Is a tortuous atherosclerotic aorta a contraindication to surgery?

Management of Tortuous Atherosclerotic Aorta in Surgical Candidates

A tortuous atherosclerotic aorta is not an absolute contraindication to surgery, but requires careful risk assessment and may necessitate modification of surgical approach to reduce embolic and procedural complications. 1

Risk Assessment of Atherosclerotic Aorta

Anatomical Considerations

• Tortuosity Index (TI): Patients with high tortuosity (TI > 1.29) have significantly higher risk of:
  • Endoleaks (odds ratio 9.95)
  • Stroke (odds ratio 13.2)
  • Lower overall survival 2

Location-Specific Concerns

• Ascending aorta/arch atherosclerosis:
  • Associated with 6-fold increased risk of perioperative stroke during cardiac surgery 3
  • Prevalence of 3.3% in cardiovascular surgery patients 4
  • Independent predictor of postoperative cerebrovascular accidents (OR=3.46) 4

Risk Factors for Atherosclerotic Aorta

• Age > 61 years (OR 2.79)
• Coronary artery disease (OR 3.1)
• Hypertension (OR 2.26)
• Peripheral vascular disease (OR 3.15) 4

Surgical Decision-Making Algorithm

1. Preoperative Assessment

• Complete vascular evaluation including entire aorta is mandatory 1
• Imaging modalities:
  • CT angiography (preferred for calcification assessment)
  • MRI (alternative for patients with renal insufficiency)
  • Transesophageal echocardiography (TEE) for thoracic aorta
  • Epiaortic ultrasound (intraoperative) 1, 3

2. Surgical Approach Modification

• For endovascular procedures:

  • Severe tortuosity may necessitate alternative access sites
  • Consider ultrasound-guided percutaneous access for EVAR (lower rate of access-related complications) 1
  • Avoid transfemoral approach with severe iliac calcification/tortuosity 1

• For open cardiac procedures:

  • Consider aortic replacement in cases of severe ascending aorta atherosclerosis 5
  • Modify cannulation sites to avoid atheromatous areas
  • Consider deep hypothermic circulatory arrest for severely diseased aortas 5

3. Procedure-Specific Considerations

• Aortic valve procedures:

  • Tortuous atherosclerotic aorta may contraindicate transfemoral TAVI approach 1
  • Consider transapical approach if femoral access is compromised by tortuosity 1

• Aortic aneurysm repair:

  • For thoracoabdominal aortic aneurysms (TAAA), endovascular repair with fenestrated/branched grafts should be considered in experienced centers 1
  • Open repair remains recommended for ruptured TAAA 1

Perioperative Management

Reducing Embolic Risk

• Minimize aortic manipulation
• Consider off-pump techniques when appropriate
• Use intraoperative epiaortic ultrasound to guide cannulation sites 3
• Avoid routine coronary angiography and revascularization before AAA repair in patients with stable cardiac symptoms 1

Postoperative Surveillance

• More intensive monitoring for neurological complications
• Lifelong surveillance is mandatory after EVAR in patients with tortuous aortas due to higher risk of late complications 1, 2

Key Pitfalls to Avoid

1. Underestimating embolic risk: Thoracic aortic atherosclerosis is a significant embolic source that requires careful surgical planning 3

2. Inadequate imaging: Relying solely on one imaging modality may miss critical information about plaque distribution and tortuosity 1

3. Inappropriate endovascular approach: Attempting endovascular repair in highly tortuous anatomy without proper planning increases complications 2

4. Failure to modify surgical technique: Standard approaches may need modification in the presence of severe atherosclerosis 5

5. Neglecting post-procedure surveillance: Patients with tortuous atherosclerotic aortas require more vigilant follow-up due to higher complication rates 1