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Growth, Survival, Quality of Life in Untreated Thoracic Aortic Aneurysms
Quick Takes
- In a relatively large, observational cohort study from England, the growth rate for unoperated chronic thoracic aortic aneurysm was 0.2 cm/year for descending thoracic aortic aneurysms and 0.07 cm/year for arch aneurysms.
- The yearly death rate was 6.6% among patients with intention to treat.
- The risk of death increased with aneurysm size at baseline and with aneurysm growth rate.
Study Questions:
What is the natural history of chronic thoracic aortic aneurysm (TAA) prior to intervention, and what risk factors are associated with poor outcome?
Methods:
The ETTAA (Effective Treatments for Thoracic Aortic Aneurysms) study is an observational cohort study that prospectively included data for patients aged ≥18 years who were seen at a National Health Service (NHS) hospital in England between March 2014–July 2018 with previously or newly diagnosed arch or descending thoracic aorta (DTA) aneurysm ≥4 cm diameter. Patients were grouped at the time of consent as conservative management (with no plan for future intervention), watchful waiting (if future intervention would be considered), or those undergoing endovascular or open surgical intervention; intention to treat was defined as all patients except those designated as conservative management. Patients were followed until death, intervention, withdrawal, or July 2019. Outcomes were aneurysm growth, survival, quality of life (using the EQ-5D-5L utility index), and hospital admissions.
Results:
Between 2014–2018, 886 patients were recruited from 30 NHS vascular/cardiothoracic units. Maximum aneurysm diameter was in the DTA in 725 (82%) patients, growing at 0.2 (0.17–0.24) cm per year. Aneurysms ≥4 cm in the arch increased by 0.07 (0.02–0.12) cm per year. Adjusting for aneurysm location and comorbidities, larger aneurysms at baseline had a faster growth rate. Baseline diameter was related to age and comorbidities, and no clinical correlates of growth were found. During follow-up, 129 patients died, 64 from aneurysm-related events; deaths included 83 patients (6.6% deaths per year) in the intention to treat group. Adjusting for age, sex, and New York Heart Association dyspnea index, the risk of death increased with aneurysm size at baseline (hazard ratio [HR], 1.88 [95% confidence interval, 1.64–2.16] per cm, p < 0.001) and with growth (HR, 2.02 [1.70–2.41] per cm, p < 0.001). Hospital admissions increased with aneurysm size (relative risk, 1.21 [1.05–1.38] per cm, p = 0.008). Quality of life decreased annually for each 10-year increase in age (–0.013 [–0.019 to –0.007], p < 0.001) and for current smoking (–0.043 [–0.064 to –0.023], p = 0.004). Aneurysm size was not associated with change in quality of life.
Conclusions:
The authors concluded that international guidelines should consider increasing monitoring intervals to 12 months for small aneurysms and increasing intervention thresholds; and that individualized decisions about surveillance/intervention should consider age, sex, size, growth, patient characteristics, and surgical risk.
Perspective:
This relatively large, observational cohort study from NHS centers in England found that the growth rate for unoperated chronic TAA was 0.2 cm/year for DTA aneurysms and 0.07 cm/year for arch aneurysms; that the yearly death rate was 6.6% among patients with intention to treat; that only one-half of deaths were aortic related; that the risk of death increased with aneurysm size at baseline and with growth rate; and that aneurysm size was not associated with change in quality of life. In contrast to current guidelines that suggest 6-month follow-up imaging for TAA with diameter 4.0-5.4 cm, the authors suggest that the slow observed growth rates in this study could support less frequent imaging. However, with a high mortality rate among patients despite intention to treat, and the time between the first and subsequent aorta scans reported as a range from 3 days to 7.35 years, additional data might be required before feeling reassured that less frequent imaging is as safe as more frequent imaging.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Interventions and Imaging, Interventions and Vascular Medicine, Smoking
Keywords: Aneurysm, Aortic Aneurysm, Thoracic, Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Dyspnea, Endovascular Procedures, Intention to Treat Analysis, Quality of Life, Risk Factors, Secondary Prevention, Smoking, Vascular Diseases
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