From the Guidelines
Aortic stenosis and aortic aneurysm are distinct conditions with different management strategies, and the primary concern in aortic aneurysm management is the risk of dissection or rupture, which correlates with increasing aneurysm diameter, as evidenced by the 2024 ESC guidelines 1. The relationship between aortic stenosis and aortic aneurysm is complex, and while they can coexist, they have different pathophysiologies and management approaches. Aortic stenosis is a valvular disease, whereas aneurysms involve the aortic wall.
Key Considerations
- Aneurysm size is a critical factor in determining the risk of complications, with larger aneurysms (≥5.0 cm) having a greater risk of dissection or rupture, as reported in the 2022 ACC/AHA guideline 1.
- The 2024 ESC guidelines 1 emphasize the importance of considering factors such as diameter indexation, aortic length, and growth rate in assessing the risk of aortic events.
- Management of aortic aneurysms typically involves monitoring until they reach a size threshold warranting surgical repair, whereas aortic stenosis may require valve replacement surgery or transcatheter aortic valve replacement (TAVR) when severe.
- Regular monitoring with echocardiograms or CT scans and risk factor management, including blood pressure control, smoking cessation, and cholesterol management, are essential for both conditions.
Treatment Approaches
- For aortic aneurysms, surgical or endovascular repair may be considered based on size, location, and growth rate, as outlined in the 2024 ESC guidelines 1.
- Beta-blockers like metoprolol (25-200 mg daily) may be prescribed to reduce stress on the aortic wall for aneurysms, while statins such as atorvastatin (10-80 mg daily) may help slow valve calcification in stenosis.
- Multidisciplinary collaboration and advanced stent technology have increased the adoption of hybrid approaches and endovascular therapies for different thoracoabdominal aortic diseases, as noted in the 2024 ESC guidelines 1.
From the Research
Relationship Between Aortic Stenosis and Aortic Aneurysm
- The treatment of patients with severe aortic stenosis (SAS) who concomitantly present with abdominal aortic aneurysm (AAA) is not defined 2.
- Aortic valve replacement surgery, performed alone, increases the risk of AAA rupture 2.
- Transcatheter aortic valve replacement (TAVR) and endovascular abdominal aortic aneurysm repair (EVAR) in the same intervention, especially in high-risk patients, is a safe alternative 2, 3, 4, 5.
- The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population 3.
- Both conditions have adverse outcomes, if not adequately managed 3, 4.
- No clear recommendations are available in the literature until today, in regards of the management sequence, making thus the decision-making challenging 3, 4.
Treatment Options
- Simultaneous transcatheter aortic valve implantation and endovascular aneurysm repair for SAS and symptomatic AAA is a promising treatment alternative for selected patients 2, 3, 4, 5.
- The combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential 3.
- Endovascular stent graft placement for AAA has gained broad acceptance as an alternative to open surgical repair due to a lower perioperative morbidity and mortality 6.
Outcomes
- At 30 days, the pooled relative risk of all-cause mortality was lower in the endovascular group than in the open surgery group 6.
- At intermediate follow-up, the all-cause mortality had a nonsignificant difference, the AAA-related mortality was significantly lower, and reintervention rates were higher in the endovascular group than in the open surgery group 6.
- At long-term follow-up, there was no significant difference in all-cause mortality or AAA-related mortality, whereas the significant difference in the rate of reinterventions persisted 6.