What is the treatment approach for a woman with a thoracic aneurysm?

Treatment Approach for Women with Thoracic Aortic Aneurysms

For women with thoracic aortic aneurysms, elective surgical repair is recommended when the diameter reaches ≥50 mm, which is a lower threshold than the 55 mm used for men due to women's higher rupture risk. 1

Initial Assessment and Imaging

• Complete aortic evaluation: When a thoracic aortic aneurysm (TAA) is identified, assessment of the entire aorta is recommended at baseline and during follow-up 1

• Initial imaging:

  • Transthoracic echocardiography (TTE) is recommended at diagnosis to assess aortic valve anatomy, function, and aortic root/ascending aorta diameters 1
  • CT or MRI is required to confirm TTE measurements, rule out aortic asymmetry, and establish baseline diameters 1, 2

• Aortic valve assessment: When a TAA is identified, assessment of the aortic valve (especially for bicuspid aortic valve) is recommended 1

Surveillance Protocol for Women

• Aneurysm size 40-45 mm: Annual surveillance with duplex ultrasound (DUS) 1
• Aneurysm size 45-50 mm: DUS surveillance every 6 months 1
• Imaging modality selection:
  • For aortic root/ascending aorta: TTE is appropriate 1
  • For distal ascending aorta, aortic arch, or descending thoracic aorta: CMR or CCT is recommended (TTE not recommended for these segments) 1
  • If DUS does not allow adequate measurement: CCT or CMR is recommended 1

Medical Management

• Blood pressure control: Target <135/80 mmHg 2

  • First-line medications: Beta-blockers (especially for Marfan syndrome) 1, 2
  • Alternative options: Angiotensin receptor blockers (ARBs) or ACE inhibitors 1, 2
  • ARBs (particularly losartan) have shown efficacy in reducing aortic growth rate by approximately 50% 1

• Cardiovascular risk management: Optimal implementation of CV risk management is recommended to reduce major adverse cardiovascular events 1

• Smoking cessation: Critical as smoking doubles aneurysm expansion rate 2, 3

• Lipid management: Target LDL-C <1.4 mmol/L (<55 mg/dL) 1, 2

• Exercise recommendations:

  • Regular moderate exercise is beneficial 1
  • Avoid contact/competitive sports and isometric exercises 1

Surgical Intervention Criteria

• Size thresholds for elective repair:

  • Women with thoracic aortic aneurysm: ≥50 mm 1
  • Men with thoracic aortic aneurysm: ≥55 mm 1
  • Patients with genetic disorders (e.g., Marfan syndrome): Lower thresholds (40-50 mm depending on condition) 2

• Other indications for surgery regardless of size:

  • Symptomatic aneurysms 2, 4
  • Rapid growth (>0.5 cm/year) 2, 4

• Surgical approach selection:

  • Ascending aorta/aortic root: Open surgical repair 1, 2
  • Descending thoracic aorta: TEVAR (Thoracic Endovascular Aortic Repair) is recommended over open repair when anatomy is suitable 1

Special Considerations for Women

• Higher rupture risk: Women have a four-fold higher rupture risk compared to men with similarly sized aneurysms 1

• Pregnancy planning: Requires specialized management and pre-conception counseling, especially with genetic disorders 2

• Smaller baseline aortic dimensions: Women have smaller average aortic diameters (ascending thoracic aorta 31.9 ± 3.5 mm vs 34.1 ± 3.9 mm in men) 2

Post-Operative Management

• Early imaging: CCT within 1 month post-operatively 1, 2

• Long-term surveillance:

  • Yearly CCT for first 2 post-operative years 1
  • Every 5 years thereafter if findings remain stable 1
  • For patients with mechanical prosthesis: Lifelong vitamin K antagonists 1

Pitfalls and Caveats

• Underestimation of risk: Women's higher rupture risk may be underappreciated, leading to delayed intervention 1

• Medication cautions: Fluoroquinolones should generally be avoided in patients with aortic aneurysms unless absolutely necessary 1

• Imaging limitations: TTE alone is insufficient for complete assessment, particularly for distal ascending aorta, arch, and descending segments 1

• Growth rate variability: While average growth rate is 0.10 cm/year, individual variation exists, necessitating regular surveillance 4