Results of the French ACTA (Aortic concomitant thoracic and abdominal aneurysm) study “confirm that thoracic aortic aneurysms (TAAs) coexisting with abdominal aortic aneurysms (AAAs) are not rare”, write Marine Gaudry (Timone Hospital, Marseille, France) and colleagues in the European Journal of Vascular and Endovascular Surgery (EJVES). They add that “systematic screening by imaging the whole aorta in patients with AAAs is clinically relevant and should lead to an effective prevention policy”.
In terms of guidelines, Gaudry et al write that “there are no recommendations for screening for TAAs, even in patients with infrarenal AAAs”. The aims of this study, therefore, were to determine the prevalence of TAAs in patients with AAAs and to analyse the risk factors for this association.
According to the authors, only retrospective studies exist on the association between infrarenal AAA and TAA, and so they designed the ACTA study to be “the first prospective, multicentre cohort with a new classification of TAA based on gender, age, and body surface area that takes into account thoracic aortic ectasia [TAE] as a distinct anatomical status”.
The study included 331 patients with infrarenal aneurysms above 40mm between September 2012 and May 2016, the investigators note, specifying that patients were prospectively enrolled in three French academic hospitals.
Gaudry and colleagues classified patients as having a normal, aneurysmal, or ectatic (defined as non-normal, non-aneurysmal) thoracic aorta according to their maximum aortic diameter indexed by sex, age, and body surface area.
They defined TAE as “above or equal to the 90th percentile of normal aortic diameters according to gender and body surface area”; descending TAA as “above or equal to 150% of the mean normal value,” and ascending TAA as “above 47mm in men and 42mm in women”.
Writing in EJVES, Gaudry et al report that 7.6% (n=25) had either an ascending (seven cases; 2.2%) or descending aortic TAA (18 cases; 5.4%), and 54.6% (n=181) had a TAE. Among the 25 patients with TAAs, they relay the following findings: “five required surgeries; two patients had TAAs related to penetrating aortic ulcers less than 60mm in diameter, and three had a TAA above 60mm”.
In order to examine risk factors, the investigators conducted multinomial regression analysis, which revealed that atrial fibrillation (odds ratio [OR], 11.36; 95% confidence interval [CI], 2.18–59.13; p=0.004) and mild aortic valvulopathy (OR, 2.89; 95% CI, 1.04–8.05; p=0.042) were independent factors associated with TAAs. They add that age (OR, 1.06; 95% CI, 1.02–1.09; p=0.003) and atrial fibrillation (OR, 4.36; 95% CI, 1.21–15.61; p=0.024) were independently associated with ectasia.
The authors acknowledge some limitations that “could affect the external validity of this study”, including recruitment of patients from centres only in southern France, selection of patients with asymptomatic infrarenal AAA above 40mm without indexed diameter, introducing a severity bias for women, exclusion criteria related to systemic inflammation, and lack of an ethnicity report.
