Which specialist should I see for an aortic arch aneurysm?

Specialist Care for Aortic Arch Aneurysm

Patients with aortic arch aneurysms should be referred to a cardiovascular surgeon with specific expertise in aortic surgery, preferably at a center with a Multidisciplinary Aortic Team. 1

Appropriate Specialist Referral

• A cardiovascular surgeon with specific expertise in complex aortic procedures should be the primary specialist managing aortic arch aneurysms 1
• Treatment should occur at centers with Multidisciplinary Aortic Teams that have demonstrated excellent outcomes in complex aortic surgery 1
• The complexity of aortic arch repair is highest among all thoracic aortic aneurysm repairs, requiring specialized surgical expertise 1

Rationale for Specialist Selection

• Aortic arch aneurysm repair requires complex surgical techniques including:

  • Hypothermic cardiopulmonary bypass 1
  • Management of the great vessels 1
  • Brain protection strategies during circulatory arrest 1
  • Specialized branched grafts for reconstruction 1

• Operative mortality is significantly higher for aortic arch procedures compared to isolated ascending or descending thoracic aortic aneurysm repairs 1

• For high-risk patients who are not candidates for open repair, specialized hybrid or endovascular approaches may be considered, requiring expertise in both open and endovascular techniques 1, 2

Surgical Approaches Requiring Specialist Expertise

• Open surgical repair via midline sternotomy is the standard approach for most patients with low to intermediate operative risk 1
• For extensive aneurysms involving both arch and descending aorta, specialized techniques such as the elephant trunk procedure may be necessary 1
• Newer hybrid techniques combining open and endovascular approaches have decreased mortality rates that historically exceeded 15% 1
• Novel techniques using personalized aortic arch stent grafts may allow complete endovascular approaches in select cases 1, 3

Monitoring and Follow-up Considerations

• For isolated aortic arch aneurysms <4.0 cm, imaging follow-up with CT or MRI should occur at 12-month intervals 1
• For isolated aortic arch aneurysms ≥4.0 cm, more frequent imaging at 6-month intervals is recommended 1
• Growth rate exceeding 0.5 cm/year is an indication for surgical intervention even in asymptomatic patients 1, 4

Important Considerations for Referral

• Symptoms attributable to arch aneurysms (hoarseness, dysphagia, dyspnea, chest or back pain) warrant urgent surgical evaluation regardless of aneurysm size 1
• Asymptomatic patients with low operative risk should be referred for surgical evaluation when arch diameter reaches ≥5.5 cm 1, 4
• Patients with genetic disorders (Marfan syndrome, Loeys-Dietz syndrome) require earlier intervention and specialized management 4, 5

Pitfalls in Management

• Delaying referral to a specialized aortic center may result in increased morbidity and mortality 1
• Using absolute diameter thresholds without considering patient size may be inappropriate - indexed measurements should be considered for very tall or short patients 4
• A significant proportion of aortic complications occur at diameters below standard intervention thresholds, highlighting that diameter alone is an imperfect predictor 4
• Endovascular stent grafts should only be used within approved anatomic criteria, as use outside these parameters increases risk of complications 4