From the Guidelines
For patients with aortic aneurysms, intervention is recommended at a diameter of 5.0 cm or greater for sporadic aortic root and ascending aortic aneurysms, with even lower thresholds considered in specific scenarios among patients with heritable thoracic aortic aneurysms, as determined by a Multidisciplinary Aortic Team. The management of aortic aneurysms is complex and requires a multidisciplinary approach, considering factors such as patient size, growth rate, and underlying conditions 1.
Key Considerations
- The threshold for surgical intervention has been lowered from 5.5 to 5.0 cm in selected patients, and even lower in specific scenarios among patients with heritable thoracic aortic aneurysms, as stated in the 2022 aortic disease guideline-at-a-glance 1.
- Rapid aortic root growth or ascending aortic aneurysm growth, defined as ≥0.5 cm in 1 year or ≥0.3 cm/y in 2 consecutive years for those with sporadic aneurysms, is an indication for intervention 1.
- Shared decision-making involving the patient and a multidisciplinary team is highly encouraged to determine the optimal medical, endovascular, and open surgical therapies, especially in patients contemplating pregnancy or who are pregnant 1.
Surveillance and Monitoring
- Computed tomography, magnetic resonance imaging, and echocardiographic imaging of patients with aortic disease should follow recommended approaches for image acquisition, measurement, and reporting of relevant aortic dimensions, and the frequency of surveillance before and after intervention 1.
- Surveillance involves regular imaging, typically every 6-12 months for aneurysms approaching intervention thresholds, and every 2-3 years for smaller ones, to monitor growth rates and prevent rupture 1.
Medical Management
- Medical management includes blood pressure control with beta-blockers as first-line therapy, targeting systolic pressure below 130 mmHg, and angiotensin receptor blockers like losartan for patients with Marfan syndrome 1.
- Lifestyle modifications, such as smoking cessation, limiting heavy lifting, maintaining moderate exercise, and controlling cholesterol with statins, are essential for preventing rupture and managing aortic aneurysms 1.
From the Research
Aortic Aneurysm Guideline
- The clinical risk factors for the development of an abdominal aortic aneurysm (AAA) include tobacco use, hypertension, a family history of AAA, and male sex 2.
- Ultrasound is the preferred method of screening for AAA, and it is cost-effective in high-risk patients 2.
- Repair is indicated when the aneurysm becomes greater than 5.5 cm in diameter or grows more than 0.6 to 0.8 cm per year 2.
- Asymptomatic patients with an AAA should be medically optimized before repair, including institution of beta blockade 2.
- Symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention 2.
Treatment Options
- Open surgical repair (OSR) and endovascular aneurysm repair (EVAR) are two treatment options for AAA 3, 4, 5.
- EVAR is preferred due to faster recovery and lower perioperative risk, but it may have higher reintervention rates and long-term complications 3, 4, 5.
- OSR is reserved for patients with longer life expectancy and lower morbidity, and it may have higher operative mortality rates 4.
- The choice of treatment depends on patient-specific factors, including anatomical considerations and overall health 3, 5.
Outcomes and Complications
- The mortality rate for ruptured AAA is extremely high, approaching 90% if rupture occurs outside the hospital 2.
- The 30-day mortality rate after EVAR is around 1-2%, while the 30-day mortality rate after OSR is around 3-4% 3, 4.
- Patients with larger AAAs (≥6.0 cm) have higher all-cause mortality, complication, and reintervention rates after EVAR 6.
- Long-term periodic monitoring is essential to detect and treat endoleaks, document stable diameter of the eliminated aneurysmal sac, and determine whether reintervention is necessary 4.