European Aortic Guidelines 2024

[JulianM]

New guidelines on aortic conditions have just been published by the professional bodies representing aortic surgeons in Europe.

The official citation is:

Czerny M, Grabenwoger M, Berger T, et al. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg. 2024: in press.

The web link – it’s open access – is here: annalsthoracicsurgery.org/a...

This document is detailed, technical and long – 110 pages - and I seriously think it could have been better with some input from patients and from communications professionals, following the example set in 2022 by the ACC and AHA. It should at the very least have included a short summary of key points: hopefully, this can still appear at some point. However, it is what it is. And it is very thought provoking.

Here are some of my first thoughts:

1. The aorta is an organ in its own right. They’ve said it! It needs to be seen and understood as a whole. Because it crosses (surgical) disciplinary boundaries, it must be dealt with by interdisciplinary teams. They say what they mean by this. Bravo!

2. When is a dilation an aneurysm? When an aortic root or ascending aorta is over 4.5 cm, it is an aneurysm. This definition matches that used for other blood vessels, in that it is 50% larger than the normal size. Of course, it won’t be perfect for everyone. It doesn’t follow that everyone at that size should have an operation - though a minority with high-risk genetics or defective valves probably should - but to have a discussion at that point with a surgeon is no bad thing. It’s what I did myself, after all. 5 years later, I haven’t had surgery, but knowing the possible options and criteria is really important.

3. What are the aortic conditions and how are they changing? The paper starts with a diagram which maps aortic conditions onto the aortic anatomy and ranks them in order of importance/prevalence. For example, bicuspid valve disease is really important for the aortic root and ascending aorta, insignificant for abdominal aortic disease. They notice that with an ageing population, which has given up smoking and is being treated more effectively for cardiovascular conditions, there’s a shift from abdominal aortic aneurysms and ruptures towards ascending aortic aneurysms and dissections. Operations are being done on patients with more complex medical needs. With better imaging and higher quality emergency medical care, more people are surviving dissections. New surgical options are opening up, but most of them have not been assessed through randomised trials and probably never will be. How do we cope with all of this?

4. We need to mind our language and make descriptions more precise. They propose standards for describing dissections which aim at clarifying those descriptions but need to be tested in the real world and will take years to codify into clinical data systems. In patient forums, it is a total pain when people say they have been diagnosed with an ‘AAA’ but do not spell out ‘abdominal aortic aneurysm’ or ‘ascending aortic aneurysm’: these guidelines show it is not only patients who get confused in this field. When it comes to surgery on the aortic arch, the different options, which include hybrid surgery mixing open repairs and keyhole approaches, have to be described accurately for the benefit of patients and also so that when those patients are seen by different medical specialists, as they often are, everyone knows exactly what state the aorta has been left in.

5. There is a huge amount we still don’t know about aortic disease and how best to manage it. These guidelines give us a framework that highlights some of the gaps and weaknesses in what we know and how we know it. They also highlight a number of things that we really do know – perhaps, have known for years - but haven’t always paid proper attention to. Hopefully, they’ll get the discussion going in ways that are really helpful.

[LaceyLady]

My mother died from an aortic aneurysm rupture, she’d had severe arthritis and wouldn’t go near the drs due to previous experiences.

My elder sister also had an aortic aneurysm which a certain well known hospital ignored for several years till she dropped dead suddenly at 70😡 Both were tiny women and yet they were applying standard measurements usually man sized 😡

I and younger sister have had scans because as it appears this can be inherited. However we have inherited Haemochromatosis a genetic Celtic liver disease where the organs load iron and destroy them.Ice developed Peripheral Atrial Fibrillation & T2 diabetes, we seem to have heart issues on fathers side but who put all the human body as a integrated system and not a load of parts 🤷🏼‍♀️

[JulianM in reply to LaceyLady]

I'm sorry your family had that experience, though as we get older all aortas do enlarge and not all of them should be treated. There's always a balance of risks and judgements to make.

The Marfan Foundation (US charity which covers heritable thoracic aortic disease in general, not only Marfan) recently had a webinar on gender differences in aortic disease, mostly focused on mice, but never mind ... you are right, there are differences. Hormonal changes in pregnancy and in menopause do alter levels of risk for women.

There's an important section in these new guidelines about pregnancy, which is something that Aortic Dissection Awareness UK and Ireland has already been working on.

I'm glad that you and your younger sister have had scans because you are right, these conditions do run in families and this is reflected in these guidelines as well as the more comprehensive US ones that were issued in 2022. I'm hoping this will also be reflected more strongly in BHF and other public information resources as these are revised and updated.

[LaceyLady in reply to JulianM]

My sister wasn’t even monitored regularly. Her husband had said she’s a tiny woman, was only 4’ 11 tiny frame. They took no notice. She has a daughter as do I.

[JulianM in reply to LaceyLady]

Which may say something about the need to educate professionals, to get referred to centres that actually understand these conditions, and for some advocacy to raise standards of diagnosis and treatment. So far, most of the effort has gone into better responses to aortic dissection, but the people involved do recognise that prevention is better than cure - especially when there isn't a cure.

[LaceyLady in reply to JulianM]

I understood that there was a procedure to encase the defective part, sure I remember someone having a repair. My mum had severe rheumatoid arthritis. My very well qualified osteopath had said the cartilage is made from the same/similar tissue.

[JulianM in reply to LaceyLady]

There are a range of surgical options. One that I'm interested in is PEARS, which does involve fitting a kind of support stocking around the outside of the aortic root and ascending aorta: this may be what you are thinking of. However, it isn't discussed in these guidelines. There are connections between aortic disease and some connective tissue disorders which have skeletal aspects, but the aorta doesn't contain cartilage. There's one genetic syndrome - part of the Loeys-Dietz group - which involves early onset osteoarthritis, but I'm not aware of any link to rheumatoid arthritis, which I think of as more of an auto-immune inflammatory disease ... but I may be wrong!

[LaceyLady in reply to JulianM]

Complicated. I have found that my siblings and I have genetic Haemochromatosis

[DJK99 in reply to LaceyLady]

So sorry. Just wanted to say.

[Livelovelife56]

Thank you for this it is really helpful😊

[DippyDingDong]

Thank you JulianM for taking the time to read this and highlight areas of interest. My dilated ascending aorta was diagnosed at 39mm, but it now appears to have reduced to 36.7mm. I'm hoping it's not user error and that the BP control and plant based diet have had an effect.

[JulianM in reply to DippyDingDong]

A difference of 2 mm in readings is not at all unusual; aortas don't really shrink, but it is definitely more comfortable to see the second one slightly lower. If they were made using different imaging systems it would be more surprising if they were the same! Good BP control is central to avoiding problems in these conditions: these guidelines say as much, in identifying BP as the main risk factor that can be modified for the majority of current aortic patients. I'm also a fan of plant based diets, though there is no direct evidence they affect ascending aortic disease. Am currently doing the Zoe programme - and diversifying the plant based element of my diet is central to it. I also like their emphasis on finding food that is 'delicious' (as well as helpful in relation to our health).

[Petercat1 in reply to JulianM]

Hi.I had an aortic dissection, and emergency open heart surgery nearly 7 years ago, I also had my aortic valve replaced. I have to keep my BP down to 120/80.

I am so glad more medical people are getting to understand about this. I still have yearly CT scans with contrast at Southampton Hospital.

I don't know how quickly I was diagnosed, as I dissected on a plane landing at Bournemouth Airport, was rushed to Royal B'mouth Hospital's A&E, then to Southampton for the emergency op, but presume I was diagnosed in B'mth. Luckily I'm still here to tell the tale.

Denise

[MarSeven]

Very informative, I appreciate your commitment to keeping us informed, a very useful precis of the document. Thank you 😊

[Tedthedog]

thanks for keeping us updated Julian.

Its really helpful

Best

Ellen