What are the guideline sources, guidelines and references for Thoracic aortic dissection ?
Guideline sources The following summarized guidelines for the evaluation and management of thoracic aortic dissection are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2022), the Society of Thoracic Surgeons (STS/AATS 2022), the American Association for Thoracic Surgery (AATS 2021), the European Society for Vascular Surgery (ESVS/EACTS 2019), the American College of Emergency Physicians (ACEP 2015), the European Society of Cardiology (ESC 2014), and the Society for Cardiovascular Angiography and Interventions (SCAI/STS/SVM/AATS/SCA/AHA/ACR/ACC/ASA/SIR 2010). 1 2 3 4 5 6 7 Guidelines 1. Screening and diagnosis Screening of first-degree relatives: evaluate first-degree relatives (siblings and parents) of a patient with thoracic aortic aneurysm and dissection to identify a familial form in which relatives all https://web.pathway.md/diseases/recCenS8E4FsYctCz 1/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway have a 50% chance of carrying the family mutation/disease. B Show 3 more 2. Diagnostic investigations General principles: ensure a stepwise approach to the evaluation and treatment of patients with acute/subacute uncomplicated type B aortic dissection, including identification of the primary entry tear site location, defining the proximity and distance of the dissection to the left subclavian artery, calibration of the maximum orthogonal aortic diameter, and confirmation of the lack of any organ malperfusion or other indications of complicated disease. B Clinical assessment: As per ACEP 2015 guidelines, do not use existing clinical decision rules alone in an attempt to identify patients at very low risk for acute nontraumatic thoracic aortic dissection. Ensure that the decision to pursue further workup for acute nontraumatic aortic dissection is at the discretion of the treating physician. D As per AHA 2010 guidelines, consider obtaining routine evaluation of any patient presenting with complaints possibly representing acute thoracic aortic dissection to establish a pretest risk of disease that can then be used to guide diagnostic decisions. Include specific questions about medical history, family history, and pain features as well as a focused examination to identify findings that are associated with aortic dissection. C Show 4 more Electrocardiogram: obtain an ECG in all patients presenting with symptoms possibly representing acute thoracic aortic dissection. Treat the presence of ST-segment elevation suggestive of myocardial infarction as a primary cardiac event without delay for definitive aortic imaging, unless the patient is at high risk for aortic dissection. B D-dimer testing: do not rely on D-dimer alone to exclude the diagnosis of aortic dissection in adult patients with suspected nontraumatic thoracic aortic dissection. D Chest radiography: Obtain a CXR in all low-risk patients, as it may either establish an alternative diagnosis or demonstrate findings suggestive of thoracic aortic disease, indicating the need for urgent definitive aortic imaging. B Obtain a CXR in all moderate-risk patients, as it may establish a clear alternate diagnosis obviating the need for definitive aortic imaging. B Aortic imaging: As per ACEP 2015 guidelines, consider obtaining CT angiography to exclude thoracic aortic dissection in adult patients with suspected nontraumatic thoracic aortic dissection, because it has accuracy similar to that of TEE and MRA. C Show 2 more As per AHA 2010 guidelines, obtain urgent and definitive imaging of the aorta using TEE, CT angiography, or MRA to identify or exclude thoracic aortic dissection in patients at high risk for https://web.pathway.md/diseases/recCenS8E4FsYctCz 2/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway the disease by initial screening. B Show 3 more Genetic testing: As per ACC 2022 guidelines, elicit a multigenerational family history of thoracic aortic disease, unexplained sudden deaths, and peripheral and intracranial aneurysms in patients with aortic root/ascending aortic aneurysms or aortic dissection. B Show 7 more As per ESC 2014 guidelines, refer patients to a geneticist for family investigation and molecular testing once a familial form of thoracic aortic aneurysm and dissection is highly suspected. B 3. Medical management Indications for non-operative management, general principles: As per ESC 2014 guidelines, initiate medical therapy including pain relief and BP control in all patients with aortic dissection. B As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, direct initial management of thoracic aortic dissection at decreasing aortic wall stress by controlling HR and BP. Indications for non-operative management, type B aortic dissection: As per AATS/STS 2022 guidelines: Initiate optimal medical therapy for the treatment of patients with uncomplicated type B aortic dissection. B Consider initiating optimal medical therapy in patients with uncomplicated type B aortic dissection and retrograde extension of dissection from a tear at or distal to the left subclavian artery, as long as retrograde extension is limited to the arch (zones 1 and 2). C As per AHA/ACC 2022 guidelines, initiate medical therapy as the initial management strategy in all patients with uncomplicated acute type B aortic dissection. B As per ESC 2014 guidelines, initiate medical therapy in patients with uncomplicated type B aortic dissection. B As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, initiate medical therapy in patients with acute thoracic aortic dissection involving only the descending aorta, unless life-threatening complications develop (such as malperfusion syndrome, progression of dissection, enlarging aneurysm, and inability to control BP or symptoms). B Acute heart rate and blood pressure control: As per ACEP 2015 guidelines, lower BP and pulse pressure, if elevated, in adult patients with acute nontraumatic thoracic aortic dissection. B As per AHA 2010 guidelines, initiate IV -blockers, if not contraindicated, and titrate to a target HR 60 beats/minute. B Show 4 more https://web.pathway.md/diseases/recCenS8E4FsYctCz 3/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway Management of hypertension: initiate antihypertensive therapy in hypertensive patients with thoracic aortic diseases, targeting a BP < 140/90 mmHg for patients without diabetes, or < 130/80 mmHg for patients with diabetes or chronic renal disease, to reduce the risk of stroke, myocardial infarction, HF, and cardiovascular death. B Management of dyslipidemia: consider initiating a statin to achieve a target LDL cholesterol < 1.8 mmol/L (< 70 mg/dL) for patients with a coronary heart disease risk equivalent, such as noncoronary atherosclerotic disease, atherosclerotic aortic aneurysm, and coexistent coronary heart disease at high risk for coronary ischemic events. B 4. Nonpharmacologic interventions Smoking cessation: advise smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home. Provide follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement, buproprion, or varenicline), and adopt a stepwise strategy aimed at smoking cessation (the 5 As are Ask, Advise, Assess, Assist, and Arrange). B 5. Perioperative care Perioperative organ protection, brain: as per AHA/ACC 2022 guidelines, consider performing axillary cannulation over femoral cannulation, when feasible, to reduce the risk of stroke or retrograde malperfusion in patients with acute type A aortic dissection undergoing surgical repair. C Show 2 more Perioperative organ protection (spinal cord): Perform revascularization (open surgical or endovascular) of the left subclavian artery after TEVAR coverage obstructing antegrade left subclavian artery flow to decrease the risk of spinal chord ischemia. B Consider placing CSF drainage in patients with type B aortic dissection undergoing TEVAR being at high risk for spinal cord ischemia (such as coverage > 20 cm or within 2 cm of the celiac artery origin or other risk factors) and if time permits (nonemergent circumstances), or if symptoms of paraparesis/paraplegia develop. C 6. Surgical interventions Timing of surgery: As per ACC 2022 guidelines: Obtain emergency surgical consultation and evaluation and perform an immediate surgical intervention in patients presenting with suspected or confirmed acute type A aortic dissection because of the high risk of associated life-threatening complications. B https://web.pathway.md/diseases/recCenS8E4FsYctCz 4/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway Consider transferring patients presenting with acute type A aortic dissection stable enough for transfer from a low- to a high-volume aortic center to improve survival. C As per AHA 2010 guidelines: Obtain urgent surgical consultation 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. B Obtain emergent evaluation for surgical repair in patients with acute thoracic aortic dissection involving the ascending aorta, because of the high risk of associated life-threatening complications, including aortic rupture. B Thoracic endovascular aortic repair, type B aortic dissection: As per AATS/STS 2022 guidelines, perform TEVAR in patients with complicated hyperacute, acute, or subacute type B aortic dissection with rupture and/or malperfusion and favorable anatomy for TEVAR. B Show 3 more As per AHA/ACC 2022 guidelines, perform an intervention in patients with acute type B aortic dissection and rupture or other complications. B Show 3 more As per ESC 2014 guidelines: Consider performing TEVAR in patients with uncomplicated type B aortic dissection. C Perform TEVAR in patients with complicated type B aortic dissection. B Open surgical repair, type A aortic dissection: As per AHA/ACC 2022 guidelines, perform aortic valve resuspension over valve replacement in patients with acute type A aortic dissection and a partially dissected aortic root but no significant aortic valve leaflet pathology. B Show 5 more As per ESC 2014 guidelines, perform urgent surgery in patients with type A aortic dissection. B Open surgical repair, type B aortic dissection: As per AATS/STS 2022 guidelines: Consider performing open surgical repair in patients with complicated hyperacute, acute, or subacute type B aortic dissection with unsuitable anatomy for TEVAR. C Consider performing open surgical repair rather than TEVAR in patients with connective tissue disorders and type B aortic dissection having progression of disease despite optimal medical therapy. B As per ESC 2014 guidelines, consider performing surgery in patients with complicated type B aortic dissection. C Hybrid open-endovascular repair: As per ESVS 2019 guidelines, consider performing frozen elephant trunk repair (hybrid stent- graft prosthesis) or TEVAR to close the primary entry in patients with acute type A aortic dissection with a primary entry in the distal aortic arch or in the proximal half of the descending https://web.pathway.md/diseases/recCenS8E4FsYctCz 5/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway thoracic aorta to treat associated malperfusion syndrome or to avoid its postoperative development. C Show 3 more As per ESC 2014 guidelines, consider a hybrid approach (ascending aorta and/or arch replacement associated with any percutaneous aortic or branch artery procedure) in patients with acute type A aortic dissection and organ malperfusion. C Aortic fenestration: as per STS 2022 guidelines, consider performing fenestration in patients with complicated hyperacute, acute, or subacute type B aortic dissection. C Management of malperfusion: as per ACC 2022 guidelines, perform immediate operative repair of the ascending aorta in patients with acute type A aortic dissection presenting with renal, mesenteric, or lower extremity malperfusion. B Show 2 more 7. Specific circumstances Pregnant patients: perform urgent aortic surgery with fetal monitoring in patients with acute type A aortic dissection during the first or second trimester of pregnancy. B Show 4 more Patients with aortic intramural hematoma: As per ACC 2022 guidelines, obtain surveillance CT or MRI after 1 month, 6 months, and 12 months and then, if stable, annually thereafter in patients experienced acute aortic dissection and intramural hematoma managed with medical therapy alone. B Show 2 more As per AHA 2010 guidelines, consider treating patients with intramural hematoma similar to patients with aortic dissection in the corresponding segment of the aorta. C Patients with infectious aortitis: perform open surgical repair in patients with infectious aortitis and associated aneurysms or dissection of the thoracic or abdominal aorta. B Patients with stroke: consider performing surgical intervention rather than offering medical therapy to reduce mortality and improve neurologic outcomes in patients presenting with non- hemorrhagic stroke complicating acute type A aortic dissection. C Patients with chronic aortic dissection: As per STS 2022 guidelines, consider performing TEVAR in patients with chronic type B aortic dissection with an indication for intervention with suitable anatomy (adequate landing zone, absence of ascending or arch aneurysm) and being at high risk for complications of open repair due to comorbidities. C Show 2 more As per AHA 2010 guidelines: Perform open repair in patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter > 5.5 cm. B https://web.pathway.md/diseases/recCenS8E4FsYctCz 6/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway Evaluate asymptomatic patients with chronic aortic dissection for surgical repair if the ascending aorta or aortic sinus diameter is 5.5 cm. B 8. Follow-up and surveillance Serial clinical assessment: obtain close clinical follow-up after hospital discharge in patients presenting with acute type B aortic dissection. B Serial imaging assessment: consider obtaining CT angiography or MRA of the aorta at 1, 3, 6, and 12 months post-dissection and, if stable, annually thereafter, so that any threatening enlargement can be detected in a timely fashion. C Show 2 more Cardiac rehabilitation: offer postoperative cardiac rehabilitation in patients after surgery for aortic dissection. B Likelihood Ratios Pertinent positives The following findings increase the probability of thoracic aortic dissection in adults. -1 Finding LR+ Value Presence of focal neurologic deficit 6.6-33 (6-33) Presence of pulse deficit 5.7 (1.4-23) Presence of clinical findings of aortic dissection (= 2/3)* 5.3 (3.0-9.4) Presence of enlarged aorta or wide mediastinum 2.0 (1.4-3.1) aortic pain (sudden-onset severe tearing pain), blood pressure or pulse differential between arms, and wide mediastinum on chest radiograph Show 5 more Pertinent negatives The following findings decrease the probability of thoracic aortic dissection in adults. -1 Finding LR- Value Absence of clinical findings of aortic dissection* 0.1 (0-0.2) No history of sudden chest pain 0.3 (0.2-0.5) Absence of enlarged aorta or wide mediastinum 0.3 (0.2-0.4) No history of tearing chest pain or ripping chest pain 0.4-1.0 aortic pain (sudden-onset severe tearing pain), blood pressure or pulse differential between arms, and wide mediastinum on chest radiograph Show 5 more https://web.pathway.md/diseases/recCenS8E4FsYctCz 7/8 6/24/23, 4:06 PM Thoracic aortic dissection Pathway References 1. Diercks DB, Promes SB, Schuur JD et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015 Jan;65 1 32 42.e12. Open 2. Hiratzka LF, Bakris GL, Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010 Apr 6;121 13):e266 369. Open 3. Eric M Isselbacher, Ourania Preventza, James Hamilton Black rd et al. 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. Circulation. 2022 Nov 2. Open 4. Thomas E. MacGillivray, MD Thomas G. Gleason, MD Himanshu J. Patel et al. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg. 2022 Jan 25. Article in press. Open 5. S Christopher Malaisrie, Wilson Y Szeto, Monika Halas et al. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2021 Sep;162 3 735 758.e2. Open 6. Erbel R, Aboyans V, Boileau C et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology ESC . Eur Heart J. 2014 Nov 1;35 41 2873 926. Open 7. Martin Czerny, J rg Schmidli, Sabine Adler et al. Editor's Choice Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery EACTS & the European Society for Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2019 Feb;57 2 165 198. Open 8. Munir Boodhwani, Gregor Andelfinger, Jonathon Leipsic et al. Canadian Cardiovascular Society position statement on the management of thoracic aortic disease. Can J Cardiol. 2014 Jun;30 6 577 89. Open 9. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018 Sep 7;39 34 3165 3241. Open https://web.pathway.md/diseases/recCenS8E4FsYctCz 8/8