What are the preferred treatments for ascending aortic aneurysms?

From the Guidelines

Surgical repair is indicated for patients with ascending aortic aneurysms who have symptoms attributable to the aneurysm, or for asymptomatic patients with a maximum diameter of ≥5.5 cm, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.

Key Considerations

• The size of the aneurysm is a critical factor in determining the need for surgical intervention, with a diameter of ≥5.5 cm being a key threshold for most patients.
• For patients with genetic conditions, such as Marfan syndrome, surgical repair may be recommended at a smaller diameter (≥5.0 cm) to prevent acute dissection.
• The growth rate of the aneurysm is also an important consideration, with a growth rate of ≥0.3 cm/y in 2 consecutive years, or ≥0.5 cm in 1 year, being an indication for surgical repair 1.

Treatment Options

• Surgical repair: open-heart surgery to replace the damaged section of the aorta with a synthetic graft.
• Medical management: blood pressure control using beta-blockers (such as metoprolol 25-200 mg daily or atenolol 25-100 mg daily) as first-line therapy, and angiotensin receptor blockers (like losartan 25-100 mg daily) for patients with Marfan syndrome.
• Regular imaging surveillance: CT or MRI scans every 6-12 months to monitor aneurysm size.
• Lifestyle modifications: avoiding heavy lifting, maintaining blood pressure below 130/80 mmHg, smoking cessation, and moderate exercise without extreme exertion.

Benefits and Risks

• Surgical repair can prevent potentially fatal complications like aortic dissection or rupture by reducing hemodynamic stress on the aortic wall.
• Medical management and lifestyle modifications can slow aneurysm growth and reduce the risk of complications.
• However, surgical repair carries risks, such as bleeding, infection, and stroke, and medical management may not be effective in preventing complications in all patients.

Recent Guidelines

• The 2022 ACC/AHA guideline for the diagnosis and management of aortic disease provides updated recommendations for the treatment of ascending aortic aneurysms, including the use of surgical repair and medical management 1.
• The guideline emphasizes the importance of individualized treatment decisions, taking into account the patient's symptoms, aneurysm size, growth rate, and genetic conditions.

From the Research

Treatment Options for Ascending Aortic Aneurysms

• Surgical techniques such as composite replacement (CR), supracommissural aortic replacement (SCR), and aortic valve-sparing (AVS) operations are used to treat ascending aortic aneurysms 2
• The choice of surgical technique depends on various factors, including the size of the aneurysm, patient age, and presence of underlying conditions such as Marfan's syndrome 2
• Endovascular repair is also a viable option for high-risk patients, with favorable outcomes reported in studies 3, 4

Surgical Techniques

• Composite replacement (CR) involves replacing the affected portion of the aorta with a prosthetic graft 2
• Supracommissural aortic replacement (SCR) involves replacing the ascending aorta and preserving the aortic valve 2
• Aortic valve-sparing (AVS) operations, such as the David's technique, aim to preserve the native aortic valve while replacing the affected portion of the aorta 2

Endovascular Repair

• Endovascular stent graft repair (EVAR) is a minimally invasive procedure that involves placing a stent graft in the affected portion of the aorta 3, 4
• EVAR has been shown to be a feasible and effective treatment option for ascending aortic disease in high-risk patients 3
• Ongoing research and development are focused on improving endovascular technologies for the management of ascending aortic disease 4

Patient Selection and Outcomes

• Patient selection for surgical or endovascular repair depends on various factors, including aneurysm size, patient age, and underlying medical conditions 2, 5, 6
• Studies have reported favorable outcomes for patients undergoing surgical or endovascular repair, with low mortality and reoperation rates 2, 3
• Long-term survival and freedom from adverse aortic events are important considerations in the management of ascending aortic aneurysms 2, 5