Guideline sources The following summarized guidelines for the evaluation and management of thoracic aortic aneurysm (TAA) are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2022), the European Society for Vascular Surgery (ESVS/EACTS 2019), the European Society for Vascular Surgery (ESVS 2017), 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 Calculator Cardiac Anesthesia Risk Evaluati Guidelines https://web.pathway.md/diseases/recOyhB0tVbURQpkh 1/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway 1. Screening and diagnosis Screening of first-degree relatives: As per ESVS 2017 guidelines, consider screening with imaging for descending thoracic aortic and AAAs at the age of 50 and repeated thereafter at regular intervals in all first-degree relatives of patients considered to be part of a familial aneurysm disorder. C As per ESC 2014 guidelines, evaluate first-degree relatives (siblings and parents) of patients with TAA and dissection to identify a familial form where relatives all have a 50% chance of carrying the family mutation/disease. B Show 2 more As per ACC 2010 guidelines, obtain aortic imaging in first-degree relatives of patients with TAA or dissection to identify asymptomatic disease. B Show 3 more 2. Diagnostic investigations Echocardiography: As per ACC 2022 guidelines, obtain a TTE at the time of diagnosis to assess aortic valve anatomy, aortic valve function, and thoracic aortic diameters in patients with a dilated thoracic aorta. B As per ESVS 2019 guidelines, obtain a TEE in all unstable intubated patients with suspected acute aortic syndrome. B As per ESVS 2017 guidelines, consider obtaining a transoesophageal echocardiogram as second-line imaging for the diagnosis of descending thoracic aortic disease if CT is unavailable, contraindicated, or inconclusive. C Computed tomography angiography: As per ACC 2022 guidelines, consider obtaining CT or MRI at the time of diagnosis to assess thoracic aortic anatomy and diameters in patients with a dilated thoracic aorta. C As per ESVS 2017 guidelines, obtain CT angiography for diagnosis confirmation in all patients with clinical suspicion of thoracic aortic disease and abnormal chest radiograph. B Show 2 more As per ESC 2014 guidelines, obtain emergency CT angiography in patients with suspected rupture of TAA for diagnosis confirmation. B Evaluation of supra-aortic arteries: Assess the patency and morphology of the circle of Willis if treatment involves the aortic arch. B Assess the extra-cranial supra-aortic vessels down to the level of the femoral artery bifurcation if treatment involves the aortic arch. B Evaluation of cardiovascular risks: https://web.pathway.md/diseases/recOyhB0tVbURQpkh 2/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway As per ESVS 2017 guidelines, consider obtaining additional diagnostic investigations to define the severity of the underlying heart disease in candidates for open surgical repair of descending TAAs with a past medical history of coronary artery disease. C As per AHA 2010 guidelines, consider obtaining additional testing, including pulmonary function testing, coronary angiography, aortography, 24-hour Holter monitoring, noninvasive carotid artery screening, brain imaging, echocardiography, and neurocognitive testing, to assess comorbidities and refine the evaluation of cardiovascular risk. C Genetic testing: As per ESC 2014 guidelines, refer the patient to a geneticist for family investigation and molecular testing once a familial form of TAA and dissection is highly suspected. B As per ACC 2010 guidelines, consider sequencing the ACTA2 gene in patients with a family history of TAAs and/or dissections to determine whether ACTA2 mutations are responsible for the inherited predisposition. C Show 2 more 3. Medical management Antihypertensive therapy: As per ACC 2022 guidelines, initiate antihypertensive medications to reduce the risk of cardiovascular events in patients with TAA and an average systolic BP of 130 mmHg or an average diastolic BP of 80 mmHg. B Show 2 more As per AHA 2010 guidelines: Implement stringent control of hypertension in patients with small aneurysms not requiring surgery, as well as in patients not considered surgical or stent-graft candidates. B Consider initiating -blockers and ACEIs or ARBs to achieve the lowest tolerable BP not resulting in adverse effects in patients with TAA. C Statin therapy: As per ACC 2022 guidelines, consider initiating moderate- or high-intensity statin therapy in patients with TAA and imaging or clinical evidence of atherosclerosis. C Consider initiating statin therapy in patients with TAA with no evidence of atherosclerosis. C As per AHA 2010 guidelines, consider initiating statin therapy to reduce the risk of stroke in patients with aortic arch atheroma. C Antithrombotic therapy: As per ACC 2022 guidelines, consider initiating low-dose aspirin in patients with atherosclerotic TAA and concomitant aortic atheroma or penetrating atherosclerotic ulcer, unless contraindicated. C https://web.pathway.md/diseases/recOyhB0tVbURQpkh 3/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway As per AHA 2010 guidelines, consider initiating antiplatelet therapy or oral anticoagulation therapy with warfarin (target INR 2.0-3.0) to prevent recurrent stroke in patients with aortic arch atheroma 4.0 mm and previous stroke. C 4. Nonpharmacologic interventions Smoking cessation: As per ACC 2022 guidelines, advise smoking cessation in smoker patients with TAA. B As per AHA 2010 guidelines, advise smoking cessation in patients with small aneurysms not requiring surgery, as well as in patients not considered surgical or stent-graft candidates. B Physical activity: consider advising employment and lifestyle restrictions in patients with a current TAA or dissection, or a previously repaired aortic dissection, including the avoidance of strenuous lifting, pushing or straining requiring a Valsalva maneuver. C 5. Perioperative care Preoperative evaluation: As per ESVS 2019 guidelines, obtain CT angiography as first-line imaging for preoperative assessment of aortic arch pathologies. B As per ESVS 2017 guidelines, consider stratifying the perioperative risk associated with pulmonary, renal, and cerebrovascular studies. C Show 2 more As per AHA 2010 guidelines: Obtain imaging able to establish the extent of disease and the potential limits of the planned procedure in preparation for surgery. B Obtain additional studies to determine the presence of significant coronary artery disease in patients with symptoms or other findings of myocardial ischemia and thoracic aortic disease requiring surgical or catheter-based intervention. B Anesthetic technique: tailor the choice of anesthetic techniques and agents and patient monitoring techniques to individual patient needs, with an aim to optimize perfusion and facilitate surgical technique. B Intraoperative monitoring, TEE: As per ESVS/EACTS 2019 guidelines: Obtain TEE during all open thoracic aortic surgical procedures. B Ensure that TEE is available in hybrid and endovascular thoracic aortic procedures. B As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines: Consider obtaining TEE in all open surgical repairs of the thoracic aorta unless there are specific contraindications. C https://web.pathway.md/diseases/recOyhB0tVbURQpkh 4/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway Consider obtaining TEE in endovascular thoracic aortic procedures for monitoring, procedural guidance, and/or endovascular graft leak detection. C Intraoperative monitoring, arterial pressure: As per ESVS/EACTS 2019 guidelines: Consider obtaining bilateral invasive upper extremity and femoral arterial pressure monitoring during surgery for aortic arch repair. C Consider obtaining intermittent direct central aortic pressure reference measurement during surgery for aortic arch repair. C As per ESVS 2017 guidelines, consider optimizing mean and distal aortic arterial pressure to protect the spinal cord during thoracoAAA surgery. C Intraoperative monitoring, motor- and/or somatosensory-evoked potentials: As per ESVS 2017 guidelines, consider obtaining perioperative monitoring of motor- and/or somatosensory-evoked potentials to predict spinal cord ischemia during open thoracic or thoracoabdominal aortic repair. C As per ESVS 2017 guidelines, consider obtaining neuromonitoring to protect the spinal cord during thoracoAAA surgery. C As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines: Consider obtaining motor- and/or somatosensory-evoked potential monitoring to guide therapy. Consider deciding on the use of neurophysiologic monitoring based on individual patient needs, institutional resources, the urgency of the procedure, and the surgical and perfusion techniques to be employed in the open or endovascular thoracic aortic repair. C Consider obtaining neurophysiological monitoring of the spinal cord (motor- and somatosensory-evoked potentials) to detect spinal cord ischemia and to guide reimplantation of intercostal arteries and/or hemodynamic optimization to prevent or treat spinal cord ischemia. C Intraoperative monitoring (cerebral oxygenation): obtain bilateral near-infrared spectroscopy- based cerebral oximetry combined with an algorithmic approach to intervention for cortical Hgb- desaturation during surgery for aortic arch repair. B Intraoperative monitoring (coagulation): consider obtaining point-of-care coagulation monitoring in conjunction with an algorithmic approach to transfusion of blood products during aortic arch surgery. B Intraoperative monitoring (temperature): obtain multisite temperature monitoring (at a minimum nasopharyngeal, tympanic, bladder or rectal probe) during surgery for aortic arch repair. B Perioperative management: as per AHA 2010 guidelines, consider using an algorithmic approach to transfusion, antifibrinolytic, and anticoagulation management in both open and endovascular thoracic aortic repairs during the perioperative period. Institutional variations in coagulation testing capability and availability of transfusion products and other prothrombotic and antithrombotic agents are important considerations in defining such an approach. C https://web.pathway.md/diseases/recOyhB0tVbURQpkh 5/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway 6. Surgical interventions Indications for repair (aortic root and ascending aorta): perform surgery in patients with aneurysms of the aortic root and ascending aorta having symptoms attributable to the aneurysm. B Show 5 more Indications for repair, aortic arch aneurysm: As per AHA/ACC 2022 guidelines: Perform open surgical replacement in patients with an aortic arch aneurysm having symptoms attributable to the aneurysm and at low or intermediate surgical risk. B Consider performing open surgical replacement at an arch diameter of 5.5 cm in asymptomatic patients with an isolated aortic arch aneurysm at low surgical risk. C As per ESVS/EACTS 2019 guidelines, offer treatment in patients with isolated aortic arch aneurysms at a diameter of 55 mm. B As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, consider performing surgical repair in asymptomatic patients with low operative risk with an isolated degenerative or atherosclerotic aneurysm of the aortic arch with a diameter of > 5.5 cm. C Indications for repair (descending aorta): perform repair in patients with intact descending TAA with a diameter of 5.5 cm. B Show 2 more Indications for repair, progressing aneurysm: As per AHA/ACC 2022 guidelines, perform surgery in patients with an aneurysm of the aortic root or ascending aorta of < 5.5 cm if the growth rate confirmed by tomographic imaging is 0.3 cm/year in 2 consecutive years or 0.5 cm in 1 year. B As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines: Perform prompt surgical intervention in patients with symptoms suggestive of expansion of a thoracic aneurysm unless life expectancy from comorbid conditions is limited or quality of life is substantially impaired. B Consider performing surgical repair in patients with a growth rate of > 0.5 cm/year in an aorta < 5.5 cm in diameter. B Setting of repair: As per ESVS 2019 guidelines, centralize the care for aortic arch pathologies. Perform endovascular aortic arch repair in centers with adequate volume of and expertise in open and endovascular arch repair. B Show 2 more As per ESVS 2017 guidelines, consider centralizing open and endovascular repair of thoracoAAA in dedicated high-volume centers. C Choice of surgical approach, open repair: As per AHA/ACC 2022 guidelines, consider performing open surgical repair in patients with a descending TAA meeting criteria for intervention with unsuitable anatomy for endovascular https://web.pathway.md/diseases/recOyhB0tVbURQpkh 6/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway repair, without significant comorbidities, and with a life expectancy of at least 10 years. C As per ESVS/EACTS 2019 guidelines, consider performing open aortic arch repair in patients with concomitant aortic valve pathology or at high risk for retrograde type A aortic dissection (ascending aorta > 38 mm, bicuspid aortic valve, arch abnormalities, lost sinutubular junction, extensive ascending aortic length). C As per ESVS 2017 guidelines: Consider performing open repair in fit patients with a descending thoracic aorta of 56-59 mm C or > 60 mm in diameter, deemed unsuitable for endovascular repair. C Consider performing open or endovascular repair in patients at low-to-moderate surgical risk with an atherosclerotic or degenerative thoracoAAA of 60 mm diameter, rapid aneurysm enlargement (> 10 mm/year), or aneurysm-related symptoms. C As per ESC 2014 guidelines, consider performing open surgery in patients with aortic root aneurysm with maximal ascending aortic diameter 55 mm with no elastopathy. C Show 4 more Choice of surgical approach, endovascular repair: As per ESVS/EACTS 2019 guidelines, consider performing endovascular aortic arch repair in zone 0 in patients unfit for open surgery and with suitable anatomy. C Show 3 more As per ESVS 2017 guidelines, consider performing endovascular repair for descending thoracic aorta aneurysms 56-59 mm C or > 60 mm in diameter in fit or unfit patients with favorable anatomy. C Show 2 more As per ESC 2014 guidelines: Consider performing TEVAR rather than open surgery when anatomy is suitable. C Consider performing TEVAR in patients with descending aortic aneurysm with maximal diameter 55 mm. C As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, perform endovascular stent grafting, when feasible, in patients with degenerative or traumatic aneurysms of the descending thoracic aorta > 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms. B Choice of surgical approach, hybrid open-endovascular repair: As per AHA/ACC 2022 guidelines, consider performing hybrid or endovascular intervention in asymptomatic patients with an aortic arch aneurysm meeting criteria for intervention but having a high risk from open surgical repair. C As per ESVS/EACTS 2019 guidelines: Consider performing frozen elephant trunk repair in patients with concomitant distal thoracic and thoracoabdominal aortic disease that, in a later stage, will or is likely to require either surgical or endovascular treatment. C Do not perform stent-graft deployment in patients with a proximal and/or distal landing zone length < 25 mm or a maximum diameter of > 38 mm. D https://web.pathway.md/diseases/recOyhB0tVbURQpkh 7/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway As per ESVS 2017 guidelines, consider using a hybrid approach for thoracoabdominal aneurysm repair in patients unfit for open repair with aortic anatomy unfavorable for a branched/fenestrated endograft. C Technical considerations for repair, open repair: As per AHA/ACC 2022 guidelines, perform aneurysm resection and replacement with an interposition graft in patients with an aneurysm isolated to the ascending aorta meeting criteria for surgery. B Show 5 more As per ESVS/EACTS 2019 guidelines, ensure that ascending/hemiarch replacement is extensive and avoid using short ascending grafts to prevent disease progression and to anticipate future endovascular modular distal extension in any open proximal thoracic aortic surgery. B Show 3 more As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, consider performing replacement of the entire aortic arch, usually with the elephant trunk procedure, for aneurysms of the entire arch, for chronic dissection when the arch is enlarged, and for distal arch aneurysms involving the proximal descending thoracic aorta. C Show 4 more Technical considerations for repair, endovascular repair: As per AHA/ACC 2022 guidelines: Review preoperative computed tomographic angiography of the iliofemoral vessels to evaluate access in patients with descending TAA undergoing TEVAR. B Consider using alternative vascular access in patients with smaller or diseased access vessels. Use alternative conduits if iliac access is marginal or inadequate to prevent access- related complications. B Consider using total percutaneous femoral access as an alternative to open surgical cutdown to avoid access-related complications in patients with suitable anatomy. C As per ESVS/EACTS 2019 guidelines, consider using parallel graft technique in urgent TEVAR procedures requiring a seal in landing zones 0-2 without adequate options for open surgery or supra-aortic debranching and as a bail-out strategy in cases where unintended obstruction of a supra-aortic vessel occurred during the TEVAR. C Show 3 more Technical considerations for surgery, prophylactic subclavian artery revascularization: As per AHA/ACC 2022 guidelines: Perform revascularization of the left subclavian artery before TEVAR to prevent spinal cord injury and potentially reduce stroke risk and prevent other ischemic complications in patients with descending TAA undergoing TEVAR with planned left subclavian artery coverage. B Consider performing left subclavian artery revascularization in patients with descending TAA after TEVAR with left subclavian coverage and developed spinal cord injury unresponsive to an increase in BP or a CSF drain. C https://web.pathway.md/diseases/recOyhB0tVbURQpkh 8/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway As per ESVS/EACTS 2019 guidelines, consider performing preventive left subclavian artery revascularization in elective TEVAR in zones 0, 1, 2 to reduce the risk of neurological complications such as stroke and spinal cord ischemia. C As per ESVS 2017 guidelines, consider performing preventive left subclavian artery revascularization in elective thoracic endografting in patients at risk of neurological complications, if the endograft is planned to intentionally cover the left subclavian artery. C Technical considerations for surgery (prophylactic intercostal artery revascularization): consider performing reimplantation of intercostal arteries to protect the spinal cord during thoracoAAA surgery. C Technical considerations for surgery (prophylactic celiac artery revascularization): consider confirming adequate collateralization first when celiac artery coverage is being considered in patients with descending TAA undergoing TEVAR. C Technical considerations for surgery (left heart bypass): consider performing left heart bypass allowing distal perfusion to prevent spinal cord ischemia during open type I and II thoracoAAA repair. C Show 2 more Technical considerations for surgery (therapeutic hypothermia): consider administering moderate hypothermia around 32 C to prevent spinal cord ischemia during extensive open descending thoracic aorta repair. C Show 2 more Technical considerations for surgery, CSF drainage: As per ESVS/EACTS 2019 guidelines, perform selective secondary insertion of a CSF drainage tube as part of a treatment bundle in situations of delayed spinal cord injury. B As per ESVS 2017 guidelines, consider performing CSF drainage during extensive open repair of the descending thoracic aorta for the prevention of paraplegia and paraparesis. C Show 2 more 7. Specific circumstances Pregnant patients: As per ACC 2022 guidelines, perform surgery before pregnancy in patients with sporadic aortic root aneurysms, ascending aortic aneurysms, or both, and a diameter of 5.0 cm. B Show 2 more As per AHA 2010 guidelines, obtain non-contrast-enhanced MRI over CT to avoid exposing both the mother and fetus to ionizing radiation in pregnant patients with aortic arch, descending, or abdominal aortic dilatation. Consider obtaining TEE for imaging of the thoracic aorta. B Show 4 more Patients with thoracoabdominal aortic aneurysm (indications for repair): https://web.pathway.md/diseases/recOyhB0tVbURQpkh 9/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway Perform repair in patients with intact degenerative thoracoAAA with a diameter of 6.0 cm. B Consider performing aneurysm repair by experienced surgeons in a multidisciplinary aortic team in patients with intact degenerative thoracoAAA with a diameter of 5.5 cm. B Consider performing repair in patients with intact degenerative thoracoAAA with a diameter of < 5.5 cm and with features associated with an increased risk of rupture. C Patients with thoracoabdominal aortic aneurysm (endovascular repair): consider performing endovascular repair in hemodynamically stable patients with ruptured thoracoAAA requiring intervention in centers with endovascular expertise and access to appropriate endovascular stent grafts. C Show 3 more Patients with thoracoabdominal aortic aneurysm, open repair: As per AHA/ACC 2022 guidelines, perform open repair in patients with ruptured thoracoAAA requiring intervention. B Show 5 more As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, perform elective surgery in patients with thoracoabdominal aneurysms with a diameter of > 6.0 cm (or less in patients with a connective tissue disorder, such as Marfan or Loeys- Dietz syndrome) if endovascular stent graft options are limited and surgical morbidity is elevated. B Patients with genetic aortic diseases (family history): 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 Patients with genetic aortic diseases, diagnostic imaging: As per AHA/ACC 2022 guidelines: Obtain TTE at the time of initial diagnosis to determine the diameters of the aortic root and ascending aorta, and 6 months thereafter to determine the rate of aortic growth, in patients with Marfan syndrome. Obtain an annual surveillance TTE if the aortic diameters are stable. Obtain CT or MRI of the thoracic aorta if the aortic root, ascending aorta, or both, are not adequately visualized on TTE. B Consider obtaining CT or MRI of the thoracic aorta to confirm the aortic diameters and assess the remainder of the thoracic aorta after the initial TTE in adult patients with Marfan syndrome. C As per ESVS 2017 guidelines, consider obtaining a TTE to measure the aortic root or the diagnosis and follow-up of aortic involvement in patients with Marfan syndrome. C Patients with genetic aortic diseases (genetic testing): obtain genetic testing to identify pathogenic/likely pathogenic variants (mutations) in patients with aortic root/ascending aortic aneurysms or aortic dissection and risk factors for heritable thoracic aortic disease. B Patients with genetic aortic diseases, counseling: As per AHA/ACC 2022 guidelines, provide genetic counseling in patients with an established or likely pathogenic variant in a gene predisposing to heritable thoracic aortic disease. Offer clinical management informed by the specific gene and variant in the gene. B https://web.pathway.md/diseases/recOyhB0tVbURQpkh 10/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway As per ESVS 2017 guidelines: Offer reproductive health counseling by genetic specialists in patients diagnosed with any genetic connective tissue disorder. B Counsel female patients with a confirmed genetic connective tissue disorder regarding the relative risks of pregnancy to both mother and fetus. B Patients with genetic aortic diseases (screening of family relatives): obtain genetic testing in at-risk biological relatives (cascade testing) of patients with thoracic aortic disease with a pathogenic/likely pathogenic variant. B Show 3 more Patients with genetic aortic diseases (medical therapy): consider treating patients with Loeys- Dietz and Ehlers-Danlos syndromes in collaboration with highly specialized referral centers. C Show 2 more Patients with genetic aortic diseases, aneurysm repair: As per AHA/ACC 2022 guidelines, perform TEVAR over open surgery in patients without Marfan syndrome, Loeys-Dietz syndrome, or vascular Ehlers-Danlos syndrome having a descending TAA meeting criteria for intervention and with suitable anatomy for endovascular repair. B Show 4 more As per ESVS 2017 guidelines, consider performing surgery in patients with genetic syndromes associated with TAA dilatation 50 mm. C Show 2 more As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, perform elective surgery at smaller diameters (4.0-5.0 cm depending on the condition) to avoid acute dissection or rupture in patients with Marfan syndrome or other genetically mediated disorders (such as vascular Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, or familial TAA and dissection). B Show 5 more Patients with genetic aortic diseases (surveillance imaging): obtain surveillance imaging of the thoracic aorta by MRI or CT to evaluate for a distal thoracic aortic disease, initially annually and then, if normal in diameter and unchanged after 2 years, every other year in patients with Marfan syndrome undergone aortic root replacement. B Patients undergoing aortic valve surgery: As per ACC 2022 guidelines, consider performing ascending aortic replacement by experienced surgeons in a multidisciplinary aortic team in patients undergoing repair or replacement of a tricuspid aortic valve having a concomitant aneurysm of the ascending aorta with a maximum diameter of 4.5 cm. C Show 2 more As per AHA 2010 guidelines, consider performing concomitant aortic root repair or replacement of the ascending aorta in patients with an ascending aorta or aortic root of > 4.5 cm undergoing aortic valve repair or replacement. B Patients with ruptured thoracic aortic aneurysm: https://web.pathway.md/diseases/recOyhB0tVbURQpkh 11/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway As per ACC 2022 guidelines: Perform TEVAR over open repair due to low perioperative mortality and morbidity in patients with ruptured descending TAA being anatomic candidates for endovascular repair. B Consider performing intentional coverage of the left subclavian artery, celiac artery, or both, to increase the landing zone for endovascular repair in patients with ruptured descending TAA undergoing TEVAR. C As per ESVS 2017 guidelines: Perform endovascular repair as the first treatment option in patients with ruptured descending TAA with suitable anatomy. B Perform left subclavian artery revascularization before left subclavian artery coverage in emergency ruptured descending TAA in patients with a patent left mammary to coronary bypass or with a dominant or single left vertebral artery. B As per ESC 2014 guidelines, obtain emergency CT angiography in patients with suspected rupture of TAA for diagnosis confirmation. B Show 2 more Patients with coronary artery disease: As per ESVS 2017 guidelines, consider performing revascularization of symptomatic or severe asymptomatic coronary artery disease before open descending thoracic aorta surgery. C As per AHA 2010 guidelines: Consider performing concomitant CABG surgery in patients with clinically stable but significant (flow-limiting) coronary artery disease undergoing surgery for ascending or arch aortic disease. C Insufficient evidence to recommend coronary revascularization in patients with clinically stable but significant (flow-limiting) coronary artery disease undergoing surgery or endovascular intervention for descending thoracic aortic disease. I Patients with visceral artery disease: perform additional revascularization in patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease. B 8. Follow-up and surveillance Follow-up aortic imaging, unrepaired aneurysms: As per AHA/ACC 2022 guidelines, consider obtaining follow-up imaging (TTE, CT, or MRI, as appropriate based on individual anatomy) in 6-12 months to determine the rate of aortic enlargement in patients with a dilated thoracic aorta. Consider obtaining surveillance imaging every 6-24 months (depending on aortic diameter), if stable. C As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, consider obtaining follow-up CT angiography or MRA of the aorta at 12-month intervals to detect enlargement of the aneurysm in patients with isolated aortic arch aneurysms < 4.0 cm in diameter. C Show 3 more https://web.pathway.md/diseases/recOyhB0tVbURQpkh 12/13 6/24/23, 4:06 PM Thoracic aortic aneurysm Pathway Follow-up aortic imaging, repaired aneurysms: As per AHA/ACC 2022 guidelines, obtain surveillance CT after 1 month and 12 months and, if stable, annually thereafter in patients treated with TEVAR. B Show 3 more As per ESVS 2017 guidelines, consider obtaining CT aortography as first-line imaging surveillance in the acute setting of patients with thoracic aortic diseases. C Show 2 more Management of aortic leaks: perform prompt intervention in patients with any early or late type I or III endoleak after an endovascular repair of the descending thoracic aorta. B References 1. 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 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. V Riambau, D B ckler, J Brunkwall et al. Editor's Choice Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2017 Jan;53 1 4 52. Open 4. 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 5. 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 6. 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 7. Gilbert R Upchurch Jr, Guillermo A Escobar, Ali Azizzadeh et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg. 2021 Jan;73 1S 55S 83S. Open https://web.pathway.md/diseases/recOyhB0tVbURQpkh 13/13