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

TABLE OF CONTENTS Preamble ……………………………….280 Introduction ………………………281 1.1. Methodology and Evidence Review … . .281 1.2. Organization of the Writing Committee …283 1.3. Document Review and Approval …… .283 1.4. Scope of the Guideline ……………283 1.4.1. Critical Issues …………… . .283 1.5. Glossary of Terms and Abbreviations Used Throughout the Guideline …… . .284 The Thoracic Aorta ………………… .284 Thoracic Aortic Histopathology …………284 3.1. Atherosclerosis …………………284 3.2. Aneurysms and Dissections ……… . .284 3.3. Vasculitis and Inflammatory Diseases …285 Recommendations for Aortic Imaging Techniques to Determine the Presence and Progression of Thoracic Aortic Disease ……285 4.1. Chest X-Ray ……………………287 4.2. Computed Tomographic Imaging ……287 4.3. Magnetic Resonance Imaging ……… .287 4.4. Echocardiography ……………… .287 Recommendations for Genetic Syndromes …288 Recommendations for Familial Thoracic Aortic Aneurysm and Dissections ……… .289 Recommendations for Bicuspid Aortic Valve and Associated Congenital Variants in Adults .290 Recommendations for Takayasu Arteritis and Giant Cell Arteritis ………………… .290 Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection ……… .291 Initial Evaluation and Management of Acute Thoracic Aortic Disease ………………292 10.1. Recommendations for Screening Tests . .292 10.2. Recommendations for Diagnostic Imaging Studies ………………………293 10.3. Recommendations for Initial Management ………………… .293 10.4. Recommendations for Definitive Management ………………… .294 Recommendation for Surgical Intervention for Acute Thoracic Aortic Dissection ……… . .294 Recommendation for Intramural Hematoma Without Intimal Defect ……………… .295 Recommendation for History and Physical Examination for Thoracic Aortic Disease … . .295 Recommendation for Medical Treatment of Patients with Thoracic Aortic Diseases ……295 14.1. Recommendations for Blood Pressure Control ………………………295 14.2. Recommendation for Dyslipidemia … .296 14.3. Recommendation for Smoking Cessation …………………… .297 Recommendations for Asymptomatic Patients With Ascending Aortic Aneurysm ………297 Recommendation for Symptomatic Patients with thoracic Aortic Aneurysm …………298 Recommendations for Open Surgery for Ascending Aortic Aneurysm ……………………299 Recommendations for Aortic Arch Aneurysms ……………………… .299 Recommendations for Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms ……………………… .300 Recommendations for Counseling and Management of Chronic Aortic Diseases in Pregnancy ……………………… . .301 Recommendations for Aortic Arch and Thoracic Aortic Atheroma and Atheroembolic Disease . .302 Periprocedural and Perioperative Management ………………………302 22.1. Recommendations for Preoperative Evaluation …………………… .302 22.2. Recommendations for Choice of Anesthetic and Monitoring Techniques ……… .302 22.3. Recommendation for Transfusion Management and Anticoagulation in Thoracic Aortic Surgery ………………………303 22.4. Recommendations for Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery …………… .303 22.5. Recommendations for Spinal Cord Protection During Descending Aortic Open Surgical and Endovascular Repairs … .303 22.6. Recommendations for Renal Protection During Descending Aortic Open Surgical and Endovascular Repairs ……… . .303 Recommendations for Surveillance of Thoracic Aortic Disease or Previously Repaired Patients ………………………… .303 Recommendation for Employment and Lifestyle in Patients with Thoracic Aortic Disease ……… . .304 Tumors of the Thoracic Aorta ………… .304 Recommendations for Quality Assessment and Improvement for Thoracic Aortic Disease … .304 Appendix 1. Author Relationships with Industry and Other Entities ………………… .306 Appendix 2. Reviewer Relationships with Industry and Other Entities ………………308 References ………………………………309 PREAMBLE It is essential that the medical profession play a central role in critically evaluating the evidence related to drugs, devices, and procedures for the detection, management, or prevention of disease. Properly applied, rigorous, expert analysis of the available data documenting absolute and relative benefits and risks of these therapies and procedures can improve outcomes and reduce costs of care by focusing resources on the most effective strategies. One important use of such data is the production of clinical practice guidelines which, in turn, can provide a foundation for a variety of other applications such as performance measures, appropriate use criteria, clinical decision support tools, and quality improvement tools. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines is charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, and the Task Force directs and oversees this effort. Writing committees are charged with assessing the evidence as an independent group of authors to develop, update, or revise recommendations for clinical practice. Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines in partnership with representatives from other medical practitioner and specialty groups. Writing committees are specifically charged to perform a formal literature review, weigh the strength of evidence for or against particular treatments or procedures, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the of or therapies are from on is data on and clinical outcomes the for recommendations in these The ACCF/AHA Task Force on Practice Guidelines to or of that may as a of or the of the as as of the are to and to of the that may as recommendations a by the and by a of the from are on the of this from on where with and other a a with is to in are by the Task Force on Practice Guidelines and of the as and as an to the and procedures, to the for ACCF/AHA Guideline Writing and other to this for authors and are in and for the ACCF/AHA Task Force on Practice Guidelines is available practice guidelines are to in clinical decision by a of for management, and prevention of diseases or the quality and of in the area where care is guidelines to that the of most in most The recommendations a a of the available evidence and are to improve patient The Task Force that where data are to patient these to and medical and is an important of of in with these recommendations are effective are of patient and may and other to the in medical and these guidelines are as the for or the improvement in quality of care and with the The care of a particular patient by the and the patient in of of the by that are in from these guidelines are The guidelines by the ACCF/AHA Task Force on Practice Guidelines and are or from The guidelines are in the issues of the of the American College of Cardiology and ACCF/AHA Task Force on Practice Guidelines ACCF/AHA Task Force on Practice Guidelines 1. 1.1. Methodology and Evidence Review The a of the medical and literature the use of to in the and by on the and of the and and thoracic thoracic and thoracic disease and patient thoracic disease and thoracic and Takayasu and or and with as the evidence for the The ACCF/AHA Task Force on Practice Guidelines to write the and in in as the evidence for in the of The and evidence recommendations with the of evidence as the data from clinical or The available evidence as data from a or Evidence as the of the or of the of these evidence is in of Studies are as or for data are recommendations are on expert and clinical and are as is the use of for where are and is on clinical recommendations are by clinical appropriate clinical are issues where data are a of practice the on the the for recommendations and are The for of recommendations and of evidence is in the an of the of the and an of the of the of Recommendations and of provide with a of the in of clinical are to of the absolute to the relative are as relative or on the in the with other for are The that the evidence for this is in of clinical ACCF/AHA on disease and the of the evidence for this of and from with a in of thoracic disease. The to on the practitioner with recommendations for and and where as such in the The the of the and effective practice guidelines of the and The the and of the to issues of specialty and on the medical with a patient 1.2. Organization of the Writing Committee The by a of in cardiovascular and of the ACCF/AHA practice been available these of the and of thoracic as as the such the and from specialty specialty organizations that the for with thoracic diseases and support of the and are as with the and organizations the American Association for Thoracic Surgery American College of American Association of for and of of Thoracic and for The American College of and the American College of on the the of the for or by the on Surgery and and and for Blood Pressure and 1.3. Document Review and Approval by by the and by the as as or from of the the and the It by from the Committee and from the and to the and is in this Appendix for by the of the and the and the and and by the American for 1.4. Scope of the Guideline The thoracic disease a of and disease and to the for Disease Control and diseases of the and for to in the The of to thoracic diseases is that the of thoracic disease is to and and these for as as to The of thoracic or is and and in may for to or with thoracic disease to and the of and for a variety of thoracic diseases by the for this provide the practitioner with a of and that appropriate care of these can and The of this is to improve the health outcomes and quality of for with thoracic disease. diseases or of the thoracic with the of and the thoracic diseases are disease are in the and the is to the of in for the 1.4.1. Critical Issues the this issues Thoracic diseases are and an and Imaging of the thoracic with or in is the to thoracic diseases and for have in of of of thoracic disease. as the use of these the with as as these as a is in the the recommendations on a for thoracic as in Imaging for on or diseases is and by thoracic of for are the of for and disease the and of for and disease thoracic and thoracic to such an are to the and with of with are subject to or of this disease with and under and have been in the of the and of thoracic disease been for Risk and clinical are in The and of medical in the of this provide for of to the of medical is evidence that or to of the to these diseases the for of in the of disease are of and of the The in the have the to as for disease. the may to to disease. Medical and treatments are to for or of thoracic 1.5. Glossary of Terms and Abbreviations Used Throughout the Guideline Aneurysm a of an a in to the expected of the in and may the and in may that in of the are from of the with of by and by the an that with the is as a of with an in by to the expected Thoracoabdominal the thoracic and the Aortic of the of the with and the of the Dissection and an and The is and for where a in an 2. The thoracic is the the the and the of the the of the the and to the the the of the and is the of the and in of the and to the of the and the and the the the of the and the and to the and the the of the with for as on a of the thoracic Aortic of in and the of the and thoracic the to in and Aorta the the is of from the on a with and by an a of of with by an of of the and of the can the of the 3.1. Atherosclerosis from the the and of in in and of of the of the The of the the in may to in of of The and in on may in the and may the for of from Aneurysms and Dissections Aortic is by and of and of are of of in the is a of in the is literature the of in this Aortic with and to a by in the The in from in these with that for a of to the of the the with to for a of been in the of thoracic and of from with of and with the of of and on the of and been in from with or and in from with are to have of and of been in of with of in the is in thoracic have this or these are in 3.3. Vasculitis and Inflammatory Diseases Giant and Takayasu important with an is by and production disease both and of OF of to the of and in a and of by or the to the of the the of by the to the of the the of of and are of The of to the of Techniques to and of of Aortic Imaging clinical is can to to the and and of Thoracic Aortic in Aortic in or of thoracic disease or of of the most appropriate may on patient related and of of the and to with to the the use of for and the of and with and the of The of is the in and the of to the of to an may to may to and for as to can thoracic as as other disease that can and or is to or of the of and and may to or in the of the a of the of and of of are in 2. 4.1. Chest X-Ray may of or that Chest as a of the of with to other of as a to to a or 4.2. Computed Tomographic Imaging the to the and to and to of and and the to the and the have to of the and to of of to and of to The for a in the of include a to of by a to the and of the of and Imaging of the from the thoracic to the the and to or and of to the appropriate are essential in the on and the 4.3. Magnetic Resonance Imaging been to in the of thoracic with and that are to or may of and of include the to of and and and the patient to or include of the patient is to care to use in with in with or and of on an 4.4. Echocardiography Echocardiography can the of and that the of the disease of the of both and is the of that a from a or that as a the It is essential that the to from such Arch with Arch Arch with in this is the of of to the and and to the of of the of is for with of the is the is or or the from of Patients with or a to to and or and to is of have from the to the of Patients with of the and for evidence of of the or of the thoracic is and are for to or or of of a patient with with and It is to of the in with or a or and an of or by or to or by of with is to the and the of the area in of the or by the in a of is have a and of with have a of with with of the and in to or may to perform of the and to the of of are and that are with the of thoracic and with The recommendations on these and other and Associated with Familial Thoracic Aortic Aneurysm and Genetic Syndromes Associated with Thoracic Aortic Aneurysm and of have the have the of this to is with or to in have to are other that have or of thoracic to are of in with is a of is to in this is to the of or for these to are in the literature of with The of or of these is of with thoracic disease in a of these Aortic is for of with thoracic to with of the with is in a and the with the of or of a patient with thoracic are to have thoracic or of is of of the is in with a of thoracic to are for the of of other to thoracic may in with a and clinical with in these of or of a patient with thoracic are to have thoracic or to a may of of with a of thoracic disease with a of thoracic and for the of a and thoracic disease. of with a have both the and thoracic for evidence of of and Inflammatory Diseases Associated with Thoracic Aortic Aneurysm and Takayasu with of the and as on and of the and of the of the and thoracic and the with of the and thoracic Aorta the from the of of the thoracic of the and Initial for Takayasu and a to or to reduce the of The of of with Takayasu and to disease by and an or of of with Takayasu and the is and of The of Takayasu or include thoracic and or to the of or disease in these of It is to with Takayasu with an is evidence of of of or of of OF OF patient with that may thoracic to a of disease that can to include medical and as as a to that are with and of or other disease. Patients with in to to thoracic and such as and of or thoracic disease. or thoracic or of that is or in that is in that a or of of Patients with of of a and for of or other with thoracic of Patients with of a of in as is a to thoracic of Patients with of or or a of as these to of with or have a a to or the of of with the of and for as with are to thoracic the of central thoracic and Risk for of Thoracic Aortic recommendations provide to improve of The of is to as can and to may to Acute is on and this group may as of are in The and of are in is as to of with and by is in or or is is or and are of this Intimal and and to by or Patients with to this in or to the with or to or or and with from the from and Aortic and with from the OF 10.1. Recommendations for Screening Tests on with that may thoracic the relative of the of of as a for the patient is for of The role of in the of thoracic disease by the of disease as Chest on as may a that the for of Chest on as may an or that are of thoracic the for of and of the or is to or thoracic in for the disease by of in to for by of 10.2. Recommendations for Diagnostic Imaging Studies of a to or on patient and of a clinical for is a of 10.3. Recommendations for Initial Management Acute and Initial of thoracic by and as the of and to a of or of with to as an for of been other to reduce that of in the of the of to as to that may to or of a thoracic of 10.4. Recommendations for Definitive Management and Acute for thoracic and of on for with thoracic of the as as the is or of Acute thoracic the for of the of such as of Acute thoracic the of to or of with thoracic and the of the may with of the with with a or with a a is the of It is to to in the of the of with a of and with a of thoracic the perform a a and for in both and evidence of a of and with of OF of and other for with as as for are or of Studies of Medical Treatment of Thoracic Aortic Recommendations for Blood Pressure Control to with thoracic diseases to a of or with or to reduce the of and cardiovascular of to with and to reduce the of of with thoracic is to reduce with and or to the can of is for with to reduce the of of 14.2. Recommendation for Dyslipidemia Treatment with a to a of is for with a disease such as and disease for of 14.3. Recommendation for Smoking Cessation Smoking and of to and are to or is as is a are and of Ascending of and Ascending with and on Recommendations for Asymptomatic Patients With Ascending Aortic Aneurysm and Recommendations for Bicuspid Aortic Valve and Associated Congenital Variants in Adults Asymptomatic with thoracic or are and for the or is or for of Patients with or other or thoracic and to on the to or of Patients with a of in an that is in for of Patients or and have an or of for of the or of the of is for with other or the of or area in by the in of It is for with or a or to the or by or to or by of Patients with of of a thoracic for from is or quality of is of and are in in or in with have disease. of Patients with and and other with of the and of of the in with a with of thoracic the with and is of of the is for the is or is and of of the is for of the for the is and for that the thoracic with the of with in an or of the is is for the of the of with in is to or to of the of with or in is to or to of the of Preoperative disease. with of the and with a with the to the to the and the of the the of the an to the and the to a with from the with with a and a thoracic is of with or of the thoracic or of with in are and is is the or a such as or is of with and with or from an is of of of Thoracic Recommendations for Thoracic OF with and as as have the of as as the of the disease to of with thoracic or a or for specifically to is of with or or of the are to of of with or is to both the and to is an for of the thoracic of with where is of is for with or of are may of Treatment with a is a for with to reduce the of of with to or may in with or to of to recommendations the and of or thoracic procedures to are available in the Recommendations for Preoperative Evaluation for to the of disease and the of the are of Patients with thoracic disease a or have or other of to the of disease. of Patients with and disease to or the of thoracic or with or of is to the and a may include and of are to for or and have is to perform of are to or for thoracic and have the benefits of are of 22.2. Recommendations for Choice of Anesthetic and Monitoring Techniques The of and and patient to patient to and and the of and of is in of the thoracic are to is in thoracic procedures for of or can the data to It is to the decision to use on patient the of the and the and to in the or thoracic of are in of to or of to the of procedures by or is of 22.3. Recommendation for Transfusion Management and Anticoagulation in Thoracic Aortic Surgery to and is to use in both and thoracic the in and of and other and are important in such an of 22.4. Recommendations for Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery to and a of the and to of the and of and are that or in are to of the and is an important in these of Perioperative is in of the and as is to the of 22.5. Recommendations for Spinal Cord Protection During Descending Aortic Open Surgical and Endovascular Repairs is as a in and thoracic for of of Spinal such as and is as an of the and in and thoracic of is an important in these of is for of the of the thoracic of to the of the to may and thoracic for of include with with and with of of the or may as a to and to of to or of 22.6. Recommendations for Renal Protection During Descending Aortic Open Surgical and Endovascular Repairs Preoperative and may for of in of the of During or with of the by or may of or for the of in of OF Computed or of the thoracic is a or or of the of Computed or of the is and that can in a of with of the the is that of can by of a thoracic is in and of is to the of Surveillance to is in with of The of for thoracic is that with to for the the for for with and for with for of Aortic or with a thoracic or or and are the of or that a of for with thoracic disease is important in health and the of are outcomes and data of variety for that to is or for with thoracic disease. to as is with a in and most that and are with is to in such as or a to that the patient have a to with is a in the is for the of is a in by a in with or a most that or may and that such with on an to these on data can are in of of to OF of the thoracic are and related to of and or and of the thoracic are disease is the of of may include and or the of or by a for an may in the area of the or the and of the of the have been most with is that provide care for with of thoracic disease procedures for thoracic and in quality and improvement thoracic disease include and of thoracic and of that provide care for with of thoracic disease procedures for thoracic and and quality and improvement with and medical to for quality improvement and and medical of care on available data and performance in with this of Patients with may to the and the of the patient in and for the American College of Cardiology Foundation and and and and American Heart Association of Author Relationships With Industry and Other Guidelines for the and Management of Patients with Thoracic Aortic Reviewer Relationships With Industry and Other Guidelines for the and Management of Patients with Thoracic Aortic Disease