Thoracic aortic aneurysm surgery
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Thoracic aortic aneurysm Microchapters |
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Differentiating Thoracic Aortic Aneurysm from other Diseases |
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Diagnosis |
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Special Scenarios |
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Case Studies |
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Thoracic aortic aneurysm surgery On the Web |
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Directions to Hospitals Treating Thoracic aortic aneurysm surgery |
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Risk calculators and risk factors for Thoracic aortic aneurysm surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammad Salih, MD. Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3] Hibatullah Abdul Aleem, M.B.B.S[4]
Thoracic Aortic Aneurysm Surgery
Overview
Indications for surgical repair of a thoracic aortic aneurysm include rupture; symptoms such as pain consistent with impending rupture; significant aortic regurgitation; growth of 0.5 cm per year or greater; and attainment of pre-specified absolute size thresholds that vary by aortic segment and underlying aetiology. For asymptomatic patients with degenerative thoracic aneurysm, surgical or endovascular repair is generally indicated when the ascending aorta reaches 5.5 cm or greater, or at smaller diameters in the presence of heritable aortic conditions, rapid growth, or concurrent cardiac surgery. Patients with Marfan syndrome, Loeys-Dietz syndrome, bicuspid aortic valve-associated aortopathy, or other heritable thoracic aortic disease (HTAD) should be referred to experienced multidisciplinary aortic centres and undergo elective repair at smaller diameters than the general population. A woven dacron tube graft is most commonly used in the repair of thoracic aortic aneurysms. Thoracic endovascular aortic repair (TEVAR) is the preferred modality for anatomically suitable descending thoracic aortic aneurysms.
Surgery
Preoperative Medical Optimization
All patients awaiting elective thoracic aortic surgery should receive aggressive medical therapy directed at reducing aortic wall stress and slowing aneurysm growth.
- Blood pressure target: <130/80 mmHg in all patients with thoracic aortic disease (Class I, 2022 ACC/AHA).[1]
- Beta-blockers are first-line antihypertensive therapy in Marfan syndrome and remain reasonable in other heritable thoracic aortic disease and degenerative aneurysms to reduce dP/dt.[2]
- Angiotensin receptor blockers (losartan) showed comparable efficacy to atenolol in pediatric and young adult Marfan patients and may be combined with beta-blockade.[3]
- Statins are recommended for cardiovascular risk reduction in patients with atherosclerotic aortic disease (Class I, 2022 ACC/AHA).[1]
- Smoking cessation is strongly recommended; ongoing tobacco use is associated with faster aneurysm growth and higher rupture risk.
- Avoid fluoroquinolones in patients with known aortic aneurysm or heritable aortopathy due to associated risk of dissection and rupture (FDA Drug Safety Communication, 2018).
- Strenuous isometric exercise and competitive contact sport should be avoided.
Evaluating the Patient's Risk of Dissection and Rupture
The annual risk of rupture, dissection, or death is closely related to aneurysm size. The risk increases in a curvilinear fashion and forms the basis for performing surgery when the aorta reaches 5.0 to 5.5 cm in diameter depending on the aortic segment involved and patient-specific risk factors. Cross-sectional area to height ratio and aortic length have emerged as additional predictors of adverse aortic events and may refine surgical decision-making in borderline cases.[1] Once a thoracic aortic aneurysm is identified, the patient should undergo cross-sectional imaging at 6 months to establish growth rate and annually thereafter if stable.
Indications for Surgery
- Rupture
- Symptomatic states
- Pain consistent with expansion or impending rupture
- Compression of adjacent organs
- Acute aortic syndromes (aortic dissection, intramural haematoma, penetrating aortic ulcer)
- Significant aortic regurgitation in the setting of an ascending aortic aneurysm
- Rapid expansion (≥0.5 cm/year for thoracic aneurysms; ≥0.3 cm/year if confirmed on serial imaging in heritable aortopathy)
- Attainment of segment- and aetiology-specific size thresholds (see below)
Size Thresholds for Elective Repair (2022 ACC/AHA Guideline)
| Aetiology | Ascending aorta / root | Descending thoracic aorta |
|---|---|---|
| Sporadic / degenerative | ≥5.5 cm (Class I) | ≥5.5 cm (Class I; TEVAR preferred if anatomically suitable) |
| Sporadic / degenerative with risk factors or at experienced aortic centre | ≥5.0 cm (Class IIa) | ≥5.0 cm (Class IIa) |
| Marfan syndrome | ≥5.0 cm (Class I); ≥4.5 cm if risk factors | Individualised; generally ≥5.5 cm |
| Loeys-Dietz syndrome (TGFBR1/TGFBR2) | ≥4.5 cm; ≥4.0 cm with high-risk features (Class IIa) | Individualised |
| Bicuspid aortic valve aortopathy | ≥5.5 cm (Class I); ≥5.0 cm with risk factors or at experienced centre (Class IIa) | — |
| Vascular Ehlers-Danlos syndrome | Individualised; lower thresholds | Individualised; lower thresholds |
Risk factors triggering repair at smaller diameters include: family history of aortic dissection, rapid growth (≥0.5 cm/year), planned pregnancy, severe aortic valve regurgitation, short stature with cross-sectional area/height ratio >10 cm²/m, or concurrent cardiac surgery.[1]
Bicuspid Aortic Valve Aortopathy — Special Considerations
Approximately 50% of patients with bicuspid aortic valve (BAV) develop ascending aortic dilation. Key management considerations include:
- Phenotype-specific risk: root phenotype (more common in young men) and Sievers type 0 fusion of right and left coronary cusps may be associated with greater dilation rates than the more common ascending (tubular) phenotype.[1]
- Threshold of ≥5.5 cm for isolated BAV-associated aortopathy is Class I; ≥5.0 cm is reasonable (Class IIa) at experienced aortic centres or with risk factors (family history of dissection, growth ≥0.3 cm/year, aortic coarctation, planned pregnancy, severe aortic stenosis or regurgitation).[1]
- Concomitant aortic replacement should be considered when an ascending aorta of ≥4.5 cm is present at the time of aortic valve surgery (Class IIa, 2022 ACC/AHA).[1]
- Family screening: first-degree relatives of patients with BAV should be screened with transthoracic echocardiography (Class I, 2022 ACC/AHA).[1]
Surgery for Thoracic Aortic Aneurysm
The choice of operation depends on:
- Underlying pathology and aetiology
- Extent of the disease proximally and distally
- Patient life expectancy and surgical risk
- Institutional and operator experience
- Desired anticoagulation status
Ascending Aortic Aneurysms
| Anatomical scenario | Preferred surgical approach |
|---|---|
| Ascending aorta with normal aortic valve, annulus and sinuses of Valsalva | Simple dacron supracoronary tube graft |
| Diseased aortic valve with normal sinuses and annulus | Separate aortic valve replacement plus supracoronary synthetic graft |
| Normal valve with aneurysmal sinuses and aortic insufficiency | Valve-sparing root replacement: (1) Remodelling (Yacoub) — resect sinus tissue and reconstruct with dacron graft; (2) Re-implantation (David) — reimplant the scalloped native valve within a dacron graft |
| Diseased aortic valve with diseased aortic root | Aortic root replacement (Bentall procedure): composite mechanical valved conduit (younger patients, requiring lifelong warfarin) or bioprosthetic valved conduit (older patients or contraindication to anticoagulation) |
| Marfan syndrome / heritable thoracic aortic disease | Valve-sparing aortic root replacement (David procedure preferred when leaflets are pliable) or composite valve graft if leaflets are diseased |
Aortic Arch
| Extent of arch involvement | Preferred surgical approach |
|---|---|
| Proximal arch (involving the lesser curve) with ascending aortic aneurysm | Hemiarch replacement under hypothermic circulatory arrest with antegrade cerebral perfusion |
| Total arch involvement | Total arch replacement with a branched graft (e.g., trifurcated graft) and selective antegrade cerebral perfusion |
| Arch + descending aorta involvement | Frozen elephant trunk (FET) procedure or staged hybrid arch repair |
Aortic arch endovascular repair has evolved with the introduction of single-, double-, and triple-branched arch devices. These remain investigational or restricted to experienced aortic centres but offer an alternative for high-risk patients with arch pathology. The Ishimaru zone classification (zones 0–4) is used to describe proximal landing zones and inform the need for supra-aortic debranching or branched endovascular devices.
Descending Thoracic and Thoracoabdominal Aorta
- Thoracic endovascular aortic repair (TEVAR) is the preferred modality for anatomically suitable descending thoracic aortic aneurysms (Class I, 2022 ACC/AHA).[1]
- Open surgery is reserved for patients with anatomy unsuitable for endovascular repair, or those with connective tissue disorders in whom TEVAR durability is uncertain.
- Branched and fenestrated endovascular repair (B/FEVAR) is increasingly used at experienced aortic centres for thoracoabdominal aneurysms involving the visceral segment in patients who are high risk for open repair. Patient-specific custom-manufactured devices remain the standard, although off-the-shelf branched devices (e.g., t-Branch) are useful for urgent cases.
- Factors determining operative approach include age and comorbidities, aortic diameter and extent of lesion, anatomical suitability for endovascular repair (landing zones, access vessels, visceral vessel coverage), life expectancy, and presence of a connective tissue disorder.
Surgical Management of Acute Aortic Syndromes
Acute Type A Aortic Dissection
Acute Type A aortic dissection (ATAAD) is a surgical emergency with an untreated mortality of approximately 1–2% per hour in the first 48 hours.[1] Emergency open surgical repair is recommended for all patients with ATAAD irrespective of age unless prohibitive comorbidity exists (Class I, 2022 ACC/AHA).[1]
Key principles of surgical strategy:
- Resection of the primary entry tear is the central goal.
- Hemiarch replacement is the most commonly performed adjunct when the entry tear is confined to the ascending aorta.
- Total arch replacement, with or without frozen elephant trunk (FET), is reasonable when the entry tear is in the arch, when the arch is aneurysmal, in young patients, in patients with connective tissue disease, or to promote favourable distal aortic remodelling.
- Aortic root management: supracoronary ascending replacement is sufficient for an uninvolved root; root replacement (Bentall or valve-sparing David procedure) is required for root destruction, severe aortic regurgitation, or heritable aortopathy.
- Arterial cannulation: axillary or innominate artery cannulation is preferred over femoral cannulation, providing antegrade perfusion and facilitating selective antegrade cerebral perfusion.
- Cerebral protection: moderate hypothermic circulatory arrest (24–28 °C) with unilateral or bilateral selective antegrade cerebral perfusion is the contemporary standard.
- Malperfusion syndromes (cerebral, mesenteric, renal, limb) markedly increase operative mortality. Endovascular fenestration or branch vessel stenting prior to or during central aortic repair may be considered for severe organ malperfusion.
Acute Type B Aortic Dissection
Acute uncomplicated Type B aortic dissection is initially managed medically with anti-impulse therapy (target SBP <120 mmHg, HR <60 bpm). Pre-emptive TEVAR in the subacute phase (2–90 days) is reasonable in selected patients with high-risk imaging features (false lumen diameter ≥22 mm, primary entry tear ≥10 mm in the inner curvature, total aortic diameter ≥40–44 mm) to promote favourable aortic remodelling and reduce late aortic events, based on the INSTEAD-XL and ADSORB trials.[4][5]
Complicated acute Type B dissection (rupture, malperfusion, refractory pain or hypertension, rapid expansion) requires urgent intervention: TEVAR is the first-line treatment (Class I, 2022 ACC/AHA).[1]
Mycotic and Infected Aortic Aneurysms
Infected (mycotic) thoracic aortic aneurysms warrant urgent surgical or endovascular intervention combined with prolonged targeted antimicrobial therapy (typically 6 weeks of intravenous therapy followed by long-term suppressive oral therapy). Open repair with extra-anatomic bypass and aortic resection has historically been the standard, but TEVAR is now recognized as a reasonable option as definitive therapy or as a bridge to open repair in unstable patients (Class IIa, 2022 ACC/AHA).[1]
2022 ACC/AHA Guidelines for the Diagnosis and Management of Aortic Disease — Surgical Treatment[1]
Referral to Experienced Aortic Centres
| Class I |
| 1. Patients with complex thoracic aortic disease requiring surgical intervention should be referred to experienced multidisciplinary aortic centres with demonstrated expertise in open and endovascular aortic repair to optimise operative outcomes.[1] (Level of Evidence: B-NR) |
Asymptomatic Patients With Thoracic Aortic Aneurysm
| Class I |
| 1. For asymptomatic patients with sporadic aneurysm of the aortic root or ascending aorta with diameter ≥5.5 cm, surgical repair is recommended.[1] (Level of Evidence: B-NR) |
| 2. For asymptomatic patients with Marfan syndrome and aortic root diameter ≥5.0 cm, surgical repair is recommended.[1] (Level of Evidence: B-NR) |
| 3. For asymptomatic patients with bicuspid aortic valve aortopathy and aortic root or ascending aortic diameter ≥5.5 cm, surgical repair is recommended.[1] (Level of Evidence: B-NR) |
| Class IIa |
| 1. For asymptomatic patients with sporadic aneurysm of the aortic root or ascending aorta who meet specific risk criteria (rapid growth, family history of aortic dissection, cross-sectional area-to-height ratio >10 cm²/m, or planned pregnancy) and a diameter ≥5.0 cm, surgical repair at an experienced aortic centre is reasonable.[1] (Level of Evidence: B-NR) |
| 2. For patients with Loeys-Dietz syndrome or confirmed TGFBR1 or TGFBR2 mutation, it is reasonable to proceed with aortic repair when the aortic diameter reaches 4.5 cm or greater (≥4.0 cm with high-risk features) by CTA external diameter measurement.[1] (Level of Evidence: C-LD) |
Symptomatic Patients With Thoracic Aortic Aneurysm
| Class I |
| 1. Patients with symptoms suggestive of expansion of a thoracic aortic aneurysm should be evaluated for prompt surgical intervention unless life expectancy from comorbid conditions is limited or quality of life is substantially impaired.[1] (Level of Evidence: C-LD) |
Open Surgery for Ascending Aortic Aneurysm
| Class I |
| 1. Separate valve and ascending aortic replacement is recommended in patients without significant aortic root dilatation, in elderly patients, or in younger patients with minimal dilatation who have aortic valve disease.[1] (Level of Evidence: C-LD) |
| 2. Patients with Marfan syndrome, Loeys-Dietz syndrome, or other heritable thoracic aortic disease who require aortic root replacement should be referred to experienced aortic centres.[1] (Level of Evidence: B-NR) |
| Class IIa |
| 1. Valve-sparing aortic root replacement is reasonable in young patients with aortic root dilatation and tricuspid aortic valve leaflets without significant aortic insufficiency, when performed at experienced aortic centres.[1] (Level of Evidence: B-NR) |
Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms
| Class I |
| 1. For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, thoracic endovascular aortic repair (TEVAR) is recommended as the preferred treatment when anatomically feasible.[1] (Level of Evidence: B-NR) |
| 2. For patients with chronic dissection, particularly if associated with a connective tissue disorder, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended when endovascular repair is not anatomically suitable or when a durable result is required.[1] (Level of Evidence: B-NR) |
Coronary Revascularization Prior to Aortic Surgery
| Class IIa |
| 1. For patients undergoing surgery for thoracic aortic disease with significant left main or proximal multivessel coronary artery disease, concomitant coronary revascularization is reasonable.[1] (Level of Evidence: B-NR) |
| Class IIb |
| 1. For patients undergoing low- or intermediate-risk surgery for thoracic aortic disease with clinically stable but significant coronary artery disease, the benefits of coronary revascularization are not well established.[1] (Level of Evidence: B-NR) |
Choice of Anesthetic and Monitoring Techniques
| Class I |
| 1. The choice of anaesthetic techniques and agents and patient monitoring techniques should be tailored to individual patient needs to facilitate surgical and perfusion techniques and the monitoring of haemodynamics and organ function.[1] (Level of Evidence: C-LD) |
| Class IIa |
| 1. Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta unless contraindicated, to assist with intraoperative haemodynamic monitoring, valvular assessment, and detection of complications.[1] (Level of Evidence: B-NR) |
Spinal Cord Protection in Open and Endovascular Thoracic Aortic Repair
| Class I |
| 1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury.[1] (Level of Evidence: B-NR) |
| Class IIa |
| 1. Spinal cord perfusion pressure optimisation using techniques such as proximal aortic pressure maintenance and distal aortic perfusion is reasonable as an integral part of the surgical, anaesthetic, and perfusion strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury.[1] (Level of Evidence: B-NR) |
Special Populations
Pregnancy
- Pre-pregnancy counselling is recommended for all women with known thoracic aortic disease.
- Aortic root replacement before pregnancy is recommended for women with Marfan syndrome and an aortic root ≥4.5 cm (Class I, 2022 ACC/AHA).[1]
- Caesarean delivery is recommended for women with an aortic diameter >4.5 cm in Marfan syndrome or in any patient with significant aortic dilation.
- Acute Type A dissection during pregnancy: urgent surgical repair is required. In the third trimester, simultaneous Caesarean delivery before cardiopulmonary bypass is recommended; in the second trimester, the approach is individualised.
Women
Women have smaller aortas in absolute terms, and threshold-based criteria may underestimate rupture and dissection risk. Body surface area-indexed measurements (aortic size index, ASI) and height-indexed cross-sectional area-to-height ratio (>10 cm²/m) should be considered, particularly in women of short stature.[1]
Vascular Ehlers-Danlos Syndrome
Open and endovascular intervention carries a markedly elevated risk of vascular complications due to tissue fragility. Surgery should be reserved for life-threatening indications and performed at centres with specific vEDS expertise. Celiprolol has been shown to reduce arterial events in vEDS and is recommended (BBEST trial).[6]
Post-Operative Surveillance
Patients who have undergone surgical or endovascular thoracic aortic repair require lifelong imaging surveillance to detect graft complications and disease progression in the unrepaired aorta.
- Baseline post-operative imaging (CTA preferred) within 30 days of repair.
- Surveillance CTA at 6 and 12 months for the first year, then annually if stable (Class I, 2022 ACC/AHA).[1]
- After TEVAR: closer surveillance for endoleak, stent migration, and retrograde Type A dissection; CTA at 1, 6, and 12 months, then annually.
- Genetic counselling and family screening (Class I) for all patients with non-traumatic thoracic aortic disease presenting before age 60 or with a positive family history.[1]
Aortic Centre and Surgeon Volume
The 2022 ACC/AHA guideline introduced the concept of the multidisciplinary aortic centre, defined by:
- Surgeon annual volume ≥30–40 elective open proximal aortic procedures
- Institutional volume ≥30–40 open and endovascular thoracic aortic procedures annually
- Mortality benchmarks: elective ascending aortic repair <5%, elective TEVAR <3%
- On-site availability of cardiac anaesthesia, perfusion, vascular surgery, neurology, and 24/7 imaging support[1]
Referral to such centres for complex thoracic aortic disease is a Class I recommendation.
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ (December 2022). "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines". Circulation. 146 (24): e334–e482. doi:10.1161/CIR.0000000000001106. PMC 9876736 Check
|pmc=value (help). PMID 36322642 Check|pmid=value (help). - ↑ Brooke BS, Habashi JP, Judge DP, Patel N, Loeys B, Dietz HC (June 2008). "Angiotensin II blockade and aortic-root dilation in Marfan's syndrome". N Engl J Med. 358 (26): 2787–95. doi:10.1056/NEJMoa0706585. PMC 2692965. PMID 18579813.
- ↑ Lacro RV, Dietz HC, Sleeper LA, Yetman AT, Bradley TJ, Colan SD, Pearson GD, Selamet Tierney ES, Levine JC, Atz AM, Benson DW, Braverman AC, Chen S, De Backer J, Gelb BD, Grossfeld PD, Klein GL, Lai WW, Liou A, Loeys BL, Markham LW, Olson AK, Paridon SM, Pemberton VL, Pierpont ME, Pyeritz RE, Radojewski E, Roman MJ, Sharkey AM, Stylianou MP, Wechsler SB, Young LT, Mahony L (November 2014). "Atenolol versus losartan in children and young adults with Marfan's syndrome". N Engl J Med. 371 (22): 2061–71. doi:10.1056/NEJMoa1404731. PMC 4386623. PMID 25405392.
- ↑ Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G, Glass A, Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Fattori R, Ince H (August 2013). "Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial". Circ Cardiovasc Interv. 6 (4): 407–16. doi:10.1161/CIRCINTERVENTIONS.113.000463. PMID 23922146.
- ↑ Brunkwall J, Kasprzak P, Verhoeven E, Heijmen R, Taylor P, Alric P, Canaud L, Janotta M, Raithel D, Malina W, Resch T, Eckstein HH, Ockert S, Larzon T, Carlsson F, Schumacher H, Classen S, Schaub P, Lammer J, Lönn L, Clough RE, Rampoldi V, Trimarchi S, Fabiani JN, Böckler D, Kotelis D, von Tenng-Kobligk H, Mangialardi N, Ronchey S, Dialetto G, Matoussevitch V (September 2014). "Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial". Eur J Vasc Endovasc Surg. 48 (3): 285–91. doi:10.1016/j.ejvs.2014.05.012. PMID 24962744.
- ↑ Ong KT, Perdu J, De Backer J, Bozec E, Collignon P, Emmerich J, Fauret AL, Fiessinger JN, Germain DP, Georgesco G, Hulot JS, De Paepe A, Plauchu H, Jeunemaitre X, Laurent S, Boutouyrie P (October 2010). "Effect of celiprolol on prevention of cardiovascular events in vascular Ehlers-Danlos syndrome: a prospective randomised, open, blinded-endpoints trial". Lancet. 376 (9751): 1476–84. doi:10.1016/S0140-6736(10)60960-9. PMID 20825986.