What is the recommended follow-up and management for patients with aortic aneurysms?

Aortic Aneurysm Follow-up Management

The recommended follow-up for aortic aneurysms depends on aneurysm location, size, and patient characteristics, with specific imaging intervals and modalities tailored to thoracic and abdominal aneurysms to prevent fatal rupture.

Thoracic Aortic Aneurysm (TAA) Follow-up

Initial Assessment

• Transthoracic echocardiography (TTE) is recommended at diagnosis to assess aortic valve anatomy/function, aortic root, and ascending aorta diameters 1
• Cardiovascular computed tomography (CCT) or cardiovascular magnetic resonance (CMR) is recommended to confirm TTE measurements, rule out aortic asymmetry, and determine baseline diameters for follow-up 1
• CMR or CCT is required for surveillance of aneurysms at the distal ascending aorta, aortic arch, descending thoracic aorta (DTA), or thoracoabdominal aortic aneurysm (TAAA) 1

Follow-up Intervals for TAA

For root or ascending dilatation with tricuspid aortic valve (TAV) or bicuspid aortic valve (BAV):

By Aortic Diameter:

• 40-44 mm: Baseline CCT/CMR and reimage by TTE in one year 1
• 45-49 mm: Confirm by CCT or CMR, then annual imaging 1
• 50-52 mm: Confirm by CCT or CMR, then imaging every 6 months 1
• 53-54 mm: Imaging every 6 months 1
• ≥55 mm: Consider intervention 1

By Growth Rate:

• ≥3 mm/year: Confirm by CCT or CMR, consider intervention 1
• <3 mm/year: Reimage by CCT/CMR 6 months later to define projected growth rate 1

High-Risk Features Requiring Closer Monitoring

• Age <50 years
• Height <1.69 m
• Ascending aorta length >11 cm
• Uncontrolled hypertension
• For BAV: coarctation, family history of acute aortic events 1

Abdominal Aortic Aneurysm (AAA) Follow-up

Recommended Imaging Modality

• Duplex ultrasound (DUS) is recommended as the primary surveillance method 1
• CCT or CMR is recommended if DUS does not allow adequate measurement 1

Follow-up Intervals for AAA by Size

• 25-29 mm: Every 4 years 1
• 30-39 mm: Every 3 years 1
• 40-44 mm:
  • Women: Every 12 months 1
  • Men: Every 12 months 1
• 45-49 mm:
  • Women: Every 6 months 1
  • Men: Every 12 months 1
• 50-54 mm:
  • Women: Consider intervention 1
  • Men: Every 6 months 1
• ≥55 mm: Consider intervention for both men and women 1

Special Considerations

• More frequent monitoring for rapid growth (≥10 mm/year or ≥5 mm/6 months) 1
• Women have similar growth rates but a four-fold higher rupture risk compared to men 1, 2
• Smokers have increased growth rates (by 0.35 mm/year) 2
• Patients with diabetes have decreased growth rates (by 0.51 mm/year) 2

Medical Management During Surveillance

• Optimal cardiovascular risk management is recommended for all patients with aortic aneurysms 1
• Blood pressure control and smoking cessation are crucial to slow aneurysm growth 3
• Fluoroquinolones should generally be avoided in patients with aortic aneurysms unless absolutely necessary 1
• The role of antithrombotic therapy is uncertain; low-dose aspirin is not associated with higher risk of AAA rupture but could worsen prognosis in cases of rupture 1

Post-Intervention Follow-up

After Open Repair

• For TAA: Early CCT within 1 month, then yearly for first 2 years, then every 5 years if stable 1
• For AAA: First follow-up imaging within 1 post-operative year, then every 5 years if findings are stable 1

After Endovascular Repair (TEVAR/EVAR)

• Initial follow-up at 1,6, and 12 months, then yearly 1
• If no endoleak or AAA sac enlargement during first year after EVAR, annual DUS/CEUS with CCT or CMR every 5 years 1
• After TEVAR, if no abnormalities for 5 years, consider continuing follow-up with CCT every 5 years 1
• If growth of excluded aneurysm is observed without evidence of type I or III endoleak, repeat CCT every 6-12 months depending on growth rate 1

Common Pitfalls and Caveats

• TTE is not recommended for surveillance of aneurysms in the distal ascending aorta, aortic arch, or DTA 1
• Surveillance imaging should be performed with the same technique and at the same center for consistency 1
• CMR is preferred over CCT for long-term follow-up in young and female patients to minimize radiation exposure 1
• Elective repair of AAAs smaller than 5.5 cm does not improve survival, even with low operative mortality 4
• Patient compliance with follow-up programs is essential; non-compliance is associated with higher rupture rates 1
• AI-assisted measurements may improve reporting efficiency and reduce inter-reader variability in aortic measurements 5