What initial follow-up investigations should be ordered for a tortuous descending thoracic aorta noted incidentally on a plain chest X-ray (Chest Radiograph)?

From the Guidelines

For a tortuous descending thoracic aorta noted incidentally on a plain chest X-ray, the initial follow-up investigation should be a CTA chest or MRA chest, as recommended by the American College of Radiology 1. This approach is based on the latest guidelines from the American College of Radiology, which emphasize the importance of accurate radiological diagnosis of suspected thoracic aortic aneurysm. The key benefits of CTA chest or MRA chest include:

• Detailed visualization of the aorta's dimensions, course, and potential pathology
• Non-invasive nature, which reduces the risk of complications
• Ability to guide further management decisions, including vascular surgery consultation, follow-up imaging intervals, or blood pressure management strategies In certain cases, such as severe renal impairment or contrast allergy, MRA chest may be preferred over CTA chest. It is also essential to assess cardiovascular risk factors, including hypertension, which commonly contributes to aortic tortuosity, and consider complementary studies like echocardiography to evaluate aortic valve function and proximal aortic segments. By prioritizing CTA chest or MRA chest as the initial follow-up investigation, clinicians can ensure timely and accurate diagnosis, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Initial Follow-up Investigations for Tortuous Descending Thoracic Aorta

The following investigations should be considered for a tortuous descending thoracic aorta noted incidentally on a plain chest X-ray:

• Computed Tomography Angiography (CTA) scan to evaluate the extent of tortuosity and to rule out any associated aortic diseases such as aneurysms or dissections 2, 3, 4
• Trans-Thoracic Echocardiography (TTE) to assess the aortic flow pattern and to detect any signs of aortic coarctation or pseudo-coarctation 4
• Magnetic Resonance Angiography (MRA) or Magnetic Resonance Imaging (MRI) to provide detailed images of the aorta and its branches, and to evaluate the extent of tortuosity 5

Rationale for Investigations

The rationale for these investigations is to:

• Evaluate the extent of tortuosity and its potential impact on aortic blood flow 2
• Rule out any associated aortic diseases such as aneurysms or dissections, which may require urgent intervention 3, 4
• Assess the patient's suitability for endovascular repair or other treatment options 6, 5
• Monitor the patient's condition and adjust treatment plans as needed 2, 3, 4

Potential Treatment Options

Based on the results of the initial follow-up investigations, potential treatment options may include:

• Endovascular repair using stent-grafts 6, 5
• Surgical exclusion of the aneurysm or repair of the aortic dissection 3, 4
• Medical management with anti-hypertensive therapy and regular monitoring 2, 4