Who treats an ascending thoracic aortic aneurysm?

Who Treats Ascending Thoracic Aortic Aneurysm

Cardiothoracic surgeons with specialized expertise in aortic surgery are the primary specialists who treat ascending thoracic aortic aneurysms, as these lesions require open surgical repair with cardiopulmonary bypass, hypothermic circulatory arrest, and complex reconstruction techniques. 1

Primary Surgical Team

• Cardiovascular surgeons with aortic surgery expertise manage ascending aortic aneurysms because optimal outcomes are achieved at centers performing these procedures regularly 1
• These surgeons must be proficient in partial or total arch replacement when the aneurysm extends into the arch, requiring hypothermic circulatory arrest and cerebral perfusion strategies 1
• Multidisciplinary Aortic Team evaluation is recommended for surgical approach, as outcomes are enhanced at high-volume programs with experienced practitioners 2

When to Refer to Cardiovascular Surgery

Immediate/Urgent Referral Criteria

• Symptomatic patients with chest pain, back pain, dyspnea, hoarseness, or dysphagia attributable to the aneurysm require immediate surgical referral regardless of size 1, 3
• Never delay referral of symptomatic patients, as symptoms indicate impending rupture or dissection with mortality rates exceeding 50% if untreated, while operative mortality for elective surgery at experienced centers is only 1-5% 1, 3
• Rapid growth (>0.5 cm/year) requires urgent referral 3

Elective Referral Based on Size

• Sporadic ascending aortic aneurysms ≥5.0-5.5 cm require surgical evaluation 1, 2
• Genetic syndromes require earlier referral:
  • Marfan syndrome: at 4.0-5.0 cm 1, 3
  • Loeys-Dietz syndrome: at 4.0-5.0 cm (surgery recommended at 4.2-4.6 cm) 1, 2
  • Bicuspid aortic valve: at 4.0-5.0 cm 1
• Concomitant aortic valve disease: patients undergoing aortic valve repair/replacement with ascending aorta >4.5 cm need combined evaluation 1, 3

Specialized Surgical Techniques Required

• Resection and graft replacement is the most commonly performed procedure for isolated ascending aortic aneurysms 1
• Valve-sparing techniques (David procedure or Yacoub technique) for patients with pliable aortic valve cusps 1
• Composite replacement (Bentall procedure) for patients with non-salvageable aortic valves 1
• Arch replacement techniques requiring hypothermic circulatory arrest when aneurysm extends into the arch 1

Role of Other Specialists

• Primary care physicians and cardiologists coordinate surveillance imaging and medical management for subthreshold aneurysms 3
• Medical geneticists evaluate patients with suspected genetic syndromes requiring earlier intervention 1
• Multidisciplinary teams are needed for patients with multiple aneurysms (thoracic and abdominal) 3

Critical Pitfalls to Avoid

• Do not delay referral to experienced aortic surgery centers, as arch and complex aortic surgery requires specialized expertise 2
• Do not rely solely on absolute diameter thresholds without considering patient height and body surface area 1
• Do not use endovascular stent grafts for ascending aortic aneurysms, as they are not FDA-approved for this location 1
• Do not apply the same size thresholds to all genetic syndromes, as Loeys-Dietz requires intervention at significantly smaller diameters than Marfan syndrome 2