Indications and imaging for aortic surgery: Size and other matters

Objectives: To review the current general concepts and understanding of the natural history of thoracic aortic aneurysm and their clinical implications. Methods: Data on the the normal thoracic aortas were derived from the database of the Multi-Ethnic Study of Atherosclerosis (n = 3573), representative of the general population. Data on diseased thoracic aorta were derived from the database of the Aortic Institute at Yale-New Haven Hospital (n = 3263), representative of patients with thoracic aortic aneurysm and dissection. Results: Our studies have shown that the normal aorta in the general population is small (3.2 cm for the ascending aorta). Aortas larger than 5 cm are rare in the real world. The aneurysmal aorta grows at a mean of 0.2 cm/y, and larger aneurysms grow faster than do smaller ones. The dissection size paradox (which shows some aortic dissections occurring at small aneurysm sizes) is explained by the huge number of patients with small aortas in the general population. Genetic testing of patients with thoracic aortic disease helps identify genes responsible for aortic aneurysm and dissection. New imaging techniques such as 4-dimensional magnetic resonance imaging may add engineering data to our decision making. Conclusions: Size continues to be a strong predictor of natural complications and a suitable parameter for intervention. As we enter the era of personalized aneurysm care, it is likely that specific genetic mutations will facilitate the determination of the appropriate size criterion for surgical intervention in individual cases.