What specialist should a patient with an aortic aneurysm, especially an older patient or one with a history of cardiovascular disease, be referred to?

Aortic Aneurysm Specialist Referral

Patients with aortic aneurysms should be referred to a vascular surgeon or, ideally, to a multidisciplinary aortic center with experienced aortic surgeons, particularly when specific clinical thresholds are met. 1

Referral Destination Based on Aneurysm Location

Thoracic Aortic Aneurysms

• Refer to a multidisciplinary aortic center with cardiothoracic surgeons experienced in aortic procedures when possible, as outcomes are superior at high-volume centers 1
• Cardiothoracic surgeons or cardiac surgeons specializing in aortic disease are the appropriate specialists for thoracic aortic pathology 1

Abdominal Aortic Aneurysms

• Refer to a vascular surgeon for assessment and management 2, 3
• All patients diagnosed with asymptomatic AAA should be referred to a vascular surgeon for evaluation 2

Specific Indications for Specialist Referral

The 2024 Mayo Clinic guidelines provide clear criteria for when primary care physicians should refer to a specialist 1:

Mandatory Referral Situations

• Young patients or those with concerning family history/genetic syndrome (Marfan, Loeys-Dietz, Ehlers-Danlos, bicuspid aortic valve) 1
• High-risk features for dissection/rupture including:
  • Family history of aortic dissection 1
  • Rapid aneurysm growth (>3 mm/year) 1
  • Diffuse aortic dilation 1
  • Marked vertebral arterial tortuosity 1
• Multiple cardiovascular comorbidities that complicate management 1
• Aortic size warranting biannual follow-up or meeting surgical criteria 1

Size-Based Referral Thresholds for Thoracic Aneurysms

Degenerative/Bicuspid Aortic Valve Disease:

• Refer when diameter >55 mm for routine cases 1
• Refer at >50 mm for bicuspid aortic valve with additional risk factors for dissection 1
• Refer at >45 mm if bicuspid aortic valve patient requires valve surgery for another indication 1

Genetic Syndromes:

• Marfan syndrome: Refer at >50 mm (or lower with risk factors) 1
• Loeys-Dietz syndrome: Refer at >40-42 mm 1
• Turner syndrome: Refer at indexed diameter >2.5 cm/m² 1

Size-Based Referral for Abdominal Aneurysms

• Refer when AAA diameter reaches ≥5.5 cm in men or ≥5.0 cm in women 4
• Symptomatic aneurysms require emergency referral regardless of size 3, 5

When Primary Care Can Manage Surveillance

Routine surveillance imaging can be managed by primary care physicians for 1:

• Stable thoracic aneurysms <55 mm without high-risk features
• Patients without genetic syndromes or family history of dissection
• Aneurysms with slow, predictable growth rates

However, even in surveillance cases, maintain a low threshold for specialist consultation when any concerning features develop 1

Critical Pitfalls to Avoid

Do not delay referral based on patient age alone - older patients with acceptable surgical risk should still be evaluated by specialists, as modern techniques including endovascular repair have lower perioperative risks 3, 6

Do not assume asymptomatic means low-risk - most aortic aneurysms are asymptomatic until catastrophic complications occur 7, 5

Symptomatic aneurysms (chest pain, abdominal pain, back pain) require emergency vascular surgery consultation, not routine referral, as these may represent impending rupture or dissection 1, 3

Refer all first-degree relatives of patients with thoracic aortic aneurysms for screening echocardiography, as 13-19% will have similar disease 1