Aortic Aneurysm Monitoring and Management Recommendations

Initial Evaluation

The European Society of Cardiology recommends assessment of the entire aorta at baseline and during follow-up when an aortic aneurysm is identified at any location 1
For thoracic aortic aneurysms (TAA), assessment of the aortic valve, especially for bicuspid aortic valve, is recommended by the European Society of Cardiology 1
The European Society of Cardiology recommends transthoracic echocardiography (TTE) at diagnosis to assess aortic valve anatomy and function, aortic root, and ascending aorta diameters in thoracic aortic dilatation 1
Cardiovascular computed tomography (CCT) or cardiovascular magnetic resonance (CMR) is recommended by the European Society of Cardiology to confirm TTE measurements, rule out aortic asymmetry, and determine baseline diameters for follow-up in thoracic aortic dilatation 1

Duplex ultrasound (DUS) is the recommended primary modality for AAA surveillance by the European Society of Cardiology 1, 2
The European Society of Cardiology recommends the following surveillance intervals for AAA:
- AAA 25-29 mm: Every 4 years 2, 3
- AAA 30-39 mm: Every 3 years 2, 3
- AAA 40-44 mm in women or 40-49 mm in men: Annually 2, 3
- AAA 45-50 mm in women or 50-55 mm in men: Every 6 months 1, 2
CCT or CMR is recommended by the European Society of Cardiology if DUS does not allow adequate measurement of AAA diameter 1, 2
The European Society of Cardiology recommends considering shorter intervals for aneurysms with rapid growth (≥10 mm per year or ≥5 mm per 6 months) 2, 3

For aneurysms of the distal ascending aorta, aortic arch, descending thoracic aorta (DTA), or thoracoabdominal aortic aneurysms (TAAA), CMR or CCT is recommended for surveillance by the European Society of Cardiology 1
TTE is not recommended for surveillance of aneurysms in the distal ascending aorta, aortic arch, or DTA by the European Society of Cardiology 1
After open repair of TAA, early CCT is recommended within 1 month, then yearly CCT follow-up for the first 2 post-operative years, and every 5 years thereafter if findings are stable by the European Society of Cardiology 1

Elective repair is recommended by the European Society of Cardiology if AAA diameter is ≥55 mm in men or ≥50 mm in women 1, 4
The European Society of Cardiology recommends considering repair for rapidly growing aneurysms (≥10 mm per year or ≥5 mm per 6 months) 2, 5
In patients with limited life expectancy (<2 years), elective AAA repair is not recommended by the European Society of Cardiology 1
For aortic root or ascending aorta with tricuspid aortic valve, surgery is recommended when maximum diameter ≥55 mm by the European Society of Cardiology 1
For unruptured descending thoracic aortic aneurysm (without heritable thoracic aortic disease), elective repair is recommended when diameter ≥55 mm by the European Society of Cardiology 1
For unruptured degenerative thoracoabdominal aortic aneurysm, elective repair is recommended when diameter ≥60 mm by the European Society of Cardiology 1

Optimal implementation of cardiovascular risk management is recommended by the European Society of Cardiology for all patients with aortic aneurysms to reduce major adverse cardiovascular events 1, 2
Fluoroquinolones should generally be avoided in patients with aortic aneurysms but may be considered if there is a compelling clinical indication and no reasonable alternative by the European Society of Cardiology 2

After endovascular repair (TEVAR/EVAR), 30-day imaging with CCT plus DUS/contrast-enhanced ultrasound is recommended to assess intervention success by the European Society of Cardiology 1
After TEVAR, follow-up imaging is recommended at 1 and 12 months post-operatively, then yearly until the fifth post-operative year by the European Society of Cardiology 1
Re-intervention is recommended for patients with type I or type III endoleaks after TEVAR/EVAR by the European Society of Cardiology 1

Women have similar aneurysm growth rates to men but a four-fold higher rupture risk at the same diameter, according to the European Society of Cardiology and the American Heart Association 2, 5
Saccular aneurysms may have higher rupture risk at smaller diameters than fusiform aneurysms, as reported in Circulation 5
The European Society of Cardiology recommends avoiding routine evaluation with coronary angiography and systematic revascularization in patients with chronic coronary syndromes prior to AAA repair 1
The European Society of Cardiology recommends remembering that women have higher rupture risk at smaller diameters than men, requiring earlier intervention 2, 5