Aortic Aneurysm Management Guidelines

Surveillance and Diagnosis

The European Society of Cardiology recommends surveillance intervals for abdominal aortic aneurysms (AAA) based on size: every 3 years for 30-39 mm, every 2 years for 40-44 mm, annually for 45-49 mm in men (40-44 mm in women), and every 6 months for 50-55 mm in men (45-50 mm in women) 1
Duplex ultrasound (DUS) is the primary surveillance tool for AAA, with CT or MRI used when ultrasound provides inadequate measurements 1
For thoracic aortic aneurysms, transthoracic echocardiography (TTE) is used at diagnosis to assess the aortic valve, root, and ascending aorta, while CT or MRI is required for surveillance of the distal ascending aorta, arch, descending thoracic aorta (DTA), or thoracoabdominal aneurysms 1

The European Heart Society recommends optimal cardiovascular risk management to reduce major adverse cardiovascular events, which pose a greater mortality risk than rupture itself 1, 3
Avoiding fluoroquinolones unless absolutely necessary with no alternatives is recommended, as they may increase aneurysm risk 3

Surgery is indicated at ≥55 mm diameter for asymptomatic patients with ascending aortic aneurysms, with lower thresholds applying when growth rate ≥5 mm/year or ≥3 mm/year over 2 consecutive years, or when concomitant aortic valve surgery is needed 1, 2, 5, 6
Elective repair is indicated at ≥55 mm diameter for descending thoracic aortic aneurysms, with thoracic endovascular aortic repair (TEVAR) preferred over open surgery when anatomy is suitable 1
Elective repair is indicated at ≥60 mm diameter for thoracoabdominal aortic aneurysms, and at ≥55 mm in men or ≥50 mm in women for abdominal aortic aneurysms 1, 2

After open thoracic repair, CT is recommended within 1 month post-operatively, annually for the first 2 years, and every 5 years thereafter if stable 1, 8
After TEVAR, imaging is recommended at 1 month and 12 months post-operatively, annually until 5 years, and every 5 years after year 5 if no complications 1, 5, 8
After AAA repair, first imaging is recommended within 1 year, and every 5 years thereafter if stable 5
After EVAR, CT/MRI with DUS is recommended at 30 days to assess success, with surveillance at 1, 6, and 12 months, then annually 1, 5

Routine coronary angiography and systematic revascularization before AAA repair in patients with chronic coronary syndromes is not recommended, as it does not improve outcomes 1
Family screening is essential, with first-degree relatives of patients with thoracic aortic aneurysms or dissections recommended to undergo aortic imaging 2, 6