Perspective:

Current multisociety practice guidelines recommend surgical intervention on the ascending aorta at a maximum diameter of ≥5.5 cm. However, based on data from the International Registry of Acute Aortic Dissection, we know that type A dissection frequently occurs at smaller diameters. Indeed, the Aortic Institute at Yale-New Haven Hospital takes a more aggressive stance based on their data, suggesting a hinge point of increased probability of rupture or dissection at 5.25 cm. They operate on aneurysms at ≥5 cm, with good outcomes. Specifically, patients who underwent prompt surgery had a 30-day mortality of just 1%. More importantly, in patients for whom surgery was recommended, the consequences of delayed or no surgery were significant: up to 12% risk of aortic-related death and 13% risk of an aortic-related event. This study suggests that at 5 cm, the risk of surgery is low enough compared to the risk of aortic-related death or events to tilt the scales in favor of surgery. Notably, 38% of the cohort had a positive family history, while only 2.6% had a defined connective tissue syndrome, supporting the familial nature of thoracic aortic aneurysm and the need for ongoing work defining aortic aneurysm genotypes and phenotypes. Limitations as noted by the authors include the retrospective and single-center study design, possible underestimation of aortic events, and bias related to advanced age and comorbidities for which patients did not undergo surgery that may have affected survival.