What is the treatment for a tortuous aorta?

From the Guidelines

Tortuous aorta typically doesn't require specific treatment unless it causes symptoms or complications, and management focuses on controlling blood pressure and lifestyle modifications to reduce stress on the aortic wall. For most patients with an asymptomatic tortuous aorta found incidentally on imaging, regular monitoring with periodic imaging studies (such as CT angiography or MRI) every 1-2 years is sufficient to track any progression 1. If the condition causes symptoms like chest pain, difficulty swallowing, or shortness of breath, treatment focuses on managing these symptoms. Blood pressure control is essential, often using medications like ACE inhibitors (e.g., lisinopril 10-40 mg daily), ARBs (e.g., losartan 50-100 mg daily), or beta-blockers (e.g., metoprolol 25-100 mg twice daily) to reduce stress on the aortic wall, as recommended by the 2014 ESC guidelines on the diagnosis and treatment of aortic diseases 1.

Some key points to consider in the management of tortuous aorta include:

• Lifestyle modifications are also important, including smoking cessation, as studies have shown that self-reported current smoking induced a significantly faster AAA expansion (by approximately 0.4 mm/year) 1
• Maintaining healthy weight, limiting alcohol consumption, and following a heart-healthy diet low in sodium and saturated fats
• Regular moderate exercise is beneficial but patients should avoid heavy lifting or straining, and competitive sports should be avoided in patients with an enlarged aorta to prevent blood pressure spikes 1
• Surgical intervention is rarely needed for tortuous aorta alone but may be considered if there are associated complications like significant aneurysm formation (typically when diameter exceeds 5.5 cm), dissection, or severe compression of adjacent structures.

It's worth noting that the 2018 AHA/ACC guideline for the management of adults with congenital heart disease provides recommendations for the management of coarctation of the aorta, but this is a different condition from tortuous aorta, and the recommendations may not be directly applicable 1. The conservative approach is preferred for tortuous aorta because the condition itself represents a normal aging process rather than a disease requiring correction, and the risks of surgical intervention often outweigh the benefits.

From the Research

Treatment Options for Tortuous Aorta

• The treatment of tortuous aorta is complex and depends on various factors, including the severity of the condition and the presence of comorbidities 2.
• Studies have shown that the use of angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) may be beneficial in patients with aortic sclerosis, as they can help reduce mortality and slow the progression of the disease 3, 4.
• Statins have also been shown to be effective in reducing mortality and slowing the progression of aortic stenosis in patients with aortic sclerosis 3.
• Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure that can be used to treat atherosclerotic aneurysms of the thoracic aorta, but the outcomes may be affected by the tortuosity of the aorta 2.

Medical Management

• The use of ACE-Is, ARBs, and beta-blockers can help control hypertension and reduce the risk of cardiovascular disease in patients with tortuous aorta 5.
• The selection of antihypertensive therapies should be based on the presence of concomitant cardiovascular and metabolic conditions, as well as patient-specific factors such as race 5.
• Combination therapy may be necessary to achieve adequate blood pressure control, and the use of smaller doses of each medication can help reduce the risk of dose-related adverse effects 5.

Surgical Interventions

• TEVAR is a viable option for patients with atherosclerotic aneurysms of the thoracic aorta, but the procedure may be more challenging in patients with highly tortuous aortas 2.
• The outcomes of TEVAR may be affected by the tortuosity of the aorta, with higher rates of endoleaks and lower survival rates in patients with highly tortuous aortas 2.
• Patients with aneurysms in highly tortuous aortas may require greater attention in preoperative planning, perioperative procedures, and follow-up examinations 2.