In patients with an ascending aortic aneurysm, what is the recommendation for performing a coronary angiogram (coronary artery imaging test) based on European Association for Cardio-Thoracic Surgery (EACTS) guidelines?

Coronary Angiography in Ascending Aortic Aneurysm: EACTS/ESC Guidelines

The 2024 ESC Guidelines explicitly state that routine coronary angiography prior to ascending aortic aneurysm repair is NOT recommended (Class III C recommendation). 1

Primary Guideline Recommendation

The most recent European guidance takes a clear position against routine preoperative coronary angiography in this population. Prior to AAA repair, routine evaluation with coronary angiography and systematic revascularization in patients with chronic coronary syndromes is not recommended. 1 While this specific statement addresses abdominal aortic aneurysm, the 2024 ESC guidelines do not provide a separate Class I recommendation mandating routine coronary angiography for thoracic aortic aneurysms either. 1

When Coronary Evaluation IS Indicated

The guidelines recommend coronary assessment in specific clinical contexts rather than routinely:

• Patients with symptoms of coronary artery disease (angina, prior MI, heart failure) should undergo appropriate cardiac evaluation before elective aortic surgery 1
• When concomitant aortic valve disease is present, assessment of the aortic valve is recommended when a thoracic aortic aneurysm is identified 1
• Patients requiring valve replacement or repair in addition to ascending aortic surgery may warrant coronary evaluation based on standard indications for valve surgery 1

Contrast with Older American Guidelines

The 2010 ACC/AHA guidelines mention that "ancillary procedures that may be performed concurrently include coronary artery bypass graft surgery" but do not mandate routine preoperative angiography. 1 This reflects an era when practice patterns were more variable.

Supporting Research Evidence

Research demonstrates that coronary angiography can be performed safely in ascending aortic aneurysm patients (98% successful left coronary engagement, 92% right coronary engagement, zero adverse events in one series), with coronary disease found in 19% and requiring bypass in 15%. 2 However, safety and feasibility do not equate to clinical necessity or improved outcomes, which is why the most recent European guidelines recommend against routine use. 1

In emergency aortic surgery settings, coronary angiography showed no impact on in-hospital mortality and did not significantly affect CABG rates, with 74% of bypass procedures performed for coronary dissection rather than underlying coronary disease. 3 This further supports selective rather than routine angiography.

Clinical Algorithm

For patients with ascending aortic aneurysm planned for elective repair:

• No routine coronary angiography 1
• Perform targeted evaluation only if:
  • Active cardiac symptoms (angina, heart failure) 1
  • Prior history of coronary disease requiring assessment of current status 1
  • Concomitant valve surgery planned with standard indications for coronary assessment 1
  • High-risk features on non-invasive testing if performed for other clinical indications 1

Key Pitfall to Avoid

Do not delay necessary ascending aortic aneurysm surgery to pursue routine coronary angiography in asymptomatic patients without cardiac symptoms. 1 The risk of aneurysm complications during unnecessary delays may exceed any theoretical benefit from identifying incidental coronary disease. 3