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Ascending Thoracic Aortic Aneurysms in a Veterans Affairs Health System: Longitudinal Outcomes and Risk Factors
Axel Gomez1, William Carroway1, Sally Tu1
1Division of Adult Cardiac Surgery and Lung Transplantation, Department of Surgery University of California San Francisco and San Francisco VA Health Care System San Francisco CA USA.
Journal of the American Heart Association
|January 14, 2026
Summary
Ascending thoracic aortic aneurysm (ATAA) all-cause mortality significantly increases with diameter, especially for aneurysms 5.5 cm or larger. Findings support the 5.5 cm threshold for prophylactic ATAA repair.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Aortic Disease
Background:
- Ascending thoracic aortic aneurysm (ATAA) repair timing is debated, often guided by diameter thresholds.
- Optimal surgical intervention timing for ATAA remains unclear.
- Analysis of ATAA outcomes in a large veteran cohort is needed.
Purpose of the Study:
- To analyze outcomes of ascending thoracic aortic aneurysms (ATAA) in a large veteran cohort.
- To evaluate the association between ATAA diameter and all-cause mortality.
- To inform optimal timing for prophylactic ATAA repair.
Main Methods:
- Retrospective cohort study of 764 veterans with ATAA (diameter ≥4.0 cm) from 1998-2024.
- Outcomes included surgical repair, all-cause mortality, and aortic events.
- Fine-Gray competing risks regression analyzed mortality risk associated with baseline diameter, adjusting for covariates.
Main Results:
- All-cause mortality rates increased significantly with ATAA diameter, from 2.83 deaths/100 person-years (4.0-4.4 cm) to 24.6 deaths/100 person-years (≥5.5 cm).
- Increasing ATAA diameter (aSHR 1.36 per 0.5cm increase) and age (aSHR 1.07 per year) were independently associated with all-cause mortality.
- Aortic dissection occurred in 0.3% of patients, exclusively in the 4.0-4.5 cm diameter group.
Conclusions:
- Ascending thoracic aortic aneurysm (ATAA) mortality rises with diameter, showing a 7-fold increase for aneurysms ≥5.5 cm.
- Findings support the 5.5 cm diameter threshold for prophylactic ATAA repair.
- Selective intervention strategies are emphasized for smaller ATAAs.
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