What is the management approach for patients with thoracic aneurysms?

From the Guidelines

The management approach for patients with thoracic aneurysms involves a multidisciplinary team care, with consideration of the patient's individual characteristics, such as size, growth rate, and comorbidities, to determine the optimal medical, endovascular, and open surgical therapies, as recommended by the 2022 aortic disease guideline-at-a-glance 1. The approach to managing thoracic aneurysms is multifaceted and includes:

• Regular monitoring with imaging (CT or MRI) every 6-12 months for aneurysms below surgical thresholds, with frequency adjusted based on growth rate
• Medical therapy, including blood pressure control with beta-blockers (such as metoprolol 25-200 mg twice daily or atenolol 25-100 mg daily) as first-line agents to reduce aortic wall stress, and ACE inhibitors or ARBs if needed
• Surgical intervention, which is generally recommended when the ascending aorta reaches 5.0 cm (as per the latest guidelines) or the descending thoracic aorta reaches 6.0-6.5 cm, or growth exceeds 0.5 cm per year
• Endovascular repair, which is increasingly used for descending thoracic aneurysms, while open surgical repair remains standard for ascending and arch aneurysms
• Lifestyle modifications, including smoking cessation, avoiding heavy lifting (>50 pounds), and limiting strenuous activities that cause blood pressure spikes This comprehensive approach aims to prevent catastrophic complications like rupture or dissection while balancing surgical risks against the natural history of the disease, as supported by the latest guidelines and recommendations 1. Key considerations in the management of thoracic aneurysms include:
• The size and growth rate of the aneurysm
• The presence of comorbidities, such as hypertension, diabetes, and chronic kidney disease
• The patient's individual characteristics, such as age, sex, and family history
• The availability of multidisciplinary team care, including experienced practitioners and extensive management capabilities By taking a comprehensive and individualized approach to the management of thoracic aneurysms, healthcare providers can help to improve outcomes and reduce the risk of complications for patients with this condition, as recommended by the latest guidelines and studies 1.

From the Research

Management Approach for Thoracic Aneurysms

The management approach for patients with thoracic aneurysms involves a combination of medical therapy, surveillance, and surgical or endovascular repair.

• Medical therapy: The use of beta-blockers to lower aortic hemodynamic stress is a common approach, although the evidence supporting their effectiveness is limited 2.
• Renin-angiotensin system (RAS) inhibition has been proposed as a potential treatment option, with angiotensin II type 1 (AT₁) receptor blockers showing promise in reducing aortic root growth in patients with Marfan's syndrome 3.
• Surveillance: Regular imaging tests, such as computed tomography angiography (CTA), are critical for monitoring aneurysm size and growth rate, and for guiding treatment decisions 4, 5.
• Surgical or endovascular repair: The current European Society for Vascular Surgery guidelines recommend elective treatment of thoracic aneurysms with a diameter > 55mm, with endovascular repair being the preferred treatment option due to lower perioperative morbidity and mortality rates compared to open surgery 4.

Treatment Strategies

Treatment strategies for thoracic aneurysms depend on various factors, including aneurysm location, size, and growth rate, as well as the presence of associated conditions such as connective tissue disorders or bicuspid aortic valves.

• Endovascular repair: This involves the implantation of an aortic stent graft, and is the treatment of choice for most patients with thoracic aneurysms 4.
• Open surgery: This is typically reserved for younger patients who are fit for open surgery, or for those with complex aneurysms that cannot be treated endovascularly 4.
• Hybrid procedures: These combine debranching of supra-aortic vessels with endovascular repair, and are used to treat aneurysms involving the aortic arch 4.

Risk Factors and Prevention

Several risk factors contribute to the development and growth of thoracic aneurysms, including:

• Hypertension: Treating hypertension can help slow aneurysm growth 6.
• Smoking: Smoking cessation is essential for reducing the risk of aneurysm growth and rupture 6.
• Connective tissue disorders: Patients with conditions such as Marfan's syndrome are at increased risk of developing thoracic aneurysms 3, 6.
• Family history: A family history of thoracic aneurysms or other aortic diseases increases the risk of developing an aneurysm 6.