From the Guidelines
Surgical repair of an ascending aortic aneurysm is indicated in patients with symptoms attributable to the aneurysm, asymptomatic patients with a maximum diameter of ≥5.5 cm, or those with a growth rate of ≥0.3 cm/y in 2 consecutive years, or ≥0.5 cm in 1 year, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.
Key Indications for Surgery
- Symptoms attributable to the aneurysm
- Asymptomatic patients with a maximum diameter of ≥5.5 cm
- Growth rate of ≥0.3 cm/y in 2 consecutive years, or ≥0.5 cm in 1 year
- Patients undergoing repair or replacement of a tricuspid aortic valve with a concomitant aneurysm of the ascending aorta with a maximum diameter of ≥4.5 cm
Rationale for Intervention
The rationale for surgical intervention is based on the increased risk of catastrophic complications like dissection or rupture when aneurysms reach these threshold sizes, with the risk rising exponentially with increasing diameter, as supported by the 2022 ACC/AHA guideline 1.
Considerations for Genetic Conditions
For patients with genetic conditions like Marfan syndrome, bicuspid aortic valve, or family history of aortic dissection, intervention is recommended at smaller diameters, as stated in the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1.
Surgical Approach
The specific surgical approach depends on the extent of the aneurysm and may include replacement of the ascending aorta with a synthetic graft, with potential additional procedures such as aortic valve replacement or repair of the aortic root if these structures are also affected.
Priority of Recent Evidence
The 2022 ACC/AHA guideline 1 takes precedence over the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines 1 due to its recency and higher quality of evidence.
From the Research
Surgical Indications for Ascending Aortic Aneurysm Repair
The surgical indications for ascending aortic aneurysm repair are based on the diameter of the aneurysm and the presence of certain risk factors.
- The current guidelines recommend surgical treatment when the diameter of the aneurysm exceeds 50 mm 2.
- In patients with a family history of aortic dissection or with Loeys-Dietz syndrome, surgery should be considered when the aneurysm diameter is smaller than 50 mm 2.
- For patients with Marfan syndrome or a bicuspid aortic valve, the indications for surgery should be determined on an individual basis, depending on additional risk factors 3.
- The risk of rupture and dissection depends on the aortic diameter, and surgery improves the outcome when the diameter exceeds 55 mm 3.
Special Considerations
Certain patient populations require special consideration when it comes to surgical indications for ascending aortic aneurysm repair.
- Patients with Marfan syndrome benefit from preventive treatment with beta-blockers, and the medical management of aneurysms of the ascending aorta consists of monitoring the size of the aneurysm, controlling blood pressure, and treating any cardiovascular risk factors 3.
- Endovascular therapy can provide a useful adjunct or bridge to open surgical treatment in selected patients with Marfan syndrome, but its use should be judicious with close follow-up to avoid delay if open surgical repair is required 4.
- Valve sparing aortic root replacement may be considered for patients with aortic root aneurysms who have normal aortic leaflet tissue and minimal regurgitation, including those with connective tissue disorders 5.
Surgical Options
Several surgical options are available for patients with ascending aortic aneurysms, including:
- Composite replacement of the aortic valve and ascending aorta 2.
- Valve sparing aortic root replacement 2, 5.
- Endovascular repair, such as thoracic endovascular aortic repair (TEVAR) or endovascular aneurysm repair (EVAR) 4.
- The Cabrol technique, which involves the formation of a conduit system from the periprosthetic space to the right atrium to decompress postoperative leaks 6.