From the Guidelines
Surgical repair is indicated for ascending aortic aneurysms when the maximum diameter reaches ≥5.5 cm, or earlier in symptomatic patients or those with specific conditions, as recommended by the 2022 ACC/AHA guideline 1. The decision to repair an ascending aortic aneurysm is based on the risk of rupture or dissection, which increases with the size of the aneurysm.
- Key factors influencing the decision for surgical intervention include:
- Maximum diameter of the aneurysm
- Presence of symptoms attributable to the aneurysm
- Growth rate of the aneurysm
- Underlying conditions such as genetic disorders (e.g., Marfan syndrome)
- According to the guidelines, surgery is recommended for asymptomatic patients with aneurysms of the aortic root or ascending aorta who have a maximum diameter of ≥5.5 cm 1.
- For patients with a growth rate confirmed by tomographic imaging of ≥0.3 cm/y in 2 consecutive years, or ≥0.5 cm in 1 year, surgery is also indicated 1.
- In addition, concomitant ascending aortic replacement is reasonable in patients undergoing repair or replacement of a tricuspid aortic valve who have an aneurysm of the ascending aorta with a maximum diameter of ≥4.5 cm, when performed by experienced surgeons in a Multidisciplinary Aortic Team 1.
- The management of ascending aortic aneurysms also involves medical therapy to reduce aortic wall stress, such as beta-blockers, and lifestyle modifications including smoking cessation and regular imaging follow-up 1.
- The choice between open surgical repair and endovascular repair techniques depends on various factors, including the location and size of the aneurysm, as well as the patient's overall health and suitability for surgery.
- Open surgical repair remains the gold standard for ascending aortic aneurysms due to their proximity to the heart and coronary arteries, but endovascular techniques may be considered in selected cases.
- The most recent and highest quality study, the 2022 ACC/AHA guideline 1, provides the basis for these recommendations, emphasizing the importance of a multidisciplinary approach in the management of aortic disease.
From the Research
Treatment for Ascending Aortic Aneurysm
The recommended treatment for repairing an ascending aortic aneurysm involves surgical intervention, with the primary goal of preventing spontaneous rupture or dissection 2.
Indications for Surgical Intervention
- The decision to operate is based on the risk of complications associated with surgical intervention versus the risk of spontaneous rupture or dissection 2.
- Maximum diameter is a major predictor of complications for aortic aneurysms, with the presence of a connective tissue disorder modifying this effect 2.
- Studies suggest that surgical replacement is indicated when the aneurysm diameter exceeds 5.5 cm for ascending aortic aneurysms 3, 4.
- For patients with connective tissue disorders, a more aggressive approach may be warranted, with consideration for surgical intervention at a smaller diameter 2.
Surgical Outcomes
- Elective surgical repair of ascending aortic aneurysms can be performed with relatively low mortality, with reported mortality rates ranging from 9.0% for elective operations to 21.7% for emergency operations 3.
- The incidence of dissection or rupture increases with aneurysm size, with a significant increase in risk for aneurysms larger than 6.0 cm for ascending aneurysms 3, 4.
Size Criterion for Intervention
- A diameter of 5.5 cm is recommended as an acceptable size for elective resection of ascending aortic aneurysms, as this operation can be performed with relatively low mortality 3, 4.
- For aneurysms of the descending aorta, a larger diameter of 6.5 cm is recommended due to greater perioperative complications and a larger median size at the time of complications 3, 4.