What are the management options for an aortic aneurysm?

Aortic Aneurysm Management

Surveillance Strategy

For abdominal aortic aneurysms (AAA), surveillance intervals depend on size: every 3 years for 30-39 mm, every 2 years for 40-44 mm, annually for 45-49 mm in men (40-44 mm in women), and every 6 months for 50-55 mm in men (45-50 mm in women). 1

Imaging Modalities by Location

Abdominal Aortic Aneurysms:

• Duplex ultrasound (DUS) is the primary surveillance tool for AAA 1
• Use CT or MRI when ultrasound provides inadequate measurements 1
• CT is preferred when approaching surgical thresholds to confirm diameter and plan intervention 1

Thoracic Aortic Aneurysms:

• Transthoracic echocardiography (TTE) at diagnosis to assess aortic valve, root, and ascending aorta 1
• CT or MRI is required for surveillance of distal ascending aorta, arch, descending thoracic aorta (DTA), or thoracoabdominal aneurysms 1
• TTE is not adequate for monitoring aneurysms beyond the proximal ascending aorta 1

Medical Management

All patients with aortic aneurysms require optimal cardiovascular risk management to reduce major adverse cardiovascular events, which pose a greater mortality risk than rupture itself. 1

Specific Pharmacotherapy

• Beta-blockers are the foundation of medical therapy to reduce aortic wall stress and slow progression 2, 3
• Statins reduce cardiovascular mortality and slow AAA growth 3
• ACE inhibitors or ARBs for blood pressure control, though they don't directly affect AAA growth 3
• Avoid fluoroquinolones unless absolutely necessary with no alternatives, as they may increase aneurysm risk 1

Surgical Intervention Thresholds

Ascending Aorta and Aortic Root (Sporadic/Tricuspid Valve)

Surgery is indicated at ≥55 mm diameter for asymptomatic patients. 1

At experienced centers with Multidisciplinary Aortic Teams, intervention is reasonable at ≥50 mm. 1

Lower thresholds apply when:

• Growth rate ≥5 mm/year or ≥3 mm/year over 2 consecutive years 1
• Concomitant aortic valve surgery needed: ≥45 mm 1
• Patient height <1.69 m, age <50 years, or uncontrolled hypertension 1

Descending Thoracic Aorta

Elective repair is indicated at ≥55 mm diameter. 1

When repair is indicated and anatomy is suitable, thoracic endovascular aortic repair (TEVAR) is preferred over open surgery. 1

Thoracoabdominal Aortic Aneurysms

Elective repair is indicated at ≥60 mm diameter. 1

Abdominal Aortic Aneurysms

Elective repair is indicated at ≥55 mm in men or ≥50 mm in women. 1

For ruptured AAA with suitable anatomy, endovascular repair is preferred over open surgery to reduce perioperative morbidity and mortality. 1

Do not repair AAA in patients with limited life expectancy (<2 years). 1

Surgical Approach Selection

Aortic Root and Ascending Aorta

• Valve-sparing root replacement (David reimplantation or Yacoub remodeling) is preferred in young patients with pliable valve cusps when performed at experienced centers 1
• Bentall procedure (composite valve-graft) requires lifelong warfarin if mechanical valve used 1
• Supracommissural tubular graft for isolated tubular ascending aorta aneurysms 1

Aortic Arch

• Hemiarch replacement when disease extends from ascending aorta 4
• Elephant trunk or frozen elephant trunk procedure when aneurysmal disease extends into proximal descending thoracic aorta 1, 4

Descending Thoracic Aorta

• TEVAR is recommended over open repair when anatomy is suitable 1
• Revascularize left subclavian artery before TEVAR if coverage is planned to reduce stroke and spinal cord ischemia risk 1

Post-Intervention Surveillance

After Open Thoracic Repair

• CT within 1 month post-operatively 1
• Annual CT for first 2 years 1
• Every 5 years thereafter if stable 1

After TEVAR

• Imaging at 1 month and 12 months post-operatively 1
• Annual imaging until 5 years 1
• Every 5 years after year 5 if no complications 1

After AAA Repair (Open)

• First imaging within 1 year 1
• Every 5 years thereafter if stable 1

After EVAR (Endovascular AAA Repair)

• CT/MRI with DUS at 30 days to assess success 1
• Surveillance at 1,6, and 12 months, then annually 1
• After first year without endoleak or sac enlargement, DUS annually with CT/MRI every 5 years 1
• Type I or III endoleaks require re-intervention to achieve seal 1

Critical Pitfalls to Avoid

Do not perform routine coronary angiography and systematic revascularization before AAA repair in patients with chronic coronary syndromes—it does not improve outcomes. 1

Recognize that patients with aortic aneurysms face 10-15 times higher risk of death from other cardiovascular causes than from aneurysm rupture itself, making aggressive cardiovascular risk management paramount. 2

For small AAAs (4.0-5.5 cm), immediate repair offers no survival advantage over surveillance regardless of whether open or endovascular repair is used—surveillance is the appropriate strategy. 5

Family screening is essential: first-degree relatives of patients with thoracic aortic aneurysms or dissections should undergo aortic imaging. 1, 2