What is the management of a supra coronary aortic aneurysm?

Management of Supra Coronary Aortic Aneurysm

Surgical intervention is recommended for patients with supra coronary aortic aneurysm when the maximum diameter reaches ≥55 mm, with consideration for earlier intervention at ≥50 mm when performed by experienced surgeons in a Multidisciplinary Aortic Team setting. 1

Diagnosis and Evaluation

• Initial imaging:

  • Computed tomography (CT) or magnetic resonance imaging (MRI) is essential for comprehensive evaluation of the thoracic aorta 1
  • Transthoracic echocardiography (TTE) with suprasternal notch views for initial assessment 1
  • Every patient should have at least one cardiovascular MRI or CT scan for complete evaluation of the thoracic aorta 1

• Coronary assessment:

  • Careful evaluation of coronary ostia is critical as coronary ostial stenosis is frequently associated with supra coronary aneurysms 1, 2
  • Intravascular ultrasound may provide better definition of coronary artery anatomy before repair 1
  • Selective coronary angiography should be approached with caution due to risk of ostial stenosis 1

Indications for Surgical Intervention

Size-based criteria:

• Absolute indications:

  • Maximum aortic diameter ≥55 mm 1
  • Rapid growth (≥0.5 cm in 1 year or ≥0.3 cm/year in 2 consecutive years) 1

• Relative indications (consider at lower thresholds):

  • Maximum diameter >52 mm in patients with low predicted surgical risk 1
  • Maximum diameter ≥50 mm when performed by experienced surgeons in a Multidisciplinary Aortic Team 1
  • Maximum diameter ≥45 mm in patients undergoing surgery for tricuspid aortic valve disease with concomitant aortic root/ascending aorta dilatation 1

Symptom-based criteria:

• Presence of symptoms (angina, dyspnea, or syncope) 1
• Recurrent episodes of chest pain not attributable to non-aortic causes 1

Other indications:

• Left ventricular hypertrophy 1
• Left ventricular systolic dysfunction 1
• Desire for greater degrees of exercise or planned pregnancy 1

Surgical Approaches

Open Surgical Repair:

• Valve-sparing aortic root replacement:

  • Recommended in patients with aortic root dilatation if performed in experienced centers and durable results are expected 1
  • Preserves native aortic valve function and avoids anticoagulation 1

• Bentall procedure:

  • Composite valve-graft replacement when valve cannot be preserved
  • Requires lifelong anticoagulation with vitamin K antagonists if mechanical valve is used 1

• Supracoronary tubular graft repair:

  • Least complex repair when aneurysm is limited to above the sinotubular junction 1
  • Can be performed with relatively short period of aortic clamping 1

• Hemi-arch replacement:

  • Should be considered if dilatation extends into the proximal aortic arch (>50 mm) 1
  • May be considered in experienced centers if dilatation extends into the aortic arch (>45 mm) 1

Endovascular Approaches:

• Generally not recommended as first-line treatment for supra coronary aortic aneurysms 1
• May be considered in patients with high surgical risk who meet criteria for intervention 1
• Contraindicated for elective intervention in patients with genetically mediated aortic disorders 1

Perioperative Considerations

• Procedures should be performed in high-volume aortic centers with multidisciplinary teams 1
• Careful attention to coronary perfusion during surgery is critical 1
• Avoid circumstances that decrease diastolic pressure to maintain critical coronary perfusion 1

Postoperative Management and Follow-up

• Annual follow-up at a regional Adult Congenital Heart Disease (ACHD) center 1
• After open repair, CT is recommended within 1 month, then yearly for 2 years, then every 5 years if stable 1
• After endovascular repair (if performed), imaging at 1 month and 12 months, then annually 1
• Monitor for potential complications:
  • Coronary button aneurysms or pseudoaneurysms at reimplantation sites 1
  • Recurrent obstruction (though incidence is low) 1
  • Development of coronary insufficiency or systemic hypertension 1

Special Considerations

• Family screening:

  • First-degree relatives should undergo aortic imaging due to potential genetic component 1

• Pregnancy considerations:

  • Patients with significant obstruction, coronary involvement, or aortic disease should be counseled against pregnancy 1
  • Surgical repair before pregnancy should be considered for women planning pregnancy 1

Pitfalls and Caveats

• Coronary ostial stenosis is a frequent occurrence and requires careful evaluation before repair 1
• Embolic events can occur even with smaller aneurysms 3
• Dissection and aneurysm can occur at clamping sites during surgery due to fragile tissue 1
• Routine coronary angiography and revascularization prior to surgery is not recommended in patients with chronic coronary syndromes 1

By following these guidelines and working with experienced aortic teams, optimal outcomes can be achieved for patients with supra coronary aortic aneurysms.