Undiagnosed Thoracic Aortic Aneurysms

Summary

Background:

The prevalence of thoracic aortic aneurysms (TAA) varies from 0.01 to 10 per 100 000 people depending on the healthcare sector. Undiagnosed TAA can cause highly lethal complications, such as acute aortic dissection. In this article, we discuss the opportunities for stratified early detection.

Methods:

To assess the benefits and risks of screening in high-risk groups and in the population at large, the prevalence of TAA, as well as the sensitivity, radiation exposure, and burden of various diagnostic techniques, were determined or estimated on the basis of a selective literature review, and the identified correlations were discussed with experts and compared with the current guidelines. The prevalence and risk of TAA in patients with certain concurrent diseases were calculated from data on 394 113 adults (2000–2023) from the SHRN primary care database.

Results:

Suitable screening methods include computed tomography, magnetic resonance imaging, and, to a limited extent, transthoracic echocardiography. The use of these techniques and the choice among them must be considered individually for each patient. Population-wide screening is not recommended according to current data. Diagnostic testing may be reasonable for persons at elevated risk of TAA (high pretest probability), e.g., those with a family history of TAA or aortic dissection and those with a genetic predisposition, or persons with a bicuspid aortic valve (adjusted odds ratios 43.95 [9.84. 196.5] to 91.8 [18.7; 450.0], depending on age and sex), an abdominal aortic aneurysm (OR 25.6 [13.9; 47.2] to 31.1 [15.9; 60.7]), or giant cell arteritis (OR 4.99 [0.52; 47.5] to 25.3 [3.10; 206.3]).

Conclusion:

Early detection measures are reasonable for specific patient groups; current treatment guidelines reflect this only to a limited extent. In the future, the sensitivity and specificity of the diagnostic tests used should be estimated more precisely in studies conducted for this purpose, and TAA should be documented as a cause of death in Germany, as in other countries.

Information on CME.

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Participation is possible at cme.aerzteblatt.de

Screening for the early detection of a specific disease should be introduced if the condition is common, associated with a significant disease burden, detectable in its early stages, and more amenable to treatment when detected early. The screening method used for this purpose should offer high sensitivity and specificity, be timeand cost-effective, and should cause minimal discomfort to individuals eligible for screening. The correct interpretation of screening results requires a basic understanding of test theory: The predictive value of a test varies with the prevalence of a disease in the population being studied; accordingly, the benefit of an early detection measure in the general population is different from that achieved, for example, by screening pre-selected patients attending a specialized outpatient clinic.

Diseases of the thoracic aorta can be broadly classified into acute aortic syndromes (AAS; aortic dissection, intramural hematoma, rupture or trauma) (1) and chronic aortic dilation, i.e., thoracic aortic aneurysm (TAA). In contrast to AAS, which typically manifests with acute symptoms, TAA often remains clinically silent for a long time and thus goes undiagnosed; only when adjacent anatomical structures become affected, symptoms may result. In the literature, the prevalence of TAA is reported as 5–10 per 100 000 inhabitants per year; in most publications, however, this figure is not based on epidemiological or primary care data (2).

AAS, which is associated with a high fatality rate in severe cases, may develop from TAA (1). As a result, aortic aneurysms rank among the 20 leading causes of death in the United States (3); no data is available for Germany, where diseases of the aorta are not reported separately as a cause of death (4). The risk of developing AAS increases significantly from 1% to approximately 4–5% per year in patients with an aortic diameter of 53 mm or greater; thus, outpatient management is recommended for diameters of 45 mm or greater, while surgical intervention is recommended for diameters between 50 and 53 mm (2).

Thus, when applying the above-mentioned criteria—relevance, early detection and therapeutic benefit—screening for undiagnosed TAA with the goal of achieving early diagnosis and treatment could, in principle, be beneficial. The aim of this review is to present the opportunities offered by early detection of TAA in everyday clinical practice.

Methods

To assess the benefits and risks of an early detection measure, we conducted a narrative literature review, obtained expert opinions and compared the findings with current guidelines and selected patient populations, and discussed the results. In addition, the prevalence of TAA in the general population and its risk in patients with comorbidities were determined from a secondary data analysis of general practice records within the Supraregional Health Service Research Network (SHRN). The SHRN primary care database includes data of 394 113 adults, covering the period from 2000 to 2023; a detailed description of the methods of analysis used has already been published elsewhere (e1, e2). In addition, criteria were established for specific patient groups, which, similar to red flags, prompt further measures.

Screening using imaging modalities

In the absence of specific biomarkers, the only screening method available is diagnostic imaging. Suitable imaging techniques should ideally either involve no radiation exposure or, at the very least, a justifiable level of radiation exposure. Regardless of their widespread availability, conventional radiography and transthoracic echocardiography are unsuitable screening modalities given their inadequate sensitivity, interobserver variability and occasional lack of standardization; however, no specific data are available regarding the detection of asymptomatic TAAs (5).

Magnetic resonance imaging

MR angiography (MRA) is a three-dimensional crosssectional imaging technique and therefore suitable for evaluating aortic pathologies. The reliability of MRA measurements of the aorta is comparable with that of measurements obtained with computed tomography angiography (CTA); however, the susceptibility to motion artifacts and the time requirements are greater. Using non-contrast imaging techniques, it is also possible to obtain measurements equivalent to those from MRA, so that, for screening purposes alone, the intravenous administration of gadolinium-containing MR contrast agents could be avoided (6, 7). Since MRI screening is not associated with radiation exposure, it is particularly suitable for younger patients at increased risk of TAA (5).

Computed tomography

Given its widespread availability and the minimal time required for a scan, CTA is considered the method of choice. It generates a three-dimensional image of the entire organ within a few seconds and offers a very high level of diagnostic accuracy, allowing for the differentiation of all aortic pathologies. Although radiation exposure has been significantly reduced in recent years, it must be considered as cumulative within the context of a screening program with regular follow-up examinations, along with the potential risks associated with the administration of intravenous contrast media. The diagnostic accuracy for detecting a TAA (positive finding: diameter > 45 mm) is presumably 100%. For the sole purpose of screening based on the above-mentioned criterion “diameter“, CT scanning could even be performed without contrast and using a low-dose protocol (effective dose < 1 mSv). However, this approach would severely limit the ability to discriminate between various underlying pathologies and the images required for making treatment decisions would have to be obtained in a separate scan.

Risks associated with computed tomography angiography-based blanket screening

The “ACR Appropriateness Criteria® Suspected Thoracic Aortic Aneurysm” published by the American College of Radiology are listed in Table 1 (8). A risk model analysis of 93 million CT scans performed on 62 million patients predicted approximately 103 000 new cases of radiation-associated cancer over the lifetime of the exposed patients (9). Based on this projection, annually 5% of the new cancer cases could be associated with CT exposure. The U.S. National Academy of Sciences assumes that a diagnostic radiation dose of 10 mSv in a 40-year-old man results in one additional case of cancer occurring in every 1250 persons. This means that maximizing the benefits of dose-reduction strategies, which take advantage of the latest technological advancements in equipment, significantly more sensitive detectors and advanced imageprocessing methods, would be key to the use of CT in a screening program.

Table 1. Appropriateness criteria and radiation levels for the radiological diagnosis of thoracic aortic aneurysm.

Diagnostic procedure	Appropriateness category	Contrast-related risk	Relative radiation level
X-ray chest	Not appropriate	No	•
Transesophageal echocardiography	Not appropriate	No	◦
Transthoracic echocardiography	Appropriate with limitations	No	◦
CTA chest with contrast	Appropriate	Yes	•••
CTA entire aorta, with contrast	Appropriate	Yes	••• (••••)
CT chest, without contrast	Appropriate	No	•••
CT chest, without contrast, low-dose technique	Appropriate	No	••
MRA chest, with contrast	Appropriate	Yes	◦
MRI chest, without contrast	Appropriate	No	◦
MRA entire aorta, with contrast	Appropriate	Yes	◦
MRI entire aorta, without contrast	Appropriate	No	◦
DSA aortography	Not appropriate	Yes	•••

Estimated effective dose (mSv): ◦ 0; • 0,1; •• 0,1–1; ••• 1–10; •••• 10–30; ••••• 30–100

CT, computed tomography; CTA, CT angiography; DSA, digital subtraction angiography; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging—Adapted from the American College of Radiology“ (8)

Benefit-risk analysis

The prevalence of a documented TAA in the SHRN database was 0.04% overall and 0.07% among persons aged 50 years and older (Table 2, Table 3). Assuming in the calculations that all individuals over the age of 50 years were screened using CTA and that the sensitivity and specificity were actually at the ideal level of 100%—no such source for the detection of TAA exists; however, for aortic dissections, it is ≥ 98% (10)—there would be no false-positive results. Would these values be “only” 99%—for example, due to measurement variability or pulsation-related artifacts—approximately 2318 people would already receive a false-positive screening result (e3).

Table 2. Prevalence rates and frequency of early detection examinations (screening).

2000–2024	Pts	TAA*1 n (%)	AAA*2n (%)	AAA screening*3 n (%)	AAA & screening *2 *3, n (%*4)	TAA, AAA & screening *1, *2, *3 n (%*4)	TAA & screening*1, *3 n (%*4)
Total	414 498	160 (0.04)	372 (0.09)	2 142 (0.52)	72 (3.36)	2 (0.09)	27 (1.26)
Age > 18 yrs	394 113	160 (0.04)	372 (0.09)	2 142 (0.54)	72 (3.36)	2 (0.09)	27 (1.26)
Female > 18yrs	206937	51 (0.02)	80 (0.04)	2 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)
Male > 18 yrs	189906	108 (0.06)	289 (0.15)	2 137 (1.13)	72 (3.37)	2 (0.09)	27 (1.26)
> 50 yrs	232033	151 (0.07)	366 (0.16)	2 142 (0.92)	72 (3.36)	2 (0.09)	27 (1.26)
Female > 50 yrs	125455	50 (0.04)	78 (0.06)	2 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)
Male > 50 yrs	102597	100 (0.1)	285 (0.28)	2 137 (2.08)	72 (3.37)	2 (0.09)	27 (1.26)

Analysis from the “Supraregional Health Service Research Network” (SHRN) based on ICD-10 and GOP (fee schedule code)

The SHRN primary care database comprises routine data of 414 498 pts from 17 family physician’s practices in urban and rural areas of the State of Baden-Württemberg (period 2000–2023). This represents about 3% of the state’s population (as of 2022). While all patients of the participating practices were included in the study (complete survey), the lack of a random selection process in recruiting the practices means that the patient group covered is not immediately representative of the state’s population.

^*1I71.2;

^*2I71.4;

^*3GOP 01747 ((ultrasound screening AAA);

^*4Proportion of pts with GOP

AAA, abdominal aortic aneurysm; yrs, years; Pts, patients; TAA, thoracic aortic aneurysm

Table 3. Prevalence rates of thoracic aortic aneurysms by coincidental diseases according to (12) and risk assessment based on data from the Suprareglonal Health Service Research Network (SHRN).

Coincidental disease	Pts n (%)	With TAA n (%)	Risk with disease %	Risk without disease %	Absolute risk increase	OR [95% Cl]	OR (multivariate) [95% Cl]	p-value
Age ≥ 18 years; male & female	394 113	160 (0.04)
Aortitis	1 (0.00)	0(0)	-	0.04	-	-
Giant cell arteritis	31 (0.01)	1 (0.6)	3.23	0.04	3.19	82.6 [2.01; 503.1]	4.99 [0.52; 47.5]	n. s.
Renal cyst	293 (0.07)	13 (8.1)	4.44	0.04	4.40	124.3 [63.9; 222.6]	6.46 [3.48; 12.0]	< 0.001
Inguinal hernia	876 (0.22)	16 (10)	1.83	0.03	1.80	50.8 [28.1; 85.8]	2.85 [1.63; 5.00]	< 0.001
Hypothyroidism	5 288 (1.34)	29(18.1)	0.55	0.03	0.51	16.4 [10.5; 24.6]	3.85 [2.50; 5.92]	< 0.001
Abdominal aortic aneurysm	87 (0.02)	14 (8.8)	16.09	0.04	16.05	517.4 [263.2; 949.8]	25.6 [13.9; 47.2]	< 0.001
Intracranial aneurysm	15 (0.00)	0(0)	-	0.04	-	-
Bicuspid aortic valve	16 (0.00)	2(1–3)	12.50	0.04	12.46	356.2 [38.9; 1569.5]	43.96 [9.84; 196.5]	< 0.001
Age ≥ 50 years; female	125 455	50 (0.04)
Aortitis	1 (0.00)	0(0)	-	0.04	-	-
Giant cell arteritis	22 (0.02)	0(0)	-	0.04	-	-
Renal cyst	113(0.09)	3(6)	2.65	0.04	2.62	72.7 [14.3; 231.2]	4.79 [1.45; 15.8]	< 0.05
Inguinal hernia	87 (0.07)	1 (2)	1.15	0.04	1.11	29.7 [0.70; 178.0]	2.07 [0.28; 15.3]	n. s.
Hypothyroidism	2718(2.17)	19 (38)	0.70	0.03	0.67	27.9 [14.9; 51.0]	6.39 [3.56; 11.5]	< 0.001
Abdominal aortic aneurysm	19 (0.02)	2(4)	10.53	0.04	10.49	307.3 [33.5; 1350.1]	24.2 [5.61; 104.2]	< 0.001
Intracranial aneurysm	6(0.00)	0(0)	-	0.04	-	-
Bicuspid aortic valve	1 (0.00)	0(0)	-	0.04	-	-
Age ≥ 50 years; male	102 597	100 (0.10)
Aortitis	0(0)	0(0)	-	0.10	-	-	-
Giant cell arteritis	9(0.01)	1 (1)	11.11	0.10	11.01	129.4 [2.89; 979.4]	25.3 [3.10; 206.3]	< 0.01
Renal cyst	145 (0.14)	9(9)	6.21	0.09	6.12	74.4 [32.3; 151.6]	6.77 [3.19; 14.4]	< 0.001
Inguinal hernia	593 (0.58)	14 (14)	2.36	0.08	2.28	28.7 [14.9; 51.1]	2.87 [1.55; 5.30]	< 0.001
Hypothyroidism	682 (0.66)	9(9)	1.32	0.09	1.23	15.0 [6.60; 29.8]	2.01 [0.96; 4.22]	n. s.
Abdominal aortic aneurysm	66 (0.06)	12 (12)	18.18	0.09	18.10	258.7 [121.4; 510.1]	31.1 [15.9; 60.7]	< 0.001
Intracranial aneurysm	6(0.01)	0(0)	-	0.10	-	-	-
Bicuspid aortic valve	7(0.01)	2(2)	28.57	0.10	28.48	418.3 [39.3; 2585.0]	91.8 [18.7; 450.0]	< 0.001

The data shown here are derived from a multivariate regression model in which age and sex were included as covariates. Cl, confidence interval; n. s., not significant; OR, odds ratio; Pts, patients; TAA, thoracic aortic aneurysm

On the other hand, a number needed to harm (NNH) of 1–2 radiation-induced cancers per 2000 CT scans would have to be assumed. In this case, too, there are no sources that specify the exact reference value for the NNH for CTA of the aorta.

Based on previous risk assessment studies and assuming an effective dose of 13 mSv per scan, the lifetime cancer risk attributable to radiation exposure is estimated to be approximately 0.005% per 1 mSv, according to the recognized linear calculation model, which is, however, likely only of limited suitability for this low-dose range (11).It follows that, in order to detect the 160 patients with aortic aneurysms in the SHRN database, it would be necessary to expect the induction of approximately 116 to 232 cases of cancer. Given these considerations and based on the current state of knowledge, population-wide screening using an age cutoff or similar criteria does not appear to be appropriate.

Patient groups with increased pretest probability

Conditions that increase the likelihood of a TAA have been described repeatedly in the medical literature (12); this is in principle confirmed by the analysis of the SHRN data relating to these entities (Tables 2 and 3). Further aneurysm investigations could be recommended in these closely defined patient groups, given that the introduction of targeted aneurysm screening would be more promising from a risk-benefit assessment perspective due to the increased pretest probability.

Genetic predisposition

About 15–20% of aortic aneurysms are not sporadic in nature, but are inherited family traits (13, 14). Apart from the well-known vascular connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome type IV, Loeys-Dietz syndrome), which typically present with a phenotype characteristic of the syndrome, a significant proportion of inherited aortic disorders are non-syndromic hereditary (13, 15, 16). Compared to patients with sporadic aneurysms, these patients typically present with more rapid disease progression (13, 14).

In the vast majority of cases, the trait is inherited in an autosomal dominant pattern, which means that, theoretically, there is a 50% risk of passing it on to offspring; however, its penetrance is incomplete (15).

A family history of aortic aneurysm should prompt further diagnostic work-up, bearing in mind that the definition of a positive family history varies widely. The European Reference Network on Rare Multisystemic Vascular Diseases defines a “positive family history” as follows: first-degree (parents, children) or second-degree (grandparents, siblings, grandchildren) relatives with an aortic pathology under the age of 70 years or sudden death without alternative etiology under the age of 45 years (15, 16). According to studies, first-degree kinship alone is associated with a significantly increased risk of developing an aneurysm (hazard ratio 6.7) or aortic dissection (HR 9.24), even if the exact genetic cause remains unknown (16, 17).

In patients with a family history of aneurysm, screening should be performed first with transthoracic echocardiography and, for aortic diameters of 45 mm or greater, followed up with cross-sectional imaging. Further genetic testing is recommended in patients with a positive family history (15, 16), as the screening intervals and intervention criteria can vary with the genetic variant (e4).

Bicuspid aortic valve

With a prevalence of 1–2%, bicuspid aortic valve (BAV) is the most common congenital heart defect in humans (Figure 1) (18). In many patients, BAV is associated with the premature onset of valve dysfunction and associated valvular cardiomyopathy. More than half of patients with BAV (50–70%) also present with a dilated thoracic aorta, a condition known as bicuspid aortopathy (19). Either a genetic defect in the aortic media, resulting in increased vulnerability of the proximal aorta, or hemodynamic-rheological factors, based on a highly eccentric or turbulent flow profile due to asymmetric opening of the valve pockets, appear to be causing this abnormality (20). In most patients, a combination of these two mechanisms plays a role. Clinically, two forms of aortopathy are distinguished, which differ based on the location of the aneurysm (21). The rarer, but malignant form of BAV aortopathy—the so-called root phenotype (approximately 15–20%)—occurs almost exclusively in young adult male patients and is primarily associated with genetic factors. The significantly more common form, the ascending aorta phenotype, mainly affects the tubular ascending aorta, beginning at the sinotubular junction, and is attributable to the hemodynamic effects of turbulent transvalvular blood flow. This form of aortopathy is characterized by slower progression and a lower complication rate (22). For the sake of completeness, a third hybrid form is defined that combines features of both: the “extended” phenotype.

Figure 1:

Bicuspid aortic valve of Sievers type 0; anteroposterior a) Intraoperative image b) Corresponding CT image

Screening for aortic dilation is indicated at the time of diagnosis using echocardiography and for dilations of 45 mm or greater or in cases of inconsistent echocardiographic findings using cross-sectional imaging (23). In young patients presenting with a root phenotype, this may be considered at an earlier stage. The reported frequency of familial clustering of congenital bicuspid aortic valve is approximately 9–10%; however, TAA may also occur more commonly in first-degree relatives without bicuspid aortic valve. Thus, an echocardiographic examination is also recommended for first-degree relatives (24).

Abdominal aortic aneurysm

With a prevalence of 1–2% among men aged 65 years and older, abdominal aortic aneurysm (AAA) is the most common form of aortic dilation (25). AAA rupture has an incidence of 0.4–0.67% in Western populations and is associated with high prehospital mortality (approximately 90%) and high in-hospital mortality (about 40%) (26). This extremely poor prognosis highlights the importance of early detection, based on the criteria mentioned above (27). The main diagnostic advantage compared to the thoracic aorta is that the abdominal aorta can be readily visualized using ultrasound, with no side effects and at a low cost.

One-time AAA screening as a statutory health insurance-covered early detection measure was introduced in Germany in 2018 for men aged 65 years and older. Data from the United Kingdom, Australia and Denmark provide clear evidence of the effectiveness of such screening programs, all of which have achieved a significant reduction in aneurysm-related deaths of 39–74 percent, while positively impacting long-term survival (e5–e8). Despite these well-documented successful screening programs, the AAA screening participation rate is currently less than 20 percent in Germany (28).

Concomitant thoracic aortic ectasia has been reported in just under half of all patients with AAA, and overt TAA in 7–30%, depending on the definition of an aneurysm (29, 30). Given that, according to the SHRN data, women account for about one-third of TAA diagnoses, they should also be screened for AAA. If an AAA is detected, it seems advisable to widen the screening to also include a TAA (Table 2).

Inflammatory conditions of the aorta (aortitis)

Large-vessel vasculitides, such as Takayasu arteritis and giant cell arteritis (GCA), can be associated with aortitis, as can numerous other immune-mediated diseases (eTable). Since GCA is the most common form of a vasculitis (lifetime risk of approximately 1% for women and 0.5% for men), we will focus here in particular on the involvement of the aorta in this disease.

eTable. Aortic involvement in immune-mediated diseases^*.

Classification	Disease
Primary large-vessel vasculitides	• Giant cell arteritis • Takayasu arteritis
Isolated aortitis	• Idiopathic • IgG4-related
Chronic periaortitis	• Idiopathic • IgG4-related • Drug-induced
Aortitis associated with rheumatic disease	• Ankylosing spondylitis • Cogan syndrome • Recurrent polychondritis • Behçet’s disease • Rheumatoid arthritis • Juvenile idiopathic arthritis • Systemic lupus erythematosus • Reiter’s syndrome • Polyarteritis nodosa • ANCA-associated vasculitis • Sarcoidosis

^*Adapted from (e12)

GCA occurs from the age of 50 years onward. The clinical picture is characterized by cranial symptoms such as headache, acute visual disturbances, arm claudication (rare), symptoms of polymyalgia rheumatica, or nonspecific constitutional symptoms. At the time of diagnosis, many cases already show evidence of extracranial artery involvement, most commonly of the thoracic aorta (58–85%), with a higher prevalence among patients diagnosed at a younger age (especially those aged 50 to 70 years) (Figures 2a, 2b) (31).

Figure 2:

Immune disease of the aorta

a) and b) computed tomography/positron emission tomography in active giant cell arteritis

c) and d) pan-aortic aneurysm resulting from aortitis

e) immunologically mediated aortic dissection

Structural damage to the aorta is a multifactorial late complication of the disease, resulting from inflammation-related weakening of the vessel wall (e.g., degradation of elastic fibers) and increased wall stiffness due to myointimal hyperplasia (32). Compared to the general population, the risk of developing a TAA is at least 2 to 3 times higher in people with GCA (Figures 2c–e) (33, 34); this risk is significantly increased by aortic involvement as well as persistent inflammation despite pharmacological treatment (35). In up to one-third of patients, a TAA is detected 10 years after the diagnosis of GCA (36). Conversely, active aortitis is noted in the surgical specimens of approximately 4–6% of patients with TAA (37, 38).

Thus, the European Alliance of Associations for Rheumatology recommends screening for structural changes in the aorta. However, the available data do not allow for recommendations to be made regarding details such as patient characteristics/risk profile, timing and imaging modalities; consequently, these must be determined on a case-by-case basis (39). Given that the occurrence of such changes increases significantly approximately five years after diagnosis, it seems appropriate to arrange for crosssectional imaging of the thoracic aorta at that time, at least in patients with confirmed extracranial (aortic) involvement (40).

Conservative treatment and recommendations

Reducing the cardiovascular risk profile, which includes the use of statins, forms the basis of conservative treatment for TAA, even though atherosclerotic changes play a rather minor role in this condition. The greatest impact on the TAA growth rate is achieved by consistent blood pressure control. A systolic blood pressure below 140 mmHg—or, better yet, below 120 mmHg—should be targeted. Even though limited data are available regarding the beneficial effects of beta-blockers or angiotensin receptor blockers, these drugs still appear to be appropriate as first-line treatments (23, e10). The use of systemic antithrombotic therapy or anticoagulation is not indicated.

In addition, recommendations regarding physical activity should be followed; a distinction is made here between dynamic (isotonic) and static (isometric) exercises. While engaging in low-to moderate-intensity dynamic sports 3 to 4 times a week is certainly recommended, static activities or exertions involving a Valsalva maneuver (such as weightlifting, sailing or rock climbing) should be avoided (2, e11). This also applies to contact sports.

Given that individual factors must be taken into account, it is not possible to provide a general recommendation regarding the frequency of follow-up examinations for TAA. After surgical treatment, follow-up examinations are required. They should be conducted at 12 and 24 months and may at times be necessary beyond that (2). In any case, involving a specialized aortic center or a designated specialized outpatient clinic in the care of these patients is strongly recommended (2, 23).

Questions on the article in issue 18/2026: Undiagnosed Thoracic Aortic Aneurysms

The submission deadline is 3 September 2027. Only one answer is possible per question.

Please select the answer that is most appropriate.

• Question 1

  What is the prevalence of thoracic aortic aneurysms in the general population estimated to be according to the article?

  1. < 0.5 cases/ 1 000 000
  2. 0.1–10 cases / 100 000
  3. 10–20 cases / 10 000
  4. 0.5 %
  5. Unknown

• Question 2

  Which imaging modality is particularly appropriate for younger patients at increased risk of a thoracic aortic aneurysm, since it does not involve radiation exposure?

  1. Digital subtraction angiography
  2. Magnetic resonance imaging
  3. Conventional chest radiograph
  4. Computed tomography angiography
  5. Transesophageal echocardiography

• Question 3

  What complications with high mortality rates can occur in patients with thoracic aortic aneurysm?

  1. Acute aortic syndrome (e.g., aortic dissection)
  2. Tension pneumothorax
  3. Pulmonary embolism
  4. Severe exacerbation of bronchial asthma
  5. Acute pericarditis

• Question 4

  What risks should be taken into account when using computed tomography angiography for the early detection of thoracic aortic aneurysm?

  1. About 40% of the scans yield false-positive results.
  2. About one in ten scans leads to unnecessary surgery.
  3. Thromboembolism occurs in about 5% of scans.
  4. It is difficult to distinguish between a thoracic aortic aneurysm and other aortic pathologies.
  5. About 1–2 cases of radiation-induced cancer occur per 2000 scans.

• Question 5

  Should population-wide screening for thoracic aortic aneurysms be recommended based on the current risk-benefit analysis?

  1. Population-wide screening using CT angiography is recommended given its high sensitivity.
  2. Population-wide screening using MRI is recommended as it involves no radiation exposure.
  3. Population-wide screening is not recommended according to current data.
  4. Population-wide screening is only appropriate for women over the age of 50 years..
  5. Population-wide screening is only appropriate for men over the age of 65 years.

• Question 6

  Which coincidental disease was associated with the highest adjusted odds ratio in the multivariate analysis of the Supraregional Health Service Research Network (SHRN)?

  1. Hypothyroidism
  2. Inguinal hernias
  3. Renal cysts
  4. Bicuspid aortic valve
  5. COVID-19

• Question 7

  Is there a genetic predisposition to aortic aneurysms?

  1. No, so far no genetic predisposition has been found.
  2. The findings in this regard are inconclusive.
  3. Yes, about 1–2% are hereditary.
  4. Yes, about 15–20% are hereditary.
  5. Yes, about 40–50% are hereditary.

• Question 8

  Which finding should trigger further diagnostic workup for thoracic aortic aneurysm?

  1. Abdominal aortic aneurysm
  2. Isolated arterial hypertension
  3. Coronary heart disease
  4. Atrial fibrillation without structural heart disease
  5. Chronic kidney disease (CKD) without vascular coincidental disease

• Question 9

  What conservative treatment is generally appropriate for thoracic aortic aneurysm?

  1. Systemic anticoagulation
  2. Strict blood pressure control is mandatory.
  3. Statins are contraindicated.
  4. Beta-blockers are clearly ineffective and not appropriate.
  5. Bronchodilator therapy must always be administered.

• Question 10

  What recommendations should be given to patients with a thoracic aortic aneurysm regarding physical activity?

  1. Static exercises with Valsalva maneuver are highly recommended.
  2. Contact sports and strength sports are fully recommended.
  3. Low-to moderate-intensity dynamic sports are recommended.
  4. Any physical activity should be avoided.
  5. Sailing and rock climbing have proven to be beneficial sports.