Treatment

• Unstable patients (e.g., in the case of rupture): emergency TAA repair (see “Thoracic aortic aneurysm rupture”)

• Symptomatic patients: urgent TAA repair

• Asymptomatic patients

  • Aneurysm surveillance

  • Elective TAA repair when size or growth thresholds are passed

• All patients: conservative management with reduction of cardiovascular risk factors

General indications

• TAA rupture

• Symptomatic TAA

• Asymptomatic TAA when size or growth thresholds are passed

Indications for asymptomatic patients

The decision to perform elective TAA repair in asymptomatic patients depends on the size and expansion rate of the aneurysm. In all patients, the risks and benefits of aneurysm resection should be weighed carefully

Open surgical repair (OSR) is recommended for patients with TAA of the ascending aorta and aneurysms involving the aortic arch. For patients with descending thoracic or thoracoabdominal aortic aneurysms, thoracic endovascular aneurysm repair (TEVAR) or OSR can be performed.

Open surgical repair (OSR) [8]

Open surgical repair is a major operation with high associated morbidity and mortality. [6]

• Indications: preferred in young patients with few comorbidities and low surgical risk and patients with connective tissue disorders [6]

  • Symptomatic TAAs involving the ascending aorta or the aortic arch

• Complications: 40% of all patients experience a perioperative complication [6]

  • Paralysis (due to spinal cord injury or ischemia)

  • Renal and mesenteric ischemia

Thoracic endovascular aneurysm repair (TEVAR) [8]

• Indications: Degenerative or traumatic descending aortic aneurysms

• Contraindications

  • Absence of a sufficiently long (2–3 cm) “landing zone” for the stent graft

  • Absence of adequate vascular access sites

• Complications [8][13]

  • Ischemia of the bowel, kidneys, spinal cord

  • Access site complications, e.g., infection, bleeding, hematoma

  • Embolic cerebral ischemia

All patients should receive conservative treatment to reduce the risk of further aneurysm expansion or rupture. Regular aneurysm surveillance via CT or MR is recommended for patients in whom the diameter of the aneurysm has not reached the threshold defined as the indication for repair.

Reduction of cardiovascular risk factors [8]

• Blood pressure management

  • Optimal blood pressure goal to reduce aortic wall stress: the lowest blood pressure that the patient can tolerate [8]

    • Less than 140/90 mm Hg in patients without diabetes

    • Less than 130/80 mm Hg in patients with diabetes or CKD

  • Preferred agents:

    • Beta blockers (e.g., propranolol, metoprolol)

    • ACE inhibitor (e.g., lisinopril, enalapril)

    • Angiotensin receptor blocker (e.g., losartan, candesartan) [8][14]

• Smoking cessation

• Lipid profile optimization: in patients with atherosclerotic aortic aneurysms

  • Target LDL cholesterol: < 70 mg/dL

  • Preferred agent: statin (e.g., atorvastatin)

• Embolism: caused by thrombotic material of the aneurysm

• Aortic valve regurgitation: due to aortic root dilation

• Aortic dissection

• Thoracic aortic aneurysm rupture