2010 Guidelines on Thoracic Aortic Disease

2010 Guidelines on Thoracic Aortic Disease

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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

Recommendations for Aortic Imaging Techniques

• For CT or MRI, the external diameter should be measured perpendicular to the axis of blood flow.
• For echocardiography, the internal diameter should be measured perpendicular to the axis of blood flow.
• The finding of aortic dissection, aneurysm, traumatic injury and/or aortic rupture should be immediately communicated to the referring physician.

Aortic Imaging Reports

• The location at which the aorta is abnormal.
• 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.
• 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.
• The presence of internal filling defects consistent with thrombus or atheroma.
• The presence of intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and calcification.
• Extension of aortic abnormality into branch vessels, including dissection and aneurysm, and secondary evidence of end-organ injury (eg, renal or bowel
  hypoperfusion).
• Evidence of aortic rupture, including periaortic and mediastinal hematoma, pericardial and pleural fluid, and contrast extravasation from the aortic lumen.
• When a prior examination is available, direct image to image comparison to determine if there has been any increase in diameter.

High Risk Conditions

• Marfan Syndrome
• 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

High Risk Pain Features

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.

High Risk Examination Features

• 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)

Initial Management

• IV β-blockade should be initiated and titrated to a target heart rate < 60 bpm non-dihydropyridine Ca channel-blockade should be used as an alternative for rate control if contraindications to β-blockade, If SBP > 120mmHg after heart rate control has been obtained, then ACEIs and/or other vasodilators should be administered to further reduce BP that maintains adequate end-organ perfusion.
• β-blockers should be used cautiously in the setting of acute aortic regurgitation because they will block the compensatory tachycardia.
• 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.

AoD Evaluation Pathway

Acute AoD Management Pathway

Acute Surgical Management Pathway for AoD