{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T12:07:14Z","timestamp":1779797234332,"version":"3.53.1"},"reference-count":33,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T00:00:00Z","timestamp":1779667200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Background: Immune dysregulation and clinical immunosuppression are biologically plausible contributors to thoracic aortic wall vulnerability through endothelial injury, protease-mediated extracellular matrix remodeling, vascular smooth muscle cell dysfunction, and impaired vascular repair. Yet, the clinical relevance of immunomodulated states to thoracic aortic aneurysm (TAA) incidence or growth and acute aortic syndromes remains undefined. Methods: This comprehensive review synthesizes clinical and translation evidence linking immunomodulated states in solid organ transplantation, autoimmune disease (predominantly systemic lupus erythematosus), HIV, and oncologic therapies to thoracic aortic dilation, aneurysmal progression, and acute aortic events. Principal Findings: Across transplant, autoimmune, and HIV cohorts, recurring themes include chronic immune dysregulation, endothelial dysfunction, proteolytic matrix remodeling, and impaired vascular repair capacity, although thoracic segment-specific longitudinal growth data remain limited and are often embedded within analyses of multiple vascular beds. In oncologic cohorts, aggregate analyses generally do not demonstrate uniform acceleration of aneurysm growth with malignancy or chemotherapy exposure, although agent-level models suggest that regimen-specific effects may be obscured in pooled estimates. Two studies most directly addressed our question in thoracic-relevant contexts reported (1) very low mean annual ascending aortic aneurysm growth (0.18 \u00b1 0.64 mm\/year) with no detectable association with chemotherapy or radiotherapy and (2) prior immunosuppressive\/cytostatic chemotherapy exposure to be common in a proximal TAA surgical cohort (39.3%) without a clear difference in thoracic phenotype at presentation or postoperative outcomes. In HIV cohorts, available evidence supports modest but reproducible proximal aortic remodeling and a clinically meaningful aneurysm burden across vascular beds, yet definitive thoracic segment-specific natural history data remain limited. Conclusions: The available literature supports clinical vigilance and exposure-aware surveillance, while suggesting that thoracic aortic risk is unlikely to be uniform across immunosuppressive and cytotoxic therapies. Standardized, segment-specific longitudinal imaging with granular agent-level exposure characterization (dose, duration, sequencing, and combination regimens), consistent definitions of baseline diameter and growth, careful adjustment for key confounders, and prospective ascertainment of dissection\/rupture and operative endpoints are needed to translate immunobiology into actionable risk stratification and long-term management strategies.<\/jats:p>","DOI":"10.3390\/jcdd13060224","type":"journal-article","created":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T11:57:44Z","timestamp":1779710264000},"page":"224","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A Comprehensive Review of Thoracic Aortic Disease in Immunosuppressed States: Clinical Signals, Mechanisms, and Implications for Surveillance"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-4589-6300","authenticated-orcid":false,"given":"Yashraj","family":"Srivastava","sequence":"first","affiliation":[{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4994-5908","authenticated-orcid":false,"given":"Korri","family":"Hershenhouse","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Medical Center, Bronx, NY 10467, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-2276-5656","authenticated-orcid":false,"given":"Isaac","family":"Faith","sequence":"additional","affiliation":[{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3085-9145","authenticated-orcid":false,"given":"Tanner","family":"Nelson","sequence":"additional","affiliation":[{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9295-3500","authenticated-orcid":false,"given":"Brandon E.","family":"Ferrell","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Medical Center, Bronx, NY 10467, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-0570-083X","authenticated-orcid":false,"given":"Ahren J.","family":"Alberto","sequence":"additional","affiliation":[{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4698-9814","authenticated-orcid":false,"given":"Tadahisa","family":"Sugiura","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic and Vascular Surgery, Montefiore-Einstein Medical Center, Bronx, NY 10467, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,25]]},"reference":[{"key":"ref_1","first-page":"1","article-title":"Incidence and Prevalence of Thoracic Aortic Aneurysms: A Systematic Review and Meta-analysis of Population-Based Studies","volume":"34","author":"Duarte","year":"2022","journal-title":"Semin. Thorac. Cardiovasc. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/S0003-4975(01)03236-2","article-title":"Yearly Rupture or Dissection Rates for Thoracic Aortic Aneurysms: Simple Prediction Based on Size","volume":"73","author":"Davies","year":"2002","journal-title":"Ann. Thorac. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e334","DOI":"10.1161\/CIR.0000000000001106","article-title":"2022 ACC\/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association\/American College of Cardiology Joint Committee on Clinical Practice Guidelines","volume":"146","author":"Isselbacher","year":"2022","journal-title":"Circulation"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Perone, F., Guglielmo, M., Coceani, M., La Mura, L., Dentamaro, I., Sabatino, J., and Gimelli, A. (2023). The Role of Multimodality Imaging Approach in Acute Aortic Syndromes: Diagnosis, Complications, and Clinical Management. Diagnostics, 13.","DOI":"10.3390\/diagnostics13040650"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"ezad426","DOI":"10.1093\/ejcts\/ezad426","article-title":"EACTS\/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ","volume":"65","author":"Czerny","year":"2024","journal-title":"Eur. J. Cardio-Thorac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1120","DOI":"10.1161\/CIRCULATIONAHA.107.702720","article-title":"Aortic Diameter \u22655.5 cm Is Not a Good Predictor of Type A Aortic Dissection: Observations From the International Registry of Acute Aortic Dissection (IRAD)","volume":"116","author":"Pape","year":"2007","journal-title":"Circulation"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/j.pcad.2013.04.002","article-title":"Pathophysiology of Thoracic Aortic Aneurysm (TAA): Is It Not One Uniform Aorta? Role of Embryologic Origin","volume":"56","author":"Ruddy","year":"2013","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1577","DOI":"10.1016\/S0140-6736(05)66459-8","article-title":"Abdominal Aortic Aneurysm","volume":"365","author":"Sakalihasan","year":"2005","journal-title":"Lancet"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1038\/s41392-023-01325-7","article-title":"The Mechanism and Therapy of Aortic Aneurysms","volume":"8","author":"Gao","year":"2023","journal-title":"Signal Transduct. Target. Ther."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"107558","DOI":"10.1016\/j.vph.2025.107558","article-title":"Emerging Role of the Adaptive Immunity in Aortic Aneurysm and Dissection","volume":"161","author":"Hu","year":"2025","journal-title":"Vasc. Pharmacol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1055\/s-0040-1721675","article-title":"Immunosuppressive Agents and Thoracic Aortic Aneurysm: Real Correlation or Mere Coincidence?","volume":"70","author":"Ostovar","year":"2022","journal-title":"Thorac. Cardiovasc. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"268.e13","DOI":"10.1016\/j.avsg.2017.07.013","article-title":"Effects of Chemotherapy in Patients with Concomitant Aortic Aneurysm and Malignant Disease","volume":"45","author":"Leopardi","year":"2017","journal-title":"Ann. Vasc. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2924","DOI":"10.1093\/eurheartj\/ehab348","article-title":"HIV Infection Is Associated with Thoracic and Abdominal Aortic Aneurysms: A Prospective Matched Cohort Study","volume":"42","author":"Pham","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"665","DOI":"10.1177\/0961203314523868","article-title":"Incidence and Risk Analysis of Aortic Aneurysm and Aortic Dissection Among Patients with Systemic Lupus Erythematosus: A Nationwide Population-Based Study in Taiwan","volume":"23","author":"Wang","year":"2014","journal-title":"Lupus"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e023997","DOI":"10.1161\/JAHA.121.023997","article-title":"Association of HIV Serostatus and Inflammation with Ascending Aortic Size","volume":"11","author":"Minhas","year":"2022","journal-title":"J. Am. Heart Assoc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1177\/1358863X221122577","article-title":"Association of HIV Infection with Clinical Features and Outcomes of Patients with Aortic Aneurysms","volume":"27","author":"Chehab","year":"2022","journal-title":"Vasc. Med."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Gr\u00f8nb\u00e6k, S.K., H\u00f8gh, J., Knudsen, A.D., Pham, M.H.C., Sigvardsen, P.E., Fuchs, A., K\u00fchl, J.T., K\u00f8ber, L., Gerstoft, J., and Benfield, T. (2023). Aortic Aneurysms and Markers of Platelet Activation, Hemostasis, and Endothelial Disruption in People Living with HIV. Front. Immunol., 14.","DOI":"10.3389\/fimmu.2023.1115894"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1016\/j.avsg.2020.06.042","article-title":"Patient Characteristics, Patterns, and Repair of Aneurysms in Human Immunodeficiency Virus-Positive Patients","volume":"70","author":"Kim","year":"2021","journal-title":"Ann. Vasc. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.carpath.2010.01.003","article-title":"Aortic Aneurysms in Systemic Lupus Erythematosus: A Meta-analysis of 35 Cases in the Literature and Two Different Pathogeneses","volume":"20","author":"Kurata","year":"2011","journal-title":"Cardiovasc. Pathol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1007\/s10067-021-05927-w","article-title":"Prevalence, Clinical Features, Risk Factors, and Outcomes of SLE Patients with Aortic Aneurysm: A Cross-Sectional Retrospective Study in a Chinese Single Center","volume":"41","author":"Zhang","year":"2021","journal-title":"Clin. Rheumatol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"594","DOI":"10.1016\/j.jvs.2013.09.049","article-title":"Aneurysms in Abdominal Organ Transplant Recipients","volume":"59","author":"Cron","year":"2014","journal-title":"J. Vasc. Surg."},{"key":"ref_22","first-page":"287","article-title":"Aortic Root Dilation in Kidney Transplant Recipients","volume":"128","author":"Obremska","year":"2018","journal-title":"Pol. Arch. Intern. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1016\/j.avsg.2020.08.137","article-title":"Aortic Aneurysm Natural Progression Is Not Influenced by Concomitant Malignancy and Chemotherapy","volume":"71","author":"Maxwell","year":"2021","journal-title":"Ann. Vasc. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1016\/j.jvs.2014.06.123","article-title":"The Effect of Chemotherapy for Malignancy on the Natural History of Aortic Aneurysm","volume":"61","author":"Martin","year":"2015","journal-title":"J. Vasc. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1024\/0301-1526\/a001038","article-title":"Cancer, Cancer Treatment and Aneurysmatic Ascending Aorta Growth within a Retrospective Single Center Study","volume":"52","author":"Kobus","year":"2023","journal-title":"Vasa"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1502","DOI":"10.7150\/ijms.54423","article-title":"The Effect of Immunosuppressive Drugs on MMPs Activity in the Walls of Blood Vessels\u2014A Systematic Review","volume":"18","author":"Wilk","year":"2021","journal-title":"Int. J. Med. Sci."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.jss.2014.03.027","article-title":"Matrix Metalloproteinase Levels in Chronic Thoracic Aortic Dissection","volume":"189","author":"Zhang","year":"2014","journal-title":"J. Surg. Res."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1067\/mva.2000.105665","article-title":"Acute Enlargement and Subsequent Rupture of an Abdominal Aortic Aneurysm in a Patient Receiving Chemotherapy for Pancreatic Carcinoma","volume":"32","author":"Palm","year":"2000","journal-title":"J. Vasc. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1774","DOI":"10.1253\/circj.CJ-16-0902","article-title":"Oral Steroid Use and Abdominal Aortic Aneurysm Expansion\u2014Positive Association","volume":"81","author":"Tajima","year":"2017","journal-title":"Circ. J."},{"key":"ref_30","first-page":"270","article-title":"Aortic Aneurysm in Patients with Autoimmune Diseases Treated with Corticosteroids","volume":"19","author":"Ohara","year":"2000","journal-title":"Int. Angiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2110","DOI":"10.1056\/NEJMra1100359","article-title":"Systemic Lupus Erythematosus","volume":"365","author":"Tsokos","year":"2011","journal-title":"N. Engl. J. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1007\/s12026-012-8345-z","article-title":"Linking Complement and Anti-dsDNA Antibodies in the Pathogenesis of Systemic Lupus Erythematosus","volume":"55","author":"Giles","year":"2013","journal-title":"Immunol. Res."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1016\/j.avsg.2019.01.016","article-title":"Many Different Patterns under a Common Flag: Aortic Pathology in HIV\u2014A Review of Case Reports in Literature","volume":"59","author":"Silvestri","year":"2019","journal-title":"Ann. Vasc. Surg."}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/6\/224\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T11:41:28Z","timestamp":1779795688000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/6\/224"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,25]]},"references-count":33,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jcdd13060224"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13060224","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,25]]}}}