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2010 ACCF/AHA/AATS/ACR/ASA/
SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and
Management of Patients with
Thoracic Aortic Disease


 Circulation. 2010;121:e266-e369.
Classification of Recommendations
Class I                  Class IIa                  Class IIb                  Class III

Benefit >>> Risk         Benefit >> Risk            Benefit ≥ Risk             Risk ≥ Benefit
                         Additional studies with    Additional studies with    No additional studies
                         focused objectives         broad objectives           needed
                         needed                     needed; Additional
                                                    registry data would be     Procedure/Treatment
Procedure/ Treatment     IT IS REASONABLE           helpful                    should NOT be
SHOULD be                to perform                                            performed/administered
performed/               procedure/administer       Procedure/Treatment        SINCE IT IS NOT
administered             treatment                  MAY BE                     HELPFUL AND MAY
                                                    CONSIDERED                 BE HARMFUL

 Alternative Phrasing:
should                   is reasonable              may/might be considered    is not recommended
is recommended           can be useful/effective/   may/might be reasonable    is not indicated
is indicated               beneficial               usefulness/effectiveness   should not
is useful/effective/     is probably                 is unknown/unclear/       is not
  beneficial               recommended or            uncertain or not well       useful/effective/beneficial
                           indicated                 established               may be harmful
Applying Classification of
       Recommendations and Level of Evidence
 Class I                  Class IIa                 Class IIb                  Class III

 Benefit >>> Risk         Benefit >> Risk           Benefit ≥ Risk             Risk ≥ Benefit
                          Additional studies        Additional studies with    No additional studies
                          with focused              broad objectives           needed
                          objectives needed         needed; Additional
                                                    registry data would be     Procedure/Treatment
 Procedure/               IT IS REASONABLE          helpful                    should NOT be
 Treatment SHOULD         to perform                                           performed/administered
 be performed/            procedure/administer      Procedure/Treatment        SINCE IT IS NOT
 administered             treatment                 MAY BE                     HELPFUL AND MAY BE
                                                    CONSIDERED                 HARMFUL
Level of Evidence:
 Level A:    Data derived from multiple randomized clinical trials or meta-analyses
             Multiple populations evaluated;
 Level B:    Data derived from a single randomized trial or nonrandomized studies
             Limited populations evaluated
 Level C:    Only consensus of experts opinion, case studies, or standard of care
             Very limited populations evaluated
Critical Issues for Thoracic Aortic Diseases

As the writing committee developed this TAD
  guideline, several critical issues emerged:
• Thoracic aortic diseases (TADs) are usually
  asymptomatic and not easily detectable until an acute
  and often catastrophic complication occurs.
• The identification and treatment of stable patients at risk
  for acute and catastrophic disease presentations (eg,
  thoracic aortic dissection (AoD) and thoracic aneurysm
  rupture) prior to such an occurrence are paramount to
  eliminating the high morbidity and mortality associated
  with acute presentations.
• Imaging of the thoracic aorta is the only method to detect
  thoracic aortic diseases and determine risk for future
  complications.
Critical Issues for TADs
• A subset of patients with acute AoD are subject to
  missed or delayed detection of this catastrophic disease
  state.
   – Many present with atypical symptoms and findings,
     making diagnosis even more difficult.
   – Widespread awareness of the varied and complex
     nature of TAD presentations has been lacking,
     especially for acute AoD.
Guidelines for Thoracic Aortic Disease




 Recommendations for Aortic Imaging
 Techniques to Determine the Presence
 and Progression of Thoracic Aortic
 Disease
Recommendations for Aortic Imaging Techniques to
 Determine the Presence and Progression of TAD

I IIa IIb III   Measurements of aortic diameter should be
                taken at reproducible anatomic landmarks,
                perpendicular to the axis of blood flow, and
                reported in a clear and consistent.

                For measurements taken by CT imaging or MRI,
                the external diameter should be measured
I IIa IIb III   perpendicular to the axis of blood flow. For
                aortic root measurements, the widest diameter,
                typically at the mid-sinus level, should be used.
Recommendations for Imaging Techniques to
    Determine the Presence and Progression of TAD


I IIa IIb III   For measurements taken by echocardiography,
                the internal diameter should be measured
                perpendicular to the axis of blood flow. For
                aortic root measurements, the widest diameter,
                typically at the mid-sinus level, should be used.

I IIa IIb III   Abnormalities of aortic morphology should be
                recognized and reported separately even when
                aortic diameters are within normal limits.
Recommendations for Imaging Techniques to
   Determine the Presence and Progression of TAD


I IIa IIb III   The finding of aortic dissection, aneurysm,
                traumatic injury and/or aortic rupture should be
                immediately communicated to the referring
                physician.

I IIa IIb III   Techniques to minimize episodic and cumulative
                radiation exposure should be utilized whenever
                possible.

I IIa IIb III   If clinical information is available, it can be
                useful to relate aortic diameter to the patient’s
                age and body size.
Essential Elements of Aortic Imaging Reports
      The following table outlines specific qualitative and quantitative elements that
      are important to include in CT and MR reports
 1.     The location at which the aorta is abnormal.
 2.     The maximum diameter of any dilatation, measured from the external wall of the
        aorta, perpendicular to the axis of flow, and the length of the aorta that is abnormal.
 3.     For patients with presumed or documented genetic syndromes at risk for aortic root
        disease measurements of aortic valve, sinuses of Valsalva, sinotubular junction,
        and ascending aorta.
 4.     The presence of internal filling defects consistent with thrombus or atheroma.
 5.     The presence of intramural hematoma (IMH), penetrating atherosclerotic ulcer
        (PAU), and calcification.
 6.     Extension of aortic abnormality into branch vessels, including dissection and
        aneurysm, and secondary evidence of end-organ injury (eg, renal or bowel
        hypoperfusion).
 7.     Evidence of aortic rupture, including periaortic and mediastinal hematoma,
        pericardial and pleural fluid, and contrast extravasation from the aortic lumen.
 8.     When a prior examination is available, direct image to image comparison to
        determine if there has been any increase in diameter.
Note: This is Table 5 in the full-text version of the TAD Guideline
Guidelines for Thoracic Aortic Disease



Recommendations for Initial Evaluation
 and Management of Acute Thoracic
 Aortic Disease
Recommendations for Estimation of
 Pretest Risk of Thoracic Aortic Dissection

I IIa IIbIII   Providers should routinely evaluate any patient presenting
               with complaints that may represent acute thoracic aortic
               dissection to establish a pretest risk of disease that can
               then be used to guide diagnostic decisions. This process
               should include specific questions about:

                      • medical history
                      • family history
                      • pain features

               This process should also include a focused examination
               to identify findings that are associated with aortic
               dissection (outlined in the next 3 slides).
Estimation of Pretest Risk of
    Thoracic Aortic Dissection
                  High Risk Conditions
            • Marfan Syndrome                         1
            • Connective tissue disease*
            • Family history of aortic disease
            • Known aortic valve disease
            • Recent aortic manipulation (surgical or
              catheter-based)
            • Known thoracic aortic aneurysm
            • Genetic conditions that predispose to AoD†
* Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or
    other connective tissue disease.
†Patients with mutations in genes known to predispose to thoracic aortic
   aneurysms and dissection, such as FBN1, TGFBR1, TGFBR2, ACTA2, and
   MYH11.
Estimation of Pretest Risk of
Thoracic Aortic Dissection


         High Risk Pain Features                 2
  Chest, back, or abdominal pain features
  described as pain that:
  • is abrupt or instantaneous in onset.
  • is severe in intensity.
  • has a ripping, tearing, stabbing, or sharp
    quality.
Estimation of Pretest Risk of Thoracic
Aortic Dissection

       High Risk Examination Features           3
     • Pulse deficit
     • Systolic BP limb differential > 20mm Hg
     • Focal neurologic deficit
     • Murmur of aortic regurgitation (new or not
       known to be old and in conjunction with pain)
Recommendations for Estimation of
    Pretest Risk of Thoracic Aortic Dissection


I IIa IIb III   Patients presenting with sudden onset of severe
                chest, back, and/or abdominal pain, particularly
                those less than 40 years of age, should be
                questioned about a history and examined for
                physical features of Marfan syndrome, Loeys-
                Dietz syndrome, vascular Ehlers-Danlos
                syndrome, Turner syndrome, or other connective
                tissue disorder associated with thoracic aortic
                disease.
Recommendations for Estimation of
    Pretest Risk of Thoracic Aortic Dissection

I IIa IIb III   Patients presenting with sudden onset of severe
                chest, back, and/or abdominal pain should be
                questioned about a history of aortic pathology in
                immediate family members as there is a strong
                familial component to acute thoracic aortic
                disease.

I IIa IIb III   Patients presenting with sudden onset of severe
                chest, back, and/or abdominal pain should be
                questioned about recent aortic manipulation
                (surgical or catheter-based) or a known history of
                aortic valvular disease, as these factors
                predispose to acute aortic dissection.
Recommendations for Estimation of
    Pretest Risk of Thoracic Aortic Dissection

I IIa IIb III   In patients with suspected or confirmed aortic
                dissection who have experienced a syncopal
                episode, a focused examination should be
                performed to identify associated neurologic injury
                or the presence of pericardial tamponade.

I IIa IIb III   All patients presenting with acute neurologic
                complaints should be questioned about the
                presence of chest, back, and/or abdominal pain
                and checked for peripheral pulse deficits as
                patients with dissection-related neurologic
                pathology are less likely to report thoracic pain
                than the typical aortic dissection patient.
Risk-based Diagnostic Evaluation:
 Patients with Low Risk of TAD
Patients with no high-risk features of TAD present are considered at
low risk for TAD. The following clinical steps are recommended for low-risk
TAD patients:

                                                   Expedited aortic imaging
    Proceed with diagnostic               •   TEE (preferred if clinically unstable)
     evaluation as clinically             •   CT scan (image entire aorta: chest to pelvis)
   indicated by presentation.             •   MR (image entire aorta: chest to pelvis)

         Yes                                             Yes

     Alternative diagnosis      No       Unexplained
          identified?                    hypotension or widened
                                         mediastinum on CXR?
          Yes
                                                         No
      Initiate appropriate
            Therapy.                     Consider aortic imaging study for TAD based on
                                     clinical scenario (particularly in patients with advanced
                                           age, risk factors for aortic disease, or syncope)
Risk-based Diagnostic Evaluation:
   Patients with Intermediate Risk of TAD
The following steps for patients with intermediate risk of TAD should be
  followed when any single high-risk feature is present.
                                                   Likely primary ACS. In absence of other
            EKG consistent           Yes
                                                     perfusion deficits, strongly consider
             with STEMI?
                                                 immediate coronary re-perfusion therapy. If
                No                               PTCA performed, is culprit lesion identified?
            CXR with clear                 Yes
         Alternate diagnosis?
                                                          Initiate appropriate therapy.
                No
                                                    Yes
    History and physical exam strongly                            Alternate diagnosis
 suggestive of specific alternate diagnosis?                 confirmed by further testing?

           No
                                Expedited aortic imaging
                                                                                    No
                     •   TEE (preferred if clinically unstable)
                     •   CT scan (image entire aorta: chest to pelvis)
                     •   MR (image entire aorta: chest to pelvis)
Risk-based Diagnostic Evaluation:
 Patients with High Risk of TAD
Patients at high-risk for TAD are those that present with at least 2
  high-risk features (outlined in more detail in the following slides).

The recommended course of action for high-risk TAD patients is to
  seek immediate surgical consultation and arrange for expedited
  aortic imaging.

                          Expedited aortic imaging

                •   TEE (preferred if clinically unstable)
                •   CT scan (image entire aorta: chest to pelvis)
                •   MR (image entire aorta: chest to pelvis)
Risk Factors for Development of
         Thoracic Aortic Dissection
   Conditions Associated With Increased Aortic Wall Stress

   • Hypertension, particularly if uncontrolled
   • Pheochromocytoma
   • Cocaine or other stimulant use
   • Weight lifting or other Valsalva maneuver
   • Trauma
   • Deceleration or torsional injury (eg, motor vehicle crash,
     fall)
   • Coarctation of the aorta


Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
Risk Factors for Development of
         Thoracic Aortic Dissection
   Conditions Associated With Aortic Media Abnormalities

   Genetic
   • Marfan syndrome
   • Ehlers-Danlos syndrome, vascular form
   • Bicuspid aortic valve (including prior aortic valve
     replacement)
   • Turner syndrome
   • Loeys-Dietz syndrome
   • Familial thoracic aortic aneurysm and dissection
     syndrome

Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
Risk Factors for Development of
           Thoracic Aortic Dissection
     Conditions Associated With Aortic Media Abnormalities
     (continued)

     Inflammatory vasculitides
     • Takayasu arteritis
     • Giant cell arteritis
     • Behçet arteritis

     Other
     • Pregnancy
     • Autosomal dominant polycystic kidney disease
     • Chronic corticosteroid or immunosuppression agent
       administration
     • Infections involving the aortic wall either from bacteremia or
       extension of adjacent infection
Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
Aortic Dissection Classification:
     DeBakey and Stanford Classifications




Note: Figure 20 in full-text version of TAD Guidelines. Reprinted with permission from The Cleveland Clinic
    Foundation.
Recommendations for Screening Tests


I IIa IIb III   An ECG should be obtained on all
                patients who present with symptoms that may
                represent acute thoracic aortic dissection.
                    Given the relative infrequency of dissection-
                    related coronary artery occlusion, the
                    presence of STEMI should be treated as a
                    primary cardiac event without delay for
                    definitive aortic imaging unless the patient is
                    at high risk for aortic dissection.
Recommendations for Screening Tests

I IIa IIb III   The role of CXR in the evaluation of
                possible thoracic aortic disease should be
                directed by the patient’s pretest risk of disease as
                follows.
                • Intermediate risk: CXR should be performed on
                   all intermediate-risk patients, as it may establish
                   a clear alternate diagnosis that will obviate the
                   need for definitive aortic imaging.
                • Low risk: CXR should be performed on all low-
                   risk patients, as it may either establish an
                   alternative diagnosis or demonstrate findings
                   that are suggestive of thoracic aortic disease,
                   indicating the need for urgent definitive aortic
                   imaging.
Recommendations for Screening Tests


I IIa IIb III   Urgent and definitive imaging of the aorta using
                TEE, CT imaging, or MRI is recommended to
                identify or exclude thoracic aortic dissection in
                patients at high risk for the disease by initial
                screening.

                A negative CXR should not delay definitive
I IIa IIb III   aortic imaging in patients determined to be high
                risk for aortic dissection by initial screening.
Recommendations for Initial Management
Initial management of thoracic aortic dissection should be
directed at decreasing aortic wall stress by controlling heart
rate and blood pressure as follows:

 I IIa IIb III   a. In the absence of contraindications,
                    intravenous beta blockade should be
                    initiated and titrated to a target heart rate of
                    60 beats per minute or less.

 I IIa IIb III   b. In patients with clear contraindications to
                    beta blockade, non-dihydropyridine calcium
                    channel–blocking agents should be used as
                    an alternative for rate control.
Recommendations for Initial Management

I IIa IIb III    c. If SBP > 120mm Hg after adequate heart rate
                    control has been obtained, then ACEIs and/or
                    other vasodilators should be administered
                    intravenously to further reduce BP that
                    maintains adequate end-organ perfusion.

                 d. Beta blockers should be used cautiously in the
                    setting of acute aortic regurgitation because
 I IIa IIb III      they will block the compensatory tachycardia.
Recommendations for Initial Management

 I IIa IIb III   Vasodilator therapy should not be initiated
                 prior to rate control so as to avoid associated
                 reflex tachycardia that may increase aortic
                 wall stress, leading to propagation or
                 expansion of a thoracic aortic dissection.
Acute AoD Management Pathway

STEP 1: Immediate post-diagnosis management and
       disposition considerations

   •   Arrange for definitive management:
          – Appropriate surgical consultation
          – Inter-facility transfer if indicated based on
          institutional capabilities

   •   If transfer required, initiate aggressive medical
       management until transfer occurs.
Acute AoD Management Pathway


STEP 2: Initial management of aortic wall stress

   • Obtain accurate BP prior to beginning treatment.
   • Measure in both arms.
   • Base treatment goals on highest BP reading.
Acute AoD Management Pathway
STEP 2: Initial management of aortic wall stress
   Intravenous rate and pressure control
                                                       No    Hypotension
      Rate/Pressure Control
                                          1                 or shock state?
       Intravenous beta blockade
             or Labetalol
    (If contraindication to beta blockade                                 Yes
      substitute diltiazem or verapamil)
          Titrate to heart rate <60
                      +
                                                       Anatomic based management
            Pain Control
                                      2
          Intravenous opiates
         Titrate to pain control

         Systolic BP >120mm HG?
         Secondary pressure control
                 BP Control
          Intravenous vasodilator                  3
 Titrate to BP <120mm HG (Goal is lowest possible
 BP that maintains adequate end organ perfusion)
Acute AoD Management Pathway
STEP 2: Initial management of aortic wall stress

                        Anatomic based management

        Type A dissection                        Type B dissection

 1   Urgent surgical consultation        1    Intravenous fluid bolus
                +                             •Titrate to MAP of 70mm HG
      Arrange for expedited                           or Euvolemia
     operative management                     (If still hypotensive begin
                                         intravenous vasopressor agents)
     Intravenous fluid bolus
2                                            Evaluate etiology of
       •Titrate to MAP of 70mm HG       2
             or Euvolemia                    hypotension
   (If still hypotensive begin               • Review imaging study for
intravenous vasopressor agents)                evidence of contained rupture
                                             • Consider TTE to evaluate
     Review imaging study for:                 cardiac function
3    • Pericardial tamponade
     • Contained rupture                3    Urgent surgical consultation
     • Severe aortic insufficiency
Acute AoD Management Pathway

STEP 3: Definitive management

   • Depending on the results from the pressure control or
     anatomic based management, continued treatment
     will involve either:
      – ongoing medical management, or
      – operative or interventional management.
Acute AoD Management Pathway
    STEP 3: Definitive management
Based on results from intravenous                        Based on results from anatomic
rate and pressure control:                               based management:
                                           No
     Dissection involving                                        Etiology of hypotension
    the ascending aorta?                                         Amenable to operative
                                                                      management?
                             Ongoing medical management
                             Close hemodynamic monitoring
                             Maintain systolic BP < 120mm Hg
                                 (Lowest BP that maintains
                                    end organ perfusion)




    Operative or             Complications requiring operative             Operative or
                              or interventional management?
   interventional      Yes                                       Yes      interventional
                                Limb or mesenteric ischemia
   management                                                             management
                                  Progression of dissection
                                    Aneurysm expansion
                                 Uncontrolled hypertension
Acute AoD Management Pathway

     STEP 4: Transition to outpatient management and
            disease surveillance

              • If no complications present requiring operative or
                interventional management, transition to:
                   – Oral medications (beta blockade/ anti-
                     hypertensives regimen)
                   – Outpatient disease surveillance imaging




Note: For full algorithm, see Figure 26 in full-text version of TAD Guidelines
Recommendations for Definitive Management

 I IIa IIb III   Urgent surgical consultation should be obtained
                 for all patients diagnosed with thoracic aortic
                 dissection regardless of the anatomic location
                 (ascending versus descending) as soon as the
                 diagnosis is made or highly suspected.

 I IIa IIb III   Acute thoracic aortic dissection involving the
                 ascending aorta should be urgently evaluated
                 for emergent surgical repair because of the high
                 risk of associated life-threatening complications
                 such as rupture.
Recommendations for Definitive Management

 I IIa IIb III   Acute thoracic aortic dissection involving the
                 descending aorta should be managed medically
                 unless life-threatening complications develop
                 (ie, malperfusion syndrome, progression of
                 dissection, enlarging aneurysm, inability to
                 control blood pressure or symptoms).
Guidelines for Thoracic Aortic Disease




  Recommendation for Surgical
  Intervention for Acute Thoracic Aortic
  Dissection
Recommendation for Surgical Intervention for
Acute Thoracic Aortic Dissection


I IIa IIb III   For patients with ascending thoracic aortic
                dissection, all aneurysmal aorta and the proximal
                extent of the dissection should be resected. A
                partially dissected aortic root may be repaired
                with aortic valve resuspension. Extensive
                dissection of the aortic root should be treated
                with aortic root replacement with a composite
                graft or with a valve sparing root replacement. If
                a DeBakey Type II dissection is present, the
                entire dissected aorta should be replaced.
Acute Surgical Management Pathway for AoD

  The following steps outline ascending TAD by
    imaging study.

  STEP 1: Determine patient suitability for surgery
     • If not suitable, begin medical management.


  STEP 2: Determine stability for pre-op testing

     • If not sufficiently stable, proceed with urgent
       operative management.
Acute Surgical Management Pathway for AoD
  STEP 3: Determine likelihood of coexistent CAD

                           Yes           Assess need for
     Is patient age >40?              preoperative coronary
                                          angiography
                                                   Yes

          No                          • Known CAD?
                                      • Significant risk factors
                           No           for CAD?
                                                   Yes

      Urgent operative       No        Significant CAD by
       management                        angiography?
                                                   Yes

                                         Plan for CABG if
                                        appropriate at time
                                          of AoD repair
Acute Surgical Management Pathway for AoD
  STEP 4: Intra-operative evaluation of aortic valve

         • Perform intra-operative assessment of aortic valve by
           TEE.                   Aortic Regurgitation?
                                                                      or
                                                        Dissection of aortic sinuses?


                                                               Yes                      No
  STEP 5: Surgical
  intervention     Graft replacement
                                     of ascending aorta
                                                                                  Graft replacement
                                        +/- aortic arch
                                                                                  of ascending aorta
                                              and
                                     repair/ replacement                             +/- aortic arch
                                        of aortic valve

Note: For full algorithm, see Figure 22 in full-text version of TAD Guidelines.
Guidelines for Thoracic Aortic Disease




  Recommendation for Intramural
  Hematoma Without Intimal Defect
Recommendation for Intramural
 Hematoma Without Intimal Defect



I IIa IIb III   It is reasonable to treat intramural hematoma
                similar to aortic dissection in the corresponding
                segment of the aorta.
Guidelines for Thoracic Aortic Disease




Recommendation for History and Physical
Examination for Thoracic Aortic Disease
Recommendation for History and
Physical Exam for TAD

I IIa IIb III   For patients presenting with a history of acute
                cardiac and noncardiac symptoms associated
                with a significant likelihood of thoracic aortic
                disease, the clinician should perform a focused
                physical examination, including a careful and
                complete search for arterial perfusion
                differentials in both upper and lower extremities,
                evidence of visceral ischemia, focal neurologic
                deficits, a murmur of aortic regurgitation, bruits,
                and findings compatible with possible cardiac
                tamponade.
Guidelines for Thoracic Aortic Disease



  Recommendations for General Medical
  Treatment and Risk Factor Management
  for Patients with Thoracic Aortic Diseases
Recommendation for Medical
Treatment of patients with TAD

I IIa IIb III   Stringent control of hypertension, lipid profile
                optimization, smoking cessation, and other
                atherosclerosis risk-reduction measures should
                be instituted for patients with small aneurysms
                not requiring surgery, as well as for patients who
                are not considered to be surgical or stent graft
                candidates.
Recommendations for Blood Pressure Control

 I IIa IIb III   Antihypertensive therapy should be
                 administered to hypertensive patients with
                 thoracic aortic diseases to achieve a goal of less
                 than 140/90 mmHg (patients without DM) or less
                 than 130/80 mm Hg (patients with DM or CKD)
                 to reduce the risk of stroke, MI, HF, and
                 cardiovascular death.

                 Beta adrenergic–blocking drugs should be
 I IIa IIb III   administered to all patients with Marfan
                 syndrome and aortic aneurysm to reduce the
                 rate of aortic dilatation unless contraindicated.
Recommendations for Blood Pressure Control

 I IIa IIb III   For patients with thoracic aortic aneurysm, it is
                 reasonable to reduce BP with beta blockers and
                 ACEIs or ARB to the lowest point patients can
                 tolerate without adverse effects.

 I IIa IIb III   An ARB (losartan) is reasonable for patients with
                 Marfan syndrome, to reduce the rate of aortic
                 dilatation unless contraindicated.
Guidelines for Thoracic Aortic Disease




   Recommendations for Asymptomatic
   Patients with Ascending Aortic Aneurysm
Recommendations for Asymptomatic Patients
 with Ascending Aortic Aneurysm

I IIa IIb III   Asymptomatic patients with degenerative thoracic
                aneurysm, chronic aortic dissection, intramural
                hematoma, penetrating atherosclerotic ulcer,
                mycotic aneurysm, or pseudoaneurysm, who are
                otherwise suitable candidates and for whom the
                ascending aorta or aortic sinus diameter > 5.5 cm,
                should be evaluated for surgical repair.

I IIa IIb III   Patients with Marfan syndrome or other genetically
                mediated disorders (vascular Ehlers-Danlos
                syndrome, Turner syndrome, bicuspid aortic valve,
                or familial thoracic aortic aneurysm and dissection)
                should undergo elective operation at smaller
                diameters (4.0 to 5.0 cm depending on the
                condition) to avoid acute dissection or rupture.
Recommendations for Asymptomatic Patients
 with Ascending Aortic Aneurysm

I IIa IIb III   Patients with a growth rate > 0.5 cm/y in an aorta
                that is less than 5.5 cm in diameter should be
                considered for operation.

I IIa IIb III   Patients undergoing aortic valve repair or
                replacement and who have an ascending aorta or
                aortic root of greater than 4.5 cm should be
                considered for concomitant repair of the aortic
                root or replacement of the ascending aorta.
Guidelines for Thoracic Aortic Disease




  Recommendation for Symptomatic
  Patients With Thoracic Aortic Aneurysm
Recommendation for Symptomatic
Patients With thoracic Aortic Aneurysm


I IIa IIb III   Patients with symptoms suggestive of expansion
                of a thoracic aneurysm should be evaluated for
                prompt surgical intervention unless life
                expectancy from comorbid conditions is limited
                or quality of life is substantially impaired.

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2010 Guidelines on Thoracic Aortic Disease

  • 1. 2010 ACCF/AHA/AATS/ACR/ASA/ SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease Circulation. 2010;121:e266-e369.
  • 2. Classification of Recommendations Class I Class IIa Class IIb Class III Benefit >>> Risk Benefit >> Risk Benefit ≥ Risk Risk ≥ Benefit Additional studies with Additional studies with No additional studies focused objectives broad objectives needed needed needed; Additional registry data would be Procedure/Treatment Procedure/ Treatment IT IS REASONABLE helpful should NOT be SHOULD be to perform performed/administered performed/ procedure/administer Procedure/Treatment SINCE IT IS NOT administered treatment MAY BE HELPFUL AND MAY CONSIDERED BE HARMFUL Alternative Phrasing: should is reasonable may/might be considered is not recommended is recommended can be useful/effective/ may/might be reasonable is not indicated is indicated beneficial usefulness/effectiveness should not is useful/effective/ is probably is unknown/unclear/ is not beneficial recommended or uncertain or not well useful/effective/beneficial indicated established may be harmful
  • 3. Applying Classification of Recommendations and Level of Evidence Class I Class IIa Class IIb Class III Benefit >>> Risk Benefit >> Risk Benefit ≥ Risk Risk ≥ Benefit Additional studies Additional studies with No additional studies with focused broad objectives needed objectives needed needed; Additional registry data would be Procedure/Treatment Procedure/ IT IS REASONABLE helpful should NOT be Treatment SHOULD to perform performed/administered be performed/ procedure/administer Procedure/Treatment SINCE IT IS NOT administered treatment MAY BE HELPFUL AND MAY BE CONSIDERED HARMFUL Level of Evidence: Level A: Data derived from multiple randomized clinical trials or meta-analyses Multiple populations evaluated; Level B: Data derived from a single randomized trial or nonrandomized studies Limited populations evaluated Level C: Only consensus of experts opinion, case studies, or standard of care Very limited populations evaluated
  • 4. Critical Issues for Thoracic Aortic Diseases As the writing committee developed this TAD guideline, several critical issues emerged: • Thoracic aortic diseases (TADs) are usually asymptomatic and not easily detectable until an acute and often catastrophic complication occurs. • The identification and treatment of stable patients at risk for acute and catastrophic disease presentations (eg, thoracic aortic dissection (AoD) and thoracic aneurysm rupture) prior to such an occurrence are paramount to eliminating the high morbidity and mortality associated with acute presentations. • Imaging of the thoracic aorta is the only method to detect thoracic aortic diseases and determine risk for future complications.
  • 5. Critical Issues for TADs • A subset of patients with acute AoD are subject to missed or delayed detection of this catastrophic disease state. – Many present with atypical symptoms and findings, making diagnosis even more difficult. – Widespread awareness of the varied and complex nature of TAD presentations has been lacking, especially for acute AoD.
  • 6. Guidelines for Thoracic Aortic Disease Recommendations for Aortic Imaging Techniques to Determine the Presence and Progression of Thoracic Aortic Disease
  • 7. Recommendations for Aortic Imaging Techniques to Determine the Presence and Progression of TAD I IIa IIb III Measurements of aortic diameter should be taken at reproducible anatomic landmarks, perpendicular to the axis of blood flow, and reported in a clear and consistent. For measurements taken by CT imaging or MRI, the external diameter should be measured I IIa IIb III perpendicular to the axis of blood flow. For aortic root measurements, the widest diameter, typically at the mid-sinus level, should be used.
  • 8. Recommendations for Imaging Techniques to Determine the Presence and Progression of TAD I IIa IIb III For measurements taken by echocardiography, the internal diameter should be measured perpendicular to the axis of blood flow. For aortic root measurements, the widest diameter, typically at the mid-sinus level, should be used. I IIa IIb III Abnormalities of aortic morphology should be recognized and reported separately even when aortic diameters are within normal limits.
  • 9. Recommendations for Imaging Techniques to Determine the Presence and Progression of TAD I IIa IIb III The finding of aortic dissection, aneurysm, traumatic injury and/or aortic rupture should be immediately communicated to the referring physician. I IIa IIb III Techniques to minimize episodic and cumulative radiation exposure should be utilized whenever possible. I IIa IIb III If clinical information is available, it can be useful to relate aortic diameter to the patient’s age and body size.
  • 10. Essential Elements of Aortic Imaging Reports The following table outlines specific qualitative and quantitative elements that are important to include in CT and MR reports 1. The location at which the aorta is abnormal. 2. The maximum diameter of any dilatation, measured from the external wall of the aorta, perpendicular to the axis of flow, and the length of the aorta that is abnormal. 3. For patients with presumed or documented genetic syndromes at risk for aortic root disease measurements of aortic valve, sinuses of Valsalva, sinotubular junction, and ascending aorta. 4. The presence of internal filling defects consistent with thrombus or atheroma. 5. The presence of intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and calcification. 6. Extension of aortic abnormality into branch vessels, including dissection and aneurysm, and secondary evidence of end-organ injury (eg, renal or bowel hypoperfusion). 7. Evidence of aortic rupture, including periaortic and mediastinal hematoma, pericardial and pleural fluid, and contrast extravasation from the aortic lumen. 8. When a prior examination is available, direct image to image comparison to determine if there has been any increase in diameter. Note: This is Table 5 in the full-text version of the TAD Guideline
  • 11. Guidelines for Thoracic Aortic Disease Recommendations for Initial Evaluation and Management of Acute Thoracic Aortic Disease
  • 12. Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection I IIa IIbIII Providers should routinely evaluate any patient presenting with complaints that may represent acute thoracic aortic dissection to establish a pretest risk of disease that can then be used to guide diagnostic decisions. This process should include specific questions about: • medical history • family history • pain features This process should also include a focused examination to identify findings that are associated with aortic dissection (outlined in the next 3 slides).
  • 13. Estimation of Pretest Risk of Thoracic Aortic Dissection High Risk Conditions • Marfan Syndrome 1 • Connective tissue disease* • Family history of aortic disease • Known aortic valve disease • Recent aortic manipulation (surgical or catheter-based) • Known thoracic aortic aneurysm • Genetic conditions that predispose to AoD† * Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or other connective tissue disease. †Patients with mutations in genes known to predispose to thoracic aortic aneurysms and dissection, such as FBN1, TGFBR1, TGFBR2, ACTA2, and MYH11.
  • 14. Estimation of Pretest Risk of Thoracic Aortic Dissection High Risk Pain Features 2 Chest, back, or abdominal pain features described as pain that: • is abrupt or instantaneous in onset. • is severe in intensity. • has a ripping, tearing, stabbing, or sharp quality.
  • 15. Estimation of Pretest Risk of Thoracic Aortic Dissection High Risk Examination Features 3 • Pulse deficit • Systolic BP limb differential > 20mm Hg • Focal neurologic deficit • Murmur of aortic regurgitation (new or not known to be old and in conjunction with pain)
  • 16. Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection I IIa IIb III Patients presenting with sudden onset of severe chest, back, and/or abdominal pain, particularly those less than 40 years of age, should be questioned about a history and examined for physical features of Marfan syndrome, Loeys- Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or other connective tissue disorder associated with thoracic aortic disease.
  • 17. Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection I IIa IIb III Patients presenting with sudden onset of severe chest, back, and/or abdominal pain should be questioned about a history of aortic pathology in immediate family members as there is a strong familial component to acute thoracic aortic disease. I IIa IIb III Patients presenting with sudden onset of severe chest, back, and/or abdominal pain should be questioned about recent aortic manipulation (surgical or catheter-based) or a known history of aortic valvular disease, as these factors predispose to acute aortic dissection.
  • 18. Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection I IIa IIb III In patients with suspected or confirmed aortic dissection who have experienced a syncopal episode, a focused examination should be performed to identify associated neurologic injury or the presence of pericardial tamponade. I IIa IIb III All patients presenting with acute neurologic complaints should be questioned about the presence of chest, back, and/or abdominal pain and checked for peripheral pulse deficits as patients with dissection-related neurologic pathology are less likely to report thoracic pain than the typical aortic dissection patient.
  • 19. Risk-based Diagnostic Evaluation: Patients with Low Risk of TAD Patients with no high-risk features of TAD present are considered at low risk for TAD. The following clinical steps are recommended for low-risk TAD patients: Expedited aortic imaging Proceed with diagnostic • TEE (preferred if clinically unstable) evaluation as clinically • CT scan (image entire aorta: chest to pelvis) indicated by presentation. • MR (image entire aorta: chest to pelvis) Yes Yes Alternative diagnosis No Unexplained identified? hypotension or widened mediastinum on CXR? Yes No Initiate appropriate Therapy. Consider aortic imaging study for TAD based on clinical scenario (particularly in patients with advanced age, risk factors for aortic disease, or syncope)
  • 20. Risk-based Diagnostic Evaluation: Patients with Intermediate Risk of TAD The following steps for patients with intermediate risk of TAD should be followed when any single high-risk feature is present. Likely primary ACS. In absence of other EKG consistent Yes perfusion deficits, strongly consider with STEMI? immediate coronary re-perfusion therapy. If No PTCA performed, is culprit lesion identified? CXR with clear Yes Alternate diagnosis? Initiate appropriate therapy. No Yes History and physical exam strongly Alternate diagnosis suggestive of specific alternate diagnosis? confirmed by further testing? No Expedited aortic imaging No • TEE (preferred if clinically unstable) • CT scan (image entire aorta: chest to pelvis) • MR (image entire aorta: chest to pelvis)
  • 21. Risk-based Diagnostic Evaluation: Patients with High Risk of TAD Patients at high-risk for TAD are those that present with at least 2 high-risk features (outlined in more detail in the following slides). The recommended course of action for high-risk TAD patients is to seek immediate surgical consultation and arrange for expedited aortic imaging. Expedited aortic imaging • TEE (preferred if clinically unstable) • CT scan (image entire aorta: chest to pelvis) • MR (image entire aorta: chest to pelvis)
  • 22. Risk Factors for Development of Thoracic Aortic Dissection Conditions Associated With Increased Aortic Wall Stress • Hypertension, particularly if uncontrolled • Pheochromocytoma • Cocaine or other stimulant use • Weight lifting or other Valsalva maneuver • Trauma • Deceleration or torsional injury (eg, motor vehicle crash, fall) • Coarctation of the aorta Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
  • 23. Risk Factors for Development of Thoracic Aortic Dissection Conditions Associated With Aortic Media Abnormalities Genetic • Marfan syndrome • Ehlers-Danlos syndrome, vascular form • Bicuspid aortic valve (including prior aortic valve replacement) • Turner syndrome • Loeys-Dietz syndrome • Familial thoracic aortic aneurysm and dissection syndrome Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
  • 24. Risk Factors for Development of Thoracic Aortic Dissection Conditions Associated With Aortic Media Abnormalities (continued) Inflammatory vasculitides • Takayasu arteritis • Giant cell arteritis • Behçet arteritis Other • Pregnancy • Autosomal dominant polycystic kidney disease • Chronic corticosteroid or immunosuppression agent administration • Infections involving the aortic wall either from bacteremia or extension of adjacent infection Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
  • 25. Aortic Dissection Classification: DeBakey and Stanford Classifications Note: Figure 20 in full-text version of TAD Guidelines. Reprinted with permission from The Cleveland Clinic Foundation.
  • 26. Recommendations for Screening Tests I IIa IIb III An ECG should be obtained on all patients who present with symptoms that may represent acute thoracic aortic dissection. Given the relative infrequency of dissection- related coronary artery occlusion, the presence of STEMI should be treated as a primary cardiac event without delay for definitive aortic imaging unless the patient is at high risk for aortic dissection.
  • 27. Recommendations for Screening Tests I IIa IIb III The role of CXR in the evaluation of possible thoracic aortic disease should be directed by the patient’s pretest risk of disease as follows. • Intermediate risk: CXR should be performed on all intermediate-risk patients, as it may establish a clear alternate diagnosis that will obviate the need for definitive aortic imaging. • Low risk: CXR should be performed on all low- risk patients, as it may either establish an alternative diagnosis or demonstrate findings that are suggestive of thoracic aortic disease, indicating the need for urgent definitive aortic imaging.
  • 28. Recommendations for Screening Tests I IIa IIb III Urgent and definitive imaging of the aorta using TEE, CT imaging, or MRI is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening. A negative CXR should not delay definitive I IIa IIb III aortic imaging in patients determined to be high risk for aortic dissection by initial screening.
  • 29. Recommendations for Initial Management Initial management of thoracic aortic dissection should be directed at decreasing aortic wall stress by controlling heart rate and blood pressure as follows: I IIa IIb III a. In the absence of contraindications, intravenous beta blockade should be initiated and titrated to a target heart rate of 60 beats per minute or less. I IIa IIb III b. In patients with clear contraindications to beta blockade, non-dihydropyridine calcium channel–blocking agents should be used as an alternative for rate control.
  • 30. Recommendations for Initial Management I IIa IIb III c. If SBP > 120mm Hg after adequate heart rate control has been obtained, then ACEIs and/or other vasodilators should be administered intravenously to further reduce BP that maintains adequate end-organ perfusion. d. Beta blockers should be used cautiously in the setting of acute aortic regurgitation because I IIa IIb III they will block the compensatory tachycardia.
  • 31. Recommendations for Initial Management I IIa IIb III Vasodilator therapy should not be initiated prior to rate control so as to avoid associated reflex tachycardia that may increase aortic wall stress, leading to propagation or expansion of a thoracic aortic dissection.
  • 32. Acute AoD Management Pathway STEP 1: Immediate post-diagnosis management and disposition considerations • Arrange for definitive management: – Appropriate surgical consultation – Inter-facility transfer if indicated based on institutional capabilities • If transfer required, initiate aggressive medical management until transfer occurs.
  • 33. Acute AoD Management Pathway STEP 2: Initial management of aortic wall stress • Obtain accurate BP prior to beginning treatment. • Measure in both arms. • Base treatment goals on highest BP reading.
  • 34. Acute AoD Management Pathway STEP 2: Initial management of aortic wall stress Intravenous rate and pressure control No Hypotension Rate/Pressure Control 1 or shock state? Intravenous beta blockade or Labetalol (If contraindication to beta blockade Yes substitute diltiazem or verapamil) Titrate to heart rate <60 + Anatomic based management Pain Control 2 Intravenous opiates Titrate to pain control Systolic BP >120mm HG? Secondary pressure control BP Control Intravenous vasodilator 3 Titrate to BP <120mm HG (Goal is lowest possible BP that maintains adequate end organ perfusion)
  • 35. Acute AoD Management Pathway STEP 2: Initial management of aortic wall stress Anatomic based management Type A dissection Type B dissection 1 Urgent surgical consultation 1 Intravenous fluid bolus + •Titrate to MAP of 70mm HG Arrange for expedited or Euvolemia operative management (If still hypotensive begin intravenous vasopressor agents) Intravenous fluid bolus 2 Evaluate etiology of •Titrate to MAP of 70mm HG 2 or Euvolemia hypotension (If still hypotensive begin • Review imaging study for intravenous vasopressor agents) evidence of contained rupture • Consider TTE to evaluate Review imaging study for: cardiac function 3 • Pericardial tamponade • Contained rupture 3 Urgent surgical consultation • Severe aortic insufficiency
  • 36. Acute AoD Management Pathway STEP 3: Definitive management • Depending on the results from the pressure control or anatomic based management, continued treatment will involve either: – ongoing medical management, or – operative or interventional management.
  • 37. Acute AoD Management Pathway STEP 3: Definitive management Based on results from intravenous Based on results from anatomic rate and pressure control: based management: No Dissection involving Etiology of hypotension the ascending aorta? Amenable to operative management? Ongoing medical management Close hemodynamic monitoring Maintain systolic BP < 120mm Hg (Lowest BP that maintains end organ perfusion) Operative or Complications requiring operative Operative or or interventional management? interventional Yes Yes interventional Limb or mesenteric ischemia management management Progression of dissection Aneurysm expansion Uncontrolled hypertension
  • 38. Acute AoD Management Pathway STEP 4: Transition to outpatient management and disease surveillance • If no complications present requiring operative or interventional management, transition to: – Oral medications (beta blockade/ anti- hypertensives regimen) – Outpatient disease surveillance imaging Note: For full algorithm, see Figure 26 in full-text version of TAD Guidelines
  • 39. Recommendations for Definitive Management I IIa IIb III Urgent surgical consultation should be obtained for all patients diagnosed with thoracic aortic dissection regardless of the anatomic location (ascending versus descending) as soon as the diagnosis is made or highly suspected. I IIa IIb III Acute thoracic aortic dissection involving the ascending aorta should be urgently evaluated for emergent surgical repair because of the high risk of associated life-threatening complications such as rupture.
  • 40. Recommendations for Definitive Management I IIa IIb III Acute thoracic aortic dissection involving the descending aorta should be managed medically unless life-threatening complications develop (ie, malperfusion syndrome, progression of dissection, enlarging aneurysm, inability to control blood pressure or symptoms).
  • 41. Guidelines for Thoracic Aortic Disease Recommendation for Surgical Intervention for Acute Thoracic Aortic Dissection
  • 42. Recommendation for Surgical Intervention for Acute Thoracic Aortic Dissection I IIa IIb III For patients with ascending thoracic aortic dissection, all aneurysmal aorta and the proximal extent of the dissection should be resected. A partially dissected aortic root may be repaired with aortic valve resuspension. Extensive dissection of the aortic root should be treated with aortic root replacement with a composite graft or with a valve sparing root replacement. If a DeBakey Type II dissection is present, the entire dissected aorta should be replaced.
  • 43. Acute Surgical Management Pathway for AoD The following steps outline ascending TAD by imaging study. STEP 1: Determine patient suitability for surgery • If not suitable, begin medical management. STEP 2: Determine stability for pre-op testing • If not sufficiently stable, proceed with urgent operative management.
  • 44. Acute Surgical Management Pathway for AoD STEP 3: Determine likelihood of coexistent CAD Yes Assess need for Is patient age >40? preoperative coronary angiography Yes No • Known CAD? • Significant risk factors No for CAD? Yes Urgent operative No Significant CAD by management angiography? Yes Plan for CABG if appropriate at time of AoD repair
  • 45. Acute Surgical Management Pathway for AoD STEP 4: Intra-operative evaluation of aortic valve • Perform intra-operative assessment of aortic valve by TEE. Aortic Regurgitation? or Dissection of aortic sinuses? Yes No STEP 5: Surgical intervention Graft replacement of ascending aorta Graft replacement +/- aortic arch of ascending aorta and repair/ replacement +/- aortic arch of aortic valve Note: For full algorithm, see Figure 22 in full-text version of TAD Guidelines.
  • 46. Guidelines for Thoracic Aortic Disease Recommendation for Intramural Hematoma Without Intimal Defect
  • 47. Recommendation for Intramural Hematoma Without Intimal Defect I IIa IIb III It is reasonable to treat intramural hematoma similar to aortic dissection in the corresponding segment of the aorta.
  • 48. Guidelines for Thoracic Aortic Disease Recommendation for History and Physical Examination for Thoracic Aortic Disease
  • 49. Recommendation for History and Physical Exam for TAD I IIa IIb III For patients presenting with a history of acute cardiac and noncardiac symptoms associated with a significant likelihood of thoracic aortic disease, the clinician should perform a focused physical examination, including a careful and complete search for arterial perfusion differentials in both upper and lower extremities, evidence of visceral ischemia, focal neurologic deficits, a murmur of aortic regurgitation, bruits, and findings compatible with possible cardiac tamponade.
  • 50. Guidelines for Thoracic Aortic Disease Recommendations for General Medical Treatment and Risk Factor Management for Patients with Thoracic Aortic Diseases
  • 51. Recommendation for Medical Treatment of patients with TAD I IIa IIb III Stringent control of hypertension, lipid profile optimization, smoking cessation, and other atherosclerosis risk-reduction measures should be instituted for patients with small aneurysms not requiring surgery, as well as for patients who are not considered to be surgical or stent graft candidates.
  • 52. Recommendations for Blood Pressure Control I IIa IIb III Antihypertensive therapy should be administered to hypertensive patients with thoracic aortic diseases to achieve a goal of less than 140/90 mmHg (patients without DM) or less than 130/80 mm Hg (patients with DM or CKD) to reduce the risk of stroke, MI, HF, and cardiovascular death. Beta adrenergic–blocking drugs should be I IIa IIb III administered to all patients with Marfan syndrome and aortic aneurysm to reduce the rate of aortic dilatation unless contraindicated.
  • 53. Recommendations for Blood Pressure Control I IIa IIb III For patients with thoracic aortic aneurysm, it is reasonable to reduce BP with beta blockers and ACEIs or ARB to the lowest point patients can tolerate without adverse effects. I IIa IIb III An ARB (losartan) is reasonable for patients with Marfan syndrome, to reduce the rate of aortic dilatation unless contraindicated.
  • 54. Guidelines for Thoracic Aortic Disease Recommendations for Asymptomatic Patients with Ascending Aortic Aneurysm
  • 55. Recommendations for Asymptomatic Patients with Ascending Aortic Aneurysm I IIa IIb III Asymptomatic patients with degenerative thoracic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, or pseudoaneurysm, who are otherwise suitable candidates and for whom the ascending aorta or aortic sinus diameter > 5.5 cm, should be evaluated for surgical repair. I IIa IIb III Patients with Marfan syndrome or other genetically mediated disorders (vascular Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, or familial thoracic aortic aneurysm and dissection) should undergo elective operation at smaller diameters (4.0 to 5.0 cm depending on the condition) to avoid acute dissection or rupture.
  • 56. Recommendations for Asymptomatic Patients with Ascending Aortic Aneurysm I IIa IIb III Patients with a growth rate > 0.5 cm/y in an aorta that is less than 5.5 cm in diameter should be considered for operation. I IIa IIb III Patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta.
  • 57. Guidelines for Thoracic Aortic Disease Recommendation for Symptomatic Patients With Thoracic Aortic Aneurysm
  • 58. Recommendation for Symptomatic Patients With thoracic Aortic Aneurysm I IIa IIb III Patients with symptoms suggestive of expansion of a thoracic aneurysm should be evaluated for prompt surgical intervention unless life expectancy from comorbid conditions is limited or quality of life is substantially impaired.