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Thoracic aortic aneurysm

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 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 the Society for Cardiovascular Angiography and Interventions (SCAI/STS/SVM/AATS/SCA/AHA/ACR/ACC/ASA/SIR 2010).
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Guidelines

1.Screening and diagnosis

Screening of first-degree relatives: as per ESVS 2017 guidelines, consider screening with imaging for descending thoracic aortic and AAAs at the age of 50 and repeated thereafter at regular intervals in all first-degree relatives of patients considered to be part of a familial aneurysm disorder.
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2.Diagnostic investigations

Echocardiography: as per ACC 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.
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  • CTA

  • Evaluation of supra-aortic arteries

  • Evaluation of cardiovascular risks

  • Genetic testing

3.Medical management

Antihypertensive therapy: as per ACC 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.
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  • Statin therapy

  • Antithrombotic therapy

4.Nonpharmacologic interventions

Smoking cessation: as per ACC 2022 guidelines, advise smoking cessation in smoker patients with TAA.
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  • Physical activity

5.Perioperative care

Preoperative evaluation: as per ESVS 2019 guidelines, obtain CTA as first-line imaging for preoperative assessment of aortic arch pathologies.
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  • Anesthetic technique

  • 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)

  • Perioperative management

6.Surgical interventions

Indications for repair, aortic root and ascending aorta: perform surgery in patients with aneurysms of the aortic root and ascending aorta having symptoms attributable to the aneurysm.
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  • Indications for repair (aortic arch aneurysm)

  • Indications for repair (descending aorta)

  • Indications for repair (progressing aneurysm)

  • Setting of repair

  • Choice of surgical approach (open repair)

  • Choice of surgical approach (endovascular repair)

  • Choice of surgical approach (hybrid open-endovascular repair)

  • Technical considerations for repair (open repair)

  • Technical considerations for repair (endovascular repair)

  • Technical considerations for surgery (prophylactic subclavian artery revascularization)

  • Technical considerations for surgery (prophylactic intercostal artery revascularization)

  • Technical considerations for surgery (prophylactic celiac artery revascularization)

  • Technical considerations for surgery (left heart bypass)

  • Technical considerations for surgery (therapeutic hypothermia)

  • Technical considerations for surgery (CSF drainage)

7.Specific circumstances

Pregnant patients: as per ACC 2022 guidelines, perform surgery before pregnancy in patients with sporadic aortic root aneurysms, ascending aortic aneurysms, or both, and a diameter of ≥ 5.0 cm.
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  • Patients with thoracoabdominal aortic aneurysm (indications for repair)

  • Patients with thoracoabdominal aortic aneurysm (endovascular repair)

  • Patients with thoracoabdominal aortic aneurysm (open repair)

  • Patients with genetic aortic diseases (family history)

  • Patients with genetic aortic diseases (diagnostic imaging)

  • Patients with genetic aortic diseases (genetic testing)

  • Patients with genetic aortic diseases (counseling)

  • Patients with genetic aortic diseases (screening of family relatives)

  • Patients with genetic aortic diseases (medical therapy)

  • Patients with genetic aortic diseases (aneurysm repair)

  • Patients with genetic aortic diseases (surveillance imaging)

  • Patients undergoing aortic valve surgery

  • Patients with ruptured TAA

  • Patients with coronary artery disease

  • Patients with visceral artery disease

8.Follow-up and surveillance

Follow-up aortic imaging, unrepaired aneurysms, AHA/ACC: consider obtaining follow-up imaging (TTE, CT, or MRI, as appropriate based on individual anatomy) in 6-12 months to determine the rate of aortic enlargement in patients with a dilated thoracic aorta. Consider obtaining surveillance imaging every 6-24 months (depending on aortic diameter), if stable.
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  • Follow-up aortic imaging (repaired aneurysms)

  • Management of aortic leaks