Management of Ectatic Thoracic Aorta

Medical Management

• The American College of Cardiology recommends beta blockers as the foundation of medical therapy for patients with thoracic aortic aneurysms to reduce the rate of aortic dilatation, with a target heart rate of 60 beats per minute or less 2, 3
• For patients with thoracic aortic aneurysm, blood pressure should be reduced with beta blockers and ACE inhibitors or ARBs to the lowest tolerated level, with a target blood pressure of less than 140/90 mmHg for patients without diabetes and less than 130/80 mmHg for patients with diabetes or chronic renal disease 2, 4
• The American Heart Association suggests that vasodilators should not be initiated prior to rate control to avoid reflex tachycardia that may increase aortic wall stress 1
• For patients with Marfan syndrome, an ARB (losartan) is reasonable to reduce the rate of aortic dilatation 2, 4

Risk Factor Modification

• The American College of Cardiology recommends stringent control of hypertension, lipid profile optimization, smoking cessation, and other atherosclerosis risk-reduction measures should be implemented 3
• Statin therapy is reasonable to achieve a target LDL cholesterol of less than 70 mg/dL for patients with atherosclerotic aortic aneurysm 2
• Smoking cessation is strongly recommended as it is a significant risk factor for aortic disease progression 4

Imaging Surveillance

• The European Society of Cardiology recommends assessment of the entire aorta at baseline and during follow-up when a thoracic aortic aneurysm is identified 5
• CT or MRI is recommended to confirm echocardiographic measurements, rule out aortic asymmetry, and determine baseline diameters for follow-up 5
• For stable thoracic aortic aneurysms, imaging is recommended at 1, 3, 6, and 12 months post-diagnosis and, if stable, annually thereafter 6

Surgical Management

• The European Society of Cardiology recommends that for patients with ascending thoracic aortic aneurysm with a tricuspid aortic valve, surgery is recommended when the maximum diameter reaches ≥55 mm 5
• For patients with descending thoracic aortic aneurysm without heritable thoracic aortic disease, elective repair is recommended when diameter reaches ≥55 mm 5
• For thoracoabdominal aortic aneurysms, elective repair is recommended when the diameter reaches ≥60 mm 5
• The European Society of Cardiology suggests that for descending thoracic aortic aneurysms when elective repair is indicated and anatomy is suitable, thoracic endovascular aortic repair (TEVAR) is recommended over open repair 5

Special Considerations

• The American College of Cardiology recommends that acute thoracic aortic dissection involving the ascending aorta should be urgently evaluated for emergent surgical repair due to high risk of life-threatening complications 1
• For patients with intramural hematoma, management is similar to aortic dissection in the corresponding aortic territory 7, 8
• Aneurysms 6.0 to 6.5 cm carry a 7% annual risk of rupture, and aneurysms that grow at an annual rate >1 cm are more prone to rupture 9, 10