What are the surveillance guidelines for a patient with an ascending aortic caliber of up to 3.7 cm and no adverse changes on Computed Tomography Angiography (CTA) study?

From the Guidelines

For a patient with an ascending aortic caliber of up to 3.7 cm and no adverse changes on CTA, surveillance imaging should be performed every 2-3 years. This recommendation is based on the latest guidelines from the American Heart Association/American College of Cardiology joint committee on clinical practice guidelines, which suggest that longer surveillance imaging intervals are safe for AAA diameters of 3.0 cm to 3.9 cm 1. The patient's aortic measurement falls below the threshold for more frequent monitoring, typically 4.0 cm.

Key Considerations

• Patients should continue routine follow-up with their cardiologist or vascular specialist, who may adjust the surveillance interval based on individual risk factors such as family history, genetic conditions, or hypertension.
• Between imaging studies, blood pressure control is essential, with a target of less than 130/80 mmHg using appropriate antihypertensive medications like beta-blockers (such as metoprolol 25-100 mg twice daily) or angiotensin receptor blockers.
• Patients should also modify lifestyle factors by:
  • Avoiding heavy lifting (nothing over 50 pounds)
  • Managing stress
  • Quitting smoking
  • Maintaining moderate aerobic exercise
  • Avoiding isometric exercises that cause blood pressure spikes
• The growth rate for most aortic aneurysms is approximately 0.1 cm per year, which guides these monitoring intervals 1.

Surveillance Approach

The recommended surveillance approach balances the need to monitor for potential growth while acknowledging that smaller aortic dimensions carry a lower risk of acute complications like dissection or rupture. This approach is supported by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease, which emphasizes the importance of individualized surveillance intervals based on AAA diameter and patient-specific risk factors 1.

From the Research

Surveillance Guidelines for Ascending Aortic Aneurysm

The patient's ascending aortic caliber measures up to 3.7 cm on the Computed Tomography Angiography (CTA) study with no adverse changes. The surveillance guidelines for such a patient can be based on the following evidence:

• The American Association of Thoracic Surgery published guidelines in 2018 encouraging regular surveillance rather than surgical intervention for ascending aortic aneurysms under 5.5 cm in both bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients 2.
• A study published in 2022 analyzed clinical outcomes including survival and aortic events in a cohort of BAV and TAV patients with ascending aortic aneurisms followed conservatively with routine computerized tomography (CT) surveillance per current guidelines 2.
• Another study published in 2024 provided personalized risk stratification for ascending aortic aneurysm patients based on sex, age, body surface area, and aneurysm location, and found that individualized thresholds of less than the standard criterion of 5.5 cm are applicable for the vast majority of patients 3.

Key Points to Consider

• The patient's aortic diameter is below the standard criterion of 5.5 cm, which suggests that regular surveillance is appropriate.
• The patient's age, sex, body surface area, and aneurysm location should be considered when determining the surveillance schedule.
• The use of automated calculators can help identify patients at high risk of adverse events based on their individual characteristics 3.

Surveillance Schedule

• Regular CT scans should be performed to monitor the size and growth of the aneurysm.
• The frequency of surveillance should be determined based on the patient's individual risk factors and the rate of aneurysm growth.
• The patient should be monitored for any signs or symptoms of aortic dissection or rupture, such as chest pain or shortness of breath.