He needs better control of his blood pressure.

True

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Repair is indicated for his thoracic aneurysm.

True

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False

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True

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Aortic aneurysm is a degenerative disease, commonly seen in elderly patients with a history of hypertension. It may affect the ascending aorta, descending aorta or the abdominal aorta. The upper size limit of the descending aorta is about 4cm. For an aneurysm larger than 6.0cm, the risk of rupture of the aneurysm is usually large enough to warrant surgical repair. Meticulous control of blood pressure is essential to minimize the risk of rupture of the aneurysm in these patients.

Surgical repair has been the gold standard for treatment of thoracic aneurysm. However, even in centres of excellence, the operative mortality risk and paraplegia risks are still in the 10% range. For patients with multiple co-morbidities, open repair may not be the best option due to the high surgical risk. Endovascular therapy, through multiple generations of development in recent years, has now emerged as another viable option particularly in patients with poor surgical risk.

Although long-term data are still not available, recent results demonstrated that the perioperative risk for stent-graft repair is around 7 - 8%, which includes patients treated in desperate clinical scenarios and those unfit for open surgery. In addition, the spinal cord ischaemia complication rate was around 6 - 7%, which is also a more favourable result than open repair. The mid-term survival appears to be similar between the two groups.

At this moment in time, the two techniques remain complementary to each other. There are still cases where an endovascular approach is not favourable due to restrictions such as thoracic aortic tortuosity, short landing and sealing zones, extensive mural thrombus and arterial access problems. However, due to its lower invasiveness, stent-graft repair has often been the procedure of first choice wherever it is technically feasible in many centres which are familiar with this technique.

Fig 1. Pre-op CT showing a thoracic aneurysm.	Fig 2. Post-op CT after stent-graft placement.

Fig. 3. Schematic diagram showing
a thoracic stent-graft

What is the diagnosis?

The diagnosis is Fordyce's spots.

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What is the underlying cause?

Fordyce's spots are ectopic sebaceous gland.

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Where do they usually present?

They can appear on the glans or shaft of the penis, labia of female, inside of the cheeks and on the lip.

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What are their clinical significance?

They are not known to be associated with any disease or illness and are of cosmetic concern only. However, if they occur in genitalia, patients may worry about sexually transmitted disease.

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What are the treatment options?

Vaporizing laser treatments or electrodesiccation have been used successfully to remove the spots. However, treatment is not required as they are harmless. Patients should be advised not to pick or squeeze the lesions.

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