mortality. Uncontrolled hypertension and aging are primary risk factors for such conditions and they contribute, respectively, to increasing the mechanical stress on the wall and increasing its structural vulnerability. Select genetic mutations also predispose to these lethal conditions, and the collection of known mutations suggests that dysfunctional mechanosensing and mechanoregulation of extracellular matrix may contribute to pathogenesis and disease progression. In the absence of a well-accepted pharmacotherapy, non-surgical treatments tend to focus on reducing the mechanical loading on the aorta, particularly via the use of anti-hypertensive medications and recommendations to avoid strenuous exercises such as weight lifting. In this brief review, we discuss the important effects of central artery stiffening on global hemodynamics and in particular on increasing the pulse pressure that acts on the proximal thoracic aorta. We consider Marfan syndrome as an illustrative aortopathy but discuss other conditions leading to thoracic aortic aneurysm and dissection. We highlight the importance of phenotyping the aorta biomechanically, not just clinically, and emphasize the utility of mouse models in elucidating molecular and mechanical mechanisms of disease. Notwithstanding the widely recognized role of central artery stiffening in driving end organ disease, we suggest that there is similarly a need to consider its key role in thoracic aortopathy.

Aorto-pleural fistula (APF) is a rare, potentially fatal condition that should be immediately treated by an endovascular or surgical approach. In this case, we treated APF using bronchial occlusion with Endobronchial Watanabe Spigots (EWSs) after one-lung ventilation. Notably, EWS is composed of silicon for endobronchial occlusion under bronchoscopy. An 88-year-old man was referred to our hospital for sudden massive hemoptysis. We maintained the airway by emergent intubation into the right main bronchus through guided bronchoscopy. Computed tomography demonstrated an aortic aneurysm at the aortic arch, penetrating the upper lobe of the left lung. On the 18th hospital day, we performed prophylactic endobronchial occlusion with EWS. The patient was extubated shortly thereafter. Endobronchial occlusion with EWS might be effective in patients with APF who exhibit generally poor conditions. Endobronchial occlusion treatment should be performed after controlling massive bleeding by one-lung ventilation.

The utility of Thoracic EndoVascular Aortic Repair (TEVAR) continues to progress at a very rapid rate. Initially implemented for the treatment of thoracic aortic aneurysms, TEVAR has evolved to treat a variety of aortic pathologies and reduce overall morbidity and mortality rates compared with traditional open surgical repair. Given the rapidly evolving nature of endovascular thoracic intervention, we hereby briefly review the current literature on the evolving applications of TEVAR. TEVAR continues to rapidly evolve and is being applied to a growing number of aortic pathologies. Given the perioperative, short- and mid-term morbidity and mortality rates, TEVAR is quickly surpassing traditional open surgical intervention as the ideal procedure for patients undergoing intervention of the descending thoracic aorta and applicability to ascending and arch pathologies is being explored. However, as more data becomes available TEVAR may be associated with higher rates of reoperative requirements. Data remains limited on the long-term efficacy of the intervention and should continue to be investigated.

A 42-year-old woman, with no evidence of connective tissue disease, presented with acute aortic dissection after an uneventful vaginal delivery following an uncomplicated pregnancy. Emergency computed tomography angiography showed a bovine aortic arch with a separate origin of the left vertebral artery. At surgery, a tricuspid aortic valve was found and the aortic arch was successfully repaired with reimplantation of a button incorporating the origin of the brachiocephalic vessels. Acute aortic dissection throughout pregnancy is uncommon and favoured by hemodynamic, hormonal, and histological changes. Anomalies of the aortic arch branches might represent an increased risk of thoracic aortic diseases.