Impact of image analysis methodology on diagnostic and surgical classification of patients with thoracic aortic aneurysms

Background: For patients with thoracic aortic aneurysms (TAA), aortic size on imaging is widely used to guide clinical decision making. This study examined the impact of methodological variance on aortic quantification. Methods: We studied enrollees in the National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions. Aortic size on computed tomography was quantified by 2 linear methods; cross-sectional dimensions in axial (AX) and double oblique (DO) plane. Calculated area was compared to planimetry. Established cutoffs (area/height >10 cm²/m, diameter < 5cm) for prophylactic TAA repair were used to compare surgical eligibility by each method. Results: Fifty subjects were studied. Aortic size differed between AX and DO at all locations (p ≤ 0.001), with magnitude greatest at the sinotubular junction (4.8 ± 1.1 vs 4.0 ± 1.0 cm, p < 0.001). The difference between AX and DO correlated with aortic angular displacement (r = 0.37, p < 0.01), which was threefold larger at the sinotubular junction (37 ± 12 degrees) than the ascending aorta (12 ± 5 degrees; p < 0.001). At all locations, aortic area calculated using DO yielded smaller differences with planimetry than AX (p < 0.05). DO and planimetry yielded equal prevalence (24%) of subjects eligible for prophylactic TAA repair based on area-height cutoff, whereas AX prevalence was higher (44%; p = 0.006). Using a linear cutoff, AX yielded over a twofold greater prevalence of surgically eligible subjects (56%) than did DO (24%; p < 0.001). Conclusions: Established linear methods for aortic measurement yield different results that impact surgical eligibility. DO yielded improved agreement with planimetry and differed with AX in proportion to aortic geometric obliquity. Findings support DO measurements for imaging evaluation of subjects with TAA.