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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 European Society of Cardiology (ESC 2024,2014), 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), and ...
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Screening and diagnosis

Screening of family relatives: as per ESC 2024 guidelines, obtain genetic testing in at-risk biological relatives (cascade testing) of patients with heritable thoracic aortic disease having a pathogenic/likely pathogenic variant, irrespective of age.
B
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Diagnostic investigations

General principles: as per ESC 2024 guidelines, adopt a comprehensive approach addressing the entirety of the arterial circulation when managing aortic disease.
B
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  • Medical history

  • Echocardiography

  • CTA

  • Evaluation of supra-aortic arteries

  • Evaluation of cardiovascular risks

  • Genetic testing

Medical management

General principles
As per ESC 2024 guidelines:
Initiate optimal cardiovascular risk management and medical treatment to reduce major adverse cardiac events in patients with TAA.
B
Consider guiding clinical management by the underlying gene/variant, when known, in patients with heritable thoracic aortic disease.
C
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  • Antihypertensive therapy

  • Lipid-lowering therapy

  • Antithrombotic therapy

  • Management of atheromatous plaques

  • Management of diabetes mellitus

  • Considerations for fluoroquinolone use

Nonpharmacologic interventions

Dietary changes: as per ESC 2024 guidelines, advise a healthy diet rich in legumes, dietary fiber, nuts, fruits, and vegetables, with a high flavonoid intake (Mediterranean diet) for CVD prevention in patients with aortic disease.
A
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  • Smoking cessation

  • 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

  • Perioperative antithrombotic therapy

  • 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 (pregnant patients)

  • Patients with Marfan syndrome (physical activity)

  • Patients with Marfan syndrome (surveillance imaging)

  • Patients with Loeys-Dietz syndrome (general principles)

  • Patients with Loeys-Dietz (diagnostic imaging)

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

  • Patients with Loeys-Dietz (surveillance imaging)

  • Patients with Ehlers-Danlos syndrome (medical therapy)

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

  • Patients with Ehlers-Danlos syndrome (surveillance imaging)

  • Patients with Turner syndrome (diagnostic imaging)

  • Patients with Turner syndrome (indications for repair)

  • Patients with Turner syndrome (surveillance imaging)

  • 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

General counseling: as per ESC 2024 guidelines, provide behavioral counseling to promote a healthy diet, smoking cessation, and physical activity to improve the cardiovascular risk profile in patients with aortic disease.
B
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  • Genetic counseling

Follow-up and surveillance

Follow-up aortic imaging, unrepaired aneurysms: as per ESC 2024 guidelines, obtain cardiovascular MRI or CT for surveillance of patients with aneurysm at the distal ascending aorta, aortic arch, descending thoracic aorta, or thoracoabdominal aortic aneurysm.
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