New Frontiers in the Management of Aortic Disease

The aorta has multiple functions within the cardiovascular system and disease progression remains incompletely understood. Diseases of the aorta cause substantial morbidity and mortality. This review summarizes the management of thoracic aortic disease, current knowledge gaps, and future opportunities. There is an increasing effort to incorporate aortic function, beyond diameter, into risk stratification for aortic disease. Medical therapies focus on slowing growth of aortic aneurysm, minimizing perioperative risk, and reducing overall cardiovascular mortality, focusing on treating hypertension and minimizing lifestyle risks such as smoking and strenuous isometric exercise. Surgical management aims to lower the risk of adverse aortic events, balancing natural history risk vs the risk of prophylactic surgery. Open surgical replacement of aneurysmal segments remains the gold standard for aortic root and ascending aortic aneurysms. Hybrid approaches, combining open and endovascular repair, have been used for the aortic arch with efforts to optimize neurologic outcomes. Custom-made and off-the-shelf devices are available for descending thoracic and thoracoabdominal aortic aneurysms. An interdisciplinary aortic team is essential for the management of complex aortic disease. Large multinational, prospective registries have added important knowledge regarding aortic dissection and genetic aortopathy. Randomized trials are currently underway that will help inform important management decisions. Future efforts should focus on personalized decision making, enabling less invasive therapies, and improving quality of life of those living with the disease.