From the Guidelines
Monitoring a tortuous descending thoracic aorta should include regular imaging surveillance with CMR or CCT, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Key Recommendations
- CMR or CCT is recommended for surveillance of patients with aneurysm at the distal ascending aorta, aortic arch, DTA, or TAAA 1.
- Follow-up imaging with CMR or CCT should be considered annually if there is no expansion/extension or customized according to baseline aortic diameter and the underlying condition 1.
- TTE is not recommended for the surveillance of aneurysms in the distal ascending aorta, aortic arch, or DTA 1.
Rationale
The 2024 ESC guidelines provide the most recent and highest quality evidence for the management of peripheral arterial and aortic diseases, including the surveillance of thoracic aortic aneurysms 1. The guidelines recommend CMR or CCT for surveillance of patients with aneurysm at the distal ascending aorta, aortic arch, DTA, or TAAA, as these imaging modalities provide accurate and detailed assessment of the aortic anatomy and diameters.
Additional Considerations
- Blood pressure control is essential, with a target of <130/80 mmHg, to reduce aortic wall stress and prevent further dilation or complications.
- Regular clinical follow-up should include assessment of symptoms such as chest pain, back pain, or dysphagia.
- Lifestyle modifications, including smoking cessation, moderate aerobic exercise, and maintaining a heart-healthy diet, are important to reduce the risk of aneurysm formation, dissection, or rupture.
From the Research
Monitoring Protocol for Tortuous Descending Thoracic Aorta
The recommended monitoring protocol for a tortuous descending thoracic aorta involves regular imaging to assess the aorta's condition and detect any potential complications. The following points outline the key aspects of the monitoring protocol:
- Imaging modalities: Computed tomography angiography (CTA) is the preferred imaging modality for monitoring the descending thoracic aorta due to its speed and ease of use for preoperative planning 2.
- Imaging frequency: Contrast-enhanced computed tomography scanning is recommended at 1 month and 12 months after thoracic endovascular aortic repair (TEVAR) and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at 1 month 2.
- Three-dimensional centerline reconstruction software: The use of three-dimensional centerline reconstruction software is recommended for accurate case planning and execution in TEVAR 2.
- Tortuosity assessment: Tortuosity in the descending thoracic aorta should be assessed using measurements such as tortuosity index, curvature ratio, and maximum tortuosity, and classified into low, moderate, and high tortuosity groups 3.
- Endoleak detection: Regular imaging is essential for detecting endoleaks, which can occur after TEVAR, and prompt treatment is necessary to prevent complications 4.
Key Considerations
When monitoring a tortuous descending thoracic aorta, the following considerations are crucial:
- Patient-specific factors: Treatment using a minimally invasive approach is largely based on anatomic eligibility rather than patient-specific factors 2.
- Aneurysm characteristics: The size and shape of the aneurysm, as well as the presence of thrombus or dissection, should be taken into account when planning TEVAR 3, 4.
- Device selection: The choice of device for TEVAR should be based on the patient's anatomy and the characteristics of the aneurysm 4.