Listing 4.10 Aneurysm of Aorta or Major Branches in 2026: Dissection Not Controlled by Prescribed Treatment

By Anthony Albert, Benefits Research Director at Disability Exchange. Published July 9, 2026.

Listing 4.10 is one of the shortest and hardest listings in the Blue Book. It covers aneurysms of the aorta and its major branches, but only when there is dissection that is not controlled by prescribed treatment. That last phrase does a lot of work. Most people with an aortic aneurysm, even a large one, will not meet 4.10 on the aneurysm itself. They meet it only if the aneurysm is actively dissecting and treatment cannot stop the progression.

This article walks through the exact listing text, what counts as appropriate medically acceptable imaging, the specific SSA definition of dissection not controlled from Section 4.00H6, how conditions like Marfan syndrome and Ehlers-Danlos type IV fit in, and how aneurysm cases that fall short of 4.10 get routed to Listing 4.02 heart failure, 6.05 renal, or 11.04 stroke. Two real fact patterns show how it plays out.

The exact text of Listing 4.10

Two elements. First, the aneurysm has to be documented by appropriate imaging. Second, there has to be dissection not controlled by treatment. Both parts are needed. A big aneurysm on CT by itself is not enough.

What counts as "appropriate medically acceptable imaging"

SSA Section 4.00A3d defines this as: the technique used is the proper one to evaluate and diagnose the impairment and is commonly recognized as accurate for assessing the cited finding.

For aortic aneurysm, the accepted modalities are:

• CT angiography (CTA) of the chest, abdomen, or full aorta. The gold standard for outpatient assessment. Measures aneurysm diameter, extent, presence of dissection flap, and involvement of branch vessels.
• MR angiography (MRA) of the aorta. Useful for surveillance without radiation, particularly in Marfan and other connective tissue disease patients.
• Transesophageal echocardiography (TEE) for thoracic aortic assessment, particularly in acute settings.
• Aortography (conventional angiogram) when done as part of endovascular repair or diagnostic angiography.

Section 4.00B6 says SSA will not purchase cardiac catheterization studies for you. If your existing records include CTA, MRA, or aortography, those are used. If they do not, SSA is not going to order a chest CT for you. You need to bring the imaging.

Plain chest x-ray, standard transthoracic echo, and ultrasound of the abdominal aorta are useful for screening but typically not sufficient to define aneurysm size, branch involvement, or dissection extent for 4.10 purposes.

What "dissection not controlled by prescribed treatment" means

This is where 4.10 gets very specific. Section 4.00H6 of the Blue Book spells it out:

So "not controlled" means at least one of these three findings:

1. Persistence of chest pain due to progression of the dissection. This is not just any chest pain. It has to be pain that matches the anatomic course of the dissection and that persists despite treatment. Aortic dissection pain is classically described as sudden, sharp, tearing, radiating to the back. When it persists, that suggests ongoing extension of the intimal tear.
2. Increase in the size of the aneurysm. Serial imaging showing enlargement despite maximal medical therapy (beta blocker, ACE inhibitor, angiotensin receptor blocker for connective tissue disease patients) and blood pressure control. Rate of growth greater than 0.5 cm per 6 months is often used clinically as a threshold for concern.
3. Compression of one or more branches of the aorta supplying the heart, kidneys, brain, or other organs. This includes malperfusion of the coronary ostia, celiac axis, superior mesenteric artery, renal arteries, spinal arteries, or brachiocephalic vessels. Malperfusion can cause heart attack, gut ischemia, renal failure, paraplegia, or stroke depending on which vessel is compromised.

Section 4.00H6 also says: "If you have an aneurysm that does not meet the requirements of 4.10 and you have one or more of these associated conditions, we will evaluate the condition(s) using the appropriate listing." That is the escape hatch. If the aneurysm alone does not meet 4.10, but it has caused stroke, kidney failure, or heart failure, SSA evaluates those complications under their own listings.

Types of aortic aneurysm and dissection

4.10 does not care about the cause of the aneurysm. Atherosclerosis, cystic medial necrosis, Marfan syndrome, and trauma are all in the listing text as examples. What matters is documented imaging plus uncontrolled dissection. That said, the etiology matters for prognosis and treatment.

Atherosclerotic abdominal aortic aneurysm (AAA)

The most common cause of aortic aneurysm in adults over 60. Risk factors are smoking history, hypertension, male sex, and family history. Most AAAs are surveilled with ultrasound until they hit 5.5 cm in men or 5.0 cm in women, at which point elective repair is offered. AAAs that dissect are relatively uncommon because most are repaired before rupture. But dissections do happen, and when they do, 4.10 applies if not controlled.

Thoracic aortic aneurysm and dissection

Stanford Type A dissection involves the ascending aorta and is a surgical emergency. Type B dissection involves the descending aorta only and is initially managed medically. Persistent Type B dissection with false lumen expansion, malperfusion, or refractory pain despite anti-impulse therapy is exactly what 4.10 is describing.

Marfan syndrome and connective tissue disease

Marfan syndrome is a FBN1 mutation causing fibrillin-1 defects and progressive aortic root dilation. About 25 to 30 percent of Marfan patients develop aortic dissection. Standard care is beta blocker or angiotensin receptor blocker therapy and elective aortic root replacement at 5.0 cm diameter (4.5 cm in patients with family history of dissection or rapid growth). Loeys-Dietz syndrome (TGF-beta receptor mutations) and Ehlers-Danlos vascular type (COL3A1 mutations) have similar risk profiles and often more aggressive courses.

Traumatic aortic injury

Deceleration injury from motor vehicle collision or fall. Classically involves the aortic isthmus. Emergent repair is the norm.

When the aneurysm does not meet 4.10

Most aneurysm cases do not meet 4.10 directly because they are either not dissecting or the dissection is being controlled by treatment. That does not mean the case is over. Section 4.00H6 explicitly directs the adjudicator to evaluate associated complications under the appropriate listing.

Heart failure from aortic regurgitation

An ascending aortic aneurysm can distort the aortic valve and cause severe aortic regurgitation leading to heart failure. Evaluate under Listing 4.02 chronic heart failure.

Renal failure from renal artery compression

Dissection extending into the renal arteries can cause renovascular hypertension and acute or chronic kidney injury. Evaluate under Listing 6.05 chronic kidney disease.

Stroke from arch vessel involvement

Dissection involving the brachiocephalic or carotid arteries can cause ischemic stroke. Evaluate under Listing 11.04 vascular insult to the brain.

Peripheral vascular disease and gut ischemia

Malperfusion of the celiac axis and SMA can cause chronic mesenteric ischemia. Malperfusion of iliac arteries can cause claudication that would be evaluated under Listing 4.12 peripheral arterial disease.

Cardiac arrhythmia after aortic surgery

Post-op atrial fibrillation is common after ascending aortic repair. If it becomes chronic and symptomatic, evaluate under Listing 4.05 recurrent arrhythmias.

Worked example: Miguel, 58, Chicago, IL, Type B dissection with malperfusion

Worked example: Anna, 34, Atlanta, GA, Marfan syndrome

Blood pressure control and 4.10

Blood pressure management is the cornerstone of dissection care. Standard therapy is a beta blocker to reduce heart rate and shear stress on the aortic wall. Add-on agents include ARB (losartan is favored in Marfan patients based on the LOAT and other trials), calcium channel blocker, and diuretic. Targets are systolic BP less than 120 in acute dissection and less than 130 in chronic dissection.

If your BP is not controlled on maximum medical therapy and your aneurysm is growing, that is a strong 4.10 case. If your BP is well controlled and your aneurysm is stable, it is a hard 4.10 case regardless of the size.

Genetic testing and family history

Genetic confirmation of connective tissue disease strengthens your medical evidence even when 4.10 is not directly met.

• FBN1 for Marfan syndrome.
• TGFBR1 and TGFBR2 for Loeys-Dietz syndrome.
• COL3A1 for Ehlers-Danlos vascular type.
• ACTA2, MYH11, MYLK for familial thoracic aortic aneurysm and dissection.

Positive testing helps establish long-term risk, treatment restrictions, and medical necessity for ongoing surveillance. It also supports arguments for medical equivalence and for RFC restrictions on exertion, isometric loading, and stress.

What to bring to the initial claim

• CT angiography or MR angiography reports showing aneurysm location, size, and dissection extent.
• Serial imaging over at least 6 to 12 months if possible, to show progression or stability.
• Cardiology and vascular surgery notes documenting the treatment plan, medications, and response.
• Blood pressure logs.
• Genetic testing results if a heritable connective tissue disorder is suspected.
• Any records of endovascular or open surgical repair including operative reports.
• Post-op complications including arrhythmia, effusion, valve dysfunction, or renal impairment.
• Cardiologist RFC form addressing exertion tolerance, isometric restrictions, and environmental limits.

Common mistakes with 4.10 claims

1. Assuming a big aneurysm alone meets the listing. Size does not meet 4.10. Dissection not controlled by treatment does. A 6 cm ascending aneurysm that is stable and well controlled is not 4.10.
2. Not providing serial imaging. One CT does not show progression. SSA needs to see growth or stability over time. If your imaging is limited to one study, ask your cardiologist for prior comparison imaging.
3. Confusing surveillance restrictions with disability. An exercise restriction to less than 5 METs is a real limitation but it is not automatically listing-level. It has to be integrated with an RFC or equivalence argument.
4. Missing the branch vessel malperfusion angle. Element 3 of 4.00H6 is compression of branches supplying the heart, kidneys, brain, or other organs. If your dissection is causing renal impairment, coronary malperfusion, or bowel ischemia, spell that out in the medical evidence.
5. Filing after surgical repair without documenting pre-op dissection status. If your dissection was controlled before repair, and repair fixed it, 4.10 may no longer apply. Then the case has to rest on residuals under 4.02, 6.05, or others.

Frequently Asked Questions

Bottom line

Listing 4.10 is narrow on purpose. It exists to catch the small number of aortic aneurysm patients whose dissection is actively progressing despite maximum medical treatment. Most aneurysm cases do not meet 4.10 because either the aneurysm is not dissecting, or the dissection is being controlled by medication, or the aneurysm has been surgically repaired. When 4.10 does not apply, the case shifts to associated complications under other listings, to medical equivalence arguments, or to a Residual Functional Capacity determination.

The three elements of "not controlled" under Section 4.00H6 are persistent pain from progression, aneurysm size increase, and branch vessel compression causing organ dysfunction. Any one of them is enough. Serial imaging is the key evidence. One CT is not enough. Two CTs six months apart showing growth is exactly what SSA is looking for.

If you have a heritable connective tissue disorder, genetic testing strengthens the file. If you have had surgical or endovascular repair, the case usually pivots to residuals. Either way, the paper trail matters more than the diagnosis.