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Thoracic aortic aneurysm

What's new

Updated 2024 EACTS/STS guidelines for the diagnosis and management of thoracic aortic aneurysm.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of thoracic aortic aneurysm are prepared by our editorial team based on guidelines from the Society of Thoracic Surgeons (STS/EACTS 2024), the American Heart Association (AHA/ACC 2022), the European Society for Vascular Surgery (ESVS/EACTS 2019), the European Society for Vascular Surgery (ESVS 2017), the European Society of Cardiology (ESC 2014), and ...
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Screening and diagnosis

Screening of family relatives: as per ACC/AHA 2022 guidelines, obtain genetic testing in at-risk biological relatives (cascade testing) of patients with thoracic aortic disease with a pathogenic/likely pathogenic variant.
B
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Diagnostic investigations

Echocardiography: as per ACC/AHA 2022 guidelines, obtain a TTE at the time of diagnosis to assess aortic valve anatomy, aortic valve function, and thoracic aortic diameters in patients with a dilated thoracic aorta.
B

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  • CTA

  • Evaluation of supra-aortic arteries

  • Evaluation of cardiovascular risks

  • Genetic testing

Medical management

Antihypertensive therapy: as per ACC/AHA 2022 guidelines, initiate antihypertensive medications to reduce the risk of cardiovascular events in patients with TAA and an average SBP of ≥ 130 mmHg or an average DBP of ≥ 80 mmHg.
B
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  • Statin therapy

  • Antithrombotic therapy

Nonpharmacologic interventions

Smoking cessation: as per ACC/AHA 2022 guidelines, advise smoking cessation in smoker patients with TAA.
B

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  • Physical activity

Perioperative care

Preoperative evaluation, risk assessment: as per EACTS/STS 2024 guidelines, obtain a preoperative risk assessment.
B
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  • Preoperative evaluation (imaging)

  • Anesthetic technique

  • Radiation protection

  • Intraoperative organ protection (heart)

  • Intraoperative organ protection (brain)

  • Intraoperative organ protection (spinal cord)

  • Intraoperative organ protection (visceral)

  • Intraoperative monitoring (TEE)

  • Intraoperative monitoring (arterial pressure)

  • Intraoperative monitoring (motor- and/or somatosensory-evoked potentials)

  • Intraoperative monitoring (cerebral oxygenation)

  • Intraoperative monitoring (coagulation)

  • Intraoperative monitoring (temperature)

  • Postoperative monitoring

Surgical interventions

Setting of repair: as per EACTS/STS 2024 guidelines, ensure shared decision-making for the optimal treatment of aortic pathologies by a multidisciplinary aortic team.
B
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  • Aortic root or ascending aortic aneurysm repair (indications for repair)

  • Aortic root or ascending aortic aneurysm repair (choice of repair approach)

  • Aortic root or ascending aortic aneurysm repair (surgical considerations)

  • Aortic arch aneurysm repair (indications for repair)

  • Aortic arch aneurysm repair (choice of repair approach)

  • Aortic arch aneurysm repair (surgical considerations)

  • Descending aortic aneurysm repair (indications for repair)

  • Descending aortic aneurysm repair (choice of repair approach)

  • Descending aortic aneurysm repair (surgical considerations)

  • Thoracoabdominal aortic aneurysm repair (indications for repair)

  • Thoracoabdominal aortic aneurysm repair (open repair)

  • Thoracoabdominal aortic aneurysm repair (endovascular repair)

Specific circumstances

Pregnant patients, repair before pregnancy
As per EACTS/STS 2024 guidelines:
Perform aortic repair before pregnancy in patients with Marfan's syndrome with an aortic root diameter of ≥ 45 mm.
B
Consider performing aortic repair before pregnancy in patients with an aortic root diameter of 40-45 mm and risk factors for aortic dissection, such as family history or rapid growth > 3 mm/year.
C

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  • Pregnant patients (surveillance)

  • Pregnant patients (mode of delivery)

  • Patients with Marfan syndrome (diagnostic imaging)

  • Patients with Marfan syndrome (medical therapy)

  • Patients with Marfan syndrome (indications for repair)

  • Patients with Marfan syndrome (surveillance imaging)

  • Patients with Loeys-Dietz syndrome (general principles)

  • Patients with Loeys-Dietz syndrome (indications for repair)

  • Patients with Ehlers-Danlos syndrome (medical therapy)

  • Patients with Ehlers-Danlos syndrome (indications for repair)

  • Patients with other heritable aortic diseases

  • Patients with Kommerell diverticulum

  • Patients undergoing aortic valve surgery

  • Patients with ruptured TAA

  • Patients with coronary artery disease

  • Patients with visceral artery disease

Patient education

Genetic counseling: as per ACC/AHA 2022 guidelines, provide genetic counseling in patients with an established or likely pathogenic variant in a gene predisposing to heritable thoracic aortic disease. Offer clinical management informed by the specific gene and variant in the gene.
B

Follow-up and surveillance

Follow-up aortic imaging, unrepaired aneurysms: as per EACTS/STS 2024 guidelines, discontinue surveillance in case of non-operability, no option or informed consent of refraining from treatment.
B

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  • Follow-up aortic imaging (repaired aneurysms)

  • Management of intraluminal thrombus

  • Management of aortic leaks

  • Management of graft infections (diagnostic imaging)

  • Management of graft infections (surgery)

  • Management of graft infections (antimicrobial therapy)

  • Management of spinal cord injury