Decision-Making in Thoracic Aortic Aneurysm Surgery—Clinician and Patient View

Abstract

Treatment decision-making in thoracic aortic aneurysms of the ascending aorta is complex both with regard to the timing of surgery and with regard to the invasive treatment strategy. From a clinician perspective, it is seen as important to balance the risks of watchful waiting versus preventive surgery and to choose a surgical treatment strategy that will result in the lowest early and late event occurrence. The current clinical practice guidelines and reported outcomes after surgery suggest that there are many gray zones in determining the optimal timing and the type of intervention. From a patient perspective, quality of life and in particular minimization of anxiety and depression due to the fear of aortic rupture or the potential occurrence of complications related to the different treatment strategies are important to consider. Quality of life studies and evidence on the importance of patient participation in decision-making make a strong case for evidence-based shared treatment decision in this complex patient group.

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

“…Better HRQOL was independently associated with socioeconomic factors (eg, private insurance, active employment) but not factors related to disease severity or comorbidities. 14,15 Although aneurysms are usually asymptomatic before diagnosis, surgical aortic repair is associated with an initial deterioration in HRQOL at 3 months, including decreased physical, cognitive, and social function that generally returns to preoperative levels after 6 to 12 months. 11 Standardized reporting of preoperative and postoperative HRQOL measures is needed to guide further improvements in interventional strategies and improve the overall patient experience.…”

4D flow imaging of the thoracic aorta: is there an added clinical value?

“…Current guidelines assess the risk of progression and dilatation of the aneurysm through periodic diameter measurements and the evaluation of risk factors such as smoking, blood pressure, renal failure, male sex or congenital syndromes and rapidly increasing aortic size. Surgical intervention is recommended when aortic diameter is greater than 5.5 cm (4.5-5 cm in case of MFS, BAV or other genetical disorders) or if the patient is symptomatic or if the growth rate is greater than 0.5 cm/y (59,73,77,80). But aneurysm rupture or dissection can also occur when aortic diameter is within the normal range with an incidence of 5-10% (81,82).…”

Risk of aortic dissection in patients with ascending aorta aneurysm: a new biological, morphological, and biomechanical network behind the aortic diameter

“…As a predictor of adverse aneurysmal outcomes, aortic diameter is still the most used criteria [6][7][8][9] . However, several studies have found that in a particular group of patients, complications may occur at smaller aortic sizes than we would predict [10][11][12] . In our opinion, it is necessary to investigate other parameters that better identify these high risk TAA patients for which earlier surgical intervention is necessary and at smaller aortic size [13] .…”