Who manages an ascending thoracic aortic aneurysm?

Management of Ascending Thoracic Aortic Aneurysm

Ascending thoracic aortic aneurysms are managed by cardiothoracic/cardiovascular surgeons with specialized expertise in aortic surgery, working within a multidisciplinary aortic team that includes cardiologists, cardiac imaging specialists, and geneticists when indicated. 1, 2

Primary Surgical Management Team

Cardiothoracic surgeons are the definitive managers of ascending aortic aneurysms, as these lesions require open surgical repair with cardiopulmonary bypass, hypothermic circulatory arrest, and complex reconstruction techniques including graft replacement, valve-sparing procedures, or composite valve-graft operations. 3 The surgical complexity demands specialized training and high-volume experience, with optimal outcomes achieved at centers performing these procedures regularly. 1

Multidisciplinary Team Structure

The management team should include:

• Cardiothoracic/cardiovascular surgeons who perform the definitive surgical repair 4
• Cardiologists who provide medical optimization, surveillance imaging, and risk stratification 2, 5
• Cardiac imaging specialists who perform serial CT/MRI measurements using standardized double-oblique techniques perpendicular to the aortic axis 1
• Geneticists for patients with suspected or confirmed genetic syndromes (Marfan, Loeys-Dietz, bicuspid aortic valve, familial thoracic aortic aneurysm) 6, 7

Referral Criteria to Cardiovascular Surgery

Immediate surgical referral is mandatory for:

• Any symptomatic patient with chest pain, back pain, dyspnea, hoarseness, or dysphagia attributable to the aneurysm, regardless of size 3, 1, 4
• Asymptomatic patients when diameter reaches ≥5.5 cm 1, 2
• Growth rate ≥0.5 cm/year, even if diameter <5.5 cm 1, 2

Earlier surgical evaluation (at 4.0-5.0 cm) is required for:

• Marfan syndrome patients (surgery at ≥4.5 cm with risk factors) 1, 2
• Loeys-Dietz syndrome patients (surgery at 4.2-4.6 cm) 3, 1
• Bicuspid aortic valve patients with risk factors (surgery at ≥5.0 cm) 1, 2
• Patients undergoing concomitant aortic valve surgery (repair ascending aorta if ≥4.5 cm) 1, 2

Role of Primary Care and General Cardiology

Primary care physicians and general cardiologists play critical roles in:

• Initial detection through chest imaging performed for other indications 5, 7
• Medical management including aggressive blood pressure control (target <140/90 mmHg), beta-blocker therapy (especially in Marfan syndrome), smoking cessation, and cardiovascular risk factor modification 2, 6
• Surveillance imaging with CT or MRI at 6-12 month intervals depending on size and growth rate 3, 2
• Family screening of first-degree relatives, as familial clustering is common 2
• Timely referral to cardiovascular surgery when thresholds are met 4

Surgical Techniques Requiring Specialized Expertise

The cardiovascular surgeon must be proficient in:

• Supracoronary graft replacement for isolated ascending aortic aneurysms 2
• Valve-sparing root procedures (David reimplantation or Yacoub remodeling) for patients with pliable aortic valve cusps 2
• Bentall composite valve-graft replacement for non-salvageable aortic valves 2
• Partial or total arch replacement when aneurysm extends into the arch, requiring hypothermic circulatory arrest and cerebral perfusion strategies 3

Critical Pitfalls to Avoid

Never delay referral of symptomatic patients, as symptoms indicate impending rupture or dissection with mortality rates exceeding 50% if untreated. 3, 4 The operative mortality for elective surgery at experienced centers is 1-5%, far lower than the catastrophic outcomes of rupture or dissection. 1, 2

Do not rely solely on absolute diameter thresholds without considering patient height and body surface area—use the aortic height index (diameter/height) with a threshold of 2.53 cm/m indicating increased risk. 1 Approximately 60% of type A dissections occur at diameters <5.5 cm, demonstrating that diameter alone is imperfect. 1

Endovascular stent grafts are NOT FDA-approved for ascending aortic aneurysms and should not be used in this location. 3, 2 Open surgical repair remains the only definitive treatment.

Avoid fluoroquinolone antibiotics in patients with known aortic aneurysms unless no reasonable alternative exists, as these agents may increase dissection risk. 2