What is the treatment approach for a descending aortic aneurysm?

Treatment Approach for Descending Aortic Aneurysm

For patients with descending thoracic aortic aneurysms, thoracic endovascular aortic repair (TEVAR) should be considered as the primary treatment when the maximal diameter reaches 55 mm and the anatomy is suitable. 1

Diagnosis and Monitoring

• Regular imaging surveillance is essential for patients with smaller descending aortic aneurysms to monitor growth rate 1
• Computed tomography angiography (CTA) or magnetic resonance imaging (MRI) are the preferred imaging modalities for accurate measurement 1
• Growth rates of descending thoracic aortic aneurysms average 3 mm/year, faster than ascending aortic aneurysms (1 mm/year) 1

Treatment Decision Algorithm

Indications for Intervention

• Aneurysm size threshold:

  • Intervention recommended when descending thoracic aortic diameter ≥ 55 mm 1
  • For patients with connective tissue disorders (e.g., Marfan syndrome), lower threshold may apply 1

• Other indications for intervention regardless of size:

  • Symptomatic aneurysms (chest/back pain, dysphagia, dyspnea) 1
  • Rapid growth (> 3 mm/year) 1
  • Saccular aneurysms 1
  • Rupture or impending rupture 1

Treatment Options

1. TEVAR (Thoracic Endovascular Aortic Repair):

   • First-line treatment for suitable candidates 1, 2
   • Advantages: less invasive, lower perioperative mortality, shorter hospital stay 2
   • Requirements: suitable anatomy with adequate landing zones (2-3 cm of normal aorta) 1

2. Open Surgical Repair:

   • Consider when:
     • TEVAR is not technically feasible 1
     • Patient has Marfan syndrome or other connective tissue disorders 1
     • Aneurysm diameter ≥ 60 mm and TEVAR not possible 1
   • Higher perioperative risks but may be necessary in certain anatomical configurations 1

Special Considerations

• Connective tissue disorders: Open surgical repair is generally preferred over TEVAR in patients with Marfan syndrome or other elastopathies 1

• Comorbidities: TEVAR may be particularly valuable in patients with significant comorbidities (older age, cardiac/pulmonary/renal dysfunction) 1

• Chronic dissection: For patients with chronic dissection and descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended, particularly if associated with connective tissue disorders 1

Post-intervention Follow-up

• After TEVAR:

  • First follow-up imaging within 1 month 1
  • Yearly imaging for the first 5 years 1
  • If stable, every 5 years thereafter 1

• After open surgical repair:

  • Early CTA within 1 month 1
  • Yearly follow-up for first 2 years 1
  • Every 5 years thereafter if findings are stable 1

Potential Complications to Monitor

• TEVAR-specific complications: endoleak, graft migration, stent fracture 3
• General complications: paraplegia (2.2%), stroke (3.9%), renal failure (2.8%) 3
• Risk of paraplegia increases with longer endografts 4

Comparative Outcomes

• 30-day mortality rates: 3.9% for TEVAR vs. higher rates for open repair 3
• Hospital stay: approximately 10 days for TEVAR vs. 30 days for open surgery 3
• Technical success rates for TEVAR range from 89-100% in elective cases 3

Remember that treatment decisions should be made by a multidisciplinary aortic team, considering the patient's specific anatomy, comorbidities, and risk factors 1.