Acc/aha pocket Guideline Based on the 2010 accf/aha/aats

1. 

A negative chest x-ray should not delay definitive 

aortic imaging in patients determined to be high risk 

for aortic dissection by initial screening. (LOE: C)

8.2. Recommendations for Diagnostic Imaging Studies

Class I 

1. 

Selection of a specific imaging modality to identify 

or exclude aortic dissection should be based on pa-

tient variables and institutional capabilities, includ-

ing immediate availability.  (LOE: C)

2. 

If a high clinical suspicion exists for acute aortic 

dissection but initial aortic imaging is negative, a 

second imaging study should be obtained.  (LOE: C)

36

8.3. Recommendations for Initial Management (see Figure 4)

Class I 

1. 

Initial management of thoracic aortic dissection 

should be directed at decreasing aortic wall stress by 

controlling heart rate and blood pressure as follows:

a.  In the absence of contraindications, intravenous 

beta blockade should be initiated and titrated to a 

target heart rate of 60 beats per minute or less. 

(LOE: C)

b.  In patients with clear contraindications to beta 

blockade, nondihydropyridine calcium channel–

blocking agents should be utilized as an 

alternative for rate control. (LOE: C)

c.  If systolic blood pressures remain greater than 

120 mm Hg after adequate heart rate control has 

been obtained, then angiotensin-converting 

enzyme inhibitors and/or other vasodilators 

should be administered intravenously to further 

reduce blood pressure that maintains adequate 

end-organ perfusion. (LOE: C)

d.  Beta blockers should be used cautiously in the 

setting of acute aortic regurgitation because they 

will block the compensatory tachycardia. (LOE: C)

37

Class III 

1. 

Vasodilator therapy should not be initiated prior to 

rate control so as to avoid associated reflex tachy-

cardia that may increase aortic wall stress, leading 

to propagation or expansion of a thoracic aortic dis-

section. (LOE: C)

8.4. Recommendations for Definitive Management  

(see Figures 3 and 5)

Class I 

1. 

Urgent surgical consultation should be obtained 

for all patients diagnosed with thoracic aortic dis-

section regardless of the anatomic location (ascend-

ing versus descending) as soon as the diagnosis is 

made or highly suspected. (LOE: C)

2. 

Acute thoracic aortic dissection involving the 

ascending aorta should be urgently evaluated for 

emergent surgical repair because of the high risk of 

associated life-threatening complications such as 

rupture.  (LOE: B) 

3. 

Acute thoracic aortic dissection involving the 

descending aorta should be managed medically 

unless life-threatening complications develop (ie, 

malperfusion syndrome, progression of dissection, 

enlarging aneurysm, inability to control blood 

pressure or symptoms). (LOE: B) 

38

Figur

e 4.

 

Acute 

AoD Management P

athway

.

AoD indicates aortic dissection;

 BP

, blood pressure;

 MAP

, mean arterial pressure;

 and 

TTE,

 transthoracic echocardiogram.

39

Figur

e 4.

 

Acute 

AoD Management P

athway

.

AoD indicates aortic dissection;

 BP

, blood pressure;

 MAP

, mean arterial pressure;

 and 

TTE,

 transthoracic echocardiogram.

40

Figure 5. 

Acute Surgical Management Pathway for AoD.

*Addition of ‘if appropriate’ based on Patel MR, Dehmer GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AATS/AHA/

ASNC 2009 Appropriateness Criteria for Coronary Revascularization. J Am Coll Cardiol. 2009;53:530–53.

AoD indicates aortic dissection; CABG, coronary artery bypass graft surgery; CAD, coronary artery disease; 

TAD, thoracic aortic disease; and TEE, transesophageal echocardiogram. 

41

9. Recommendation for Surgical 

Intervention for Acute Thoracic Aortic 

Dissection

Class I 

1. 

For patients with ascending thoracic aortic dissec-

tion, all aneurysmal aorta and the proximal extent of 

the dissection should be resected. A partially dissect-

ed aortic root may be repaired with aortic valve re-

suspension. Extensive dissection of the aortic root 

should be treated with aortic root replacement with a 

composite graft or with a valve sparing root replace-

ment. If a DeBakey Type II dissection is present, the 

entire dissected aorta should be replaced. (LOE: C)

42

10. Recommendation for Intramural 

Hematoma Without Intimal Defect

Class IIa 

1. 

It is reasonable to treat intramural hematoma 

similar to aortic dissection in the corresponding seg-

ment of the aorta. (LOE: C)

43

11. Recommendation for History and 

Physical Examination for Thoracic Aortic 

Disease

Class I 

1. 

For patients presenting with a history of acute car-

diac and noncardiac symptoms associated with a sig-

nificant likelihood of thoracic aortic disease, the clini-

cian should perform a focused physical examination, 

including a careful and complete search for arterial 

perfusion differentials in both upper and lower ex-

tremities, evidence of visceral ischemia, focal neuro-

logic deficits, a murmur of aortic regurgitation, bruits, 

and findings compatible with possible cardiac tam-

ponade. (LOE: C)

44

12. Recommendation for Medical Treatment 

of Patients With Thoracic Aortic Diseases 

Class I 

1. 

Stringent control of hypertension, lipid profile op-

timization, smoking cessation, and other atheroscle-

rosis risk-reduction measures should be instituted 

for patients with small aneurysms not requiring sur-

gery, as well as for patients who are not considered 

surgical or stent graft candidates. (LOE: C)

12.1. Recommendations for Blood Pressure Control

Class I 

1. 

Antihypertensive therapy should be administered 

to hypertensive patients with thoracic aortic diseases 

to achieve a goal of less than 140/90 mm Hg (pa-

tients without diabetes) or less than 130/80 mm Hg 

(patients with diabetes or chronic renal disease) to 

reduce the risk of stroke, myocardial infarction, heart 

failure, and cardiovascular death. (LOE: B) 

2. 

Beta adrenergic–blocking drugs should be 

administered to all patients with Marfan syndrome 

and aortic aneurysm to reduce the rate of aortic 

dilatation unless contraindicated. (LOE: B) 

45

Class IIa 

1. 

For patients with thoracic aortic aneurysm, it is 

reasonable to reduce blood pressure with beta block-

ers and angiotensin-converting enzyme inhibitors or 

angiotensin receptor blockers to the lowest point pa-

tients can tolerate without adverse effects. (LOE: B) 

2. 

An angiotensin receptor blocker (losartan) is 

reasonable for patients with Marfan syndrome, to 

reduce the rate of aortic dilatation unless 

contraindicated. (LOE: B) 

46

13. Recommendations for Asymptomatic 

Patients With Ascending Aortic Aneurysm 

(see Figures 6 and 7)

Class I 

1. 

Asymptomatic patients with degenerative thoracic 

aneurysm, chronic aortic dissection, intramural he-

matoma, penetrating atherosclerotic ulcer, mycotic 

aneurysm, or pseudoaneurysm, who are otherwise 

suitable candidates and for whom the ascending 

aorta or aortic sinus diameter is 5.5 cm or greater 

should be evaluated for surgical repair. (LOE: C) 

2. 

Patients with Marfan syndrome or other 

genetically mediated disorders (vascular Ehlers-

Danlos syndrome, Turner syndrome, bicuspid aortic 

valve, or familial thoracic aortic aneurysm and 

dissection) should undergo elective operation at 

smaller diameters (4.0 to 5.0 cm depending on the 

condition; see Section 4) to avoid acute dissection or 

rupture. (LOE: C)

47

3. 

Patients with a growth rate of more than 0.5 cm/y 

in an aorta that is less than 5.5 cm in diameter 

should be considered for operation. (LOE: C)

4. 

Patients undergoing aortic valve repair or 

replacement and who have an ascending aorta or 

aortic root of greater than 4.5 cm should be 

considered for concomitant repair of the aortic root 

or replacement of the ascending aorta. (LOE: C)

Class IIa 

1. 

Elective aortic replacement is reasonable for pa-

tients with Marfan syndrome, other genetic diseases, 

or bicuspid aortic valves, when the ratio of maximal 

ascending or aortic root area (∏ r

2

) in cm

2

 divided by 

the patient’s height in meters exceeds 10. (LOE: C)

2. 

It is reasonable for patients with Loeys-Dietz 

syndrome or a confirmed TGFBR1 or TGFBR2 

mutation to undergo aortic repair when the aortic 

diameter reaches 4.2 cm or greater by 

transesophageal echocardiogram (internal diameter) 

or 4.4 to 4.6 cm or greater by computed tomographic 

imaging and/or magnetic resonance imaging 

(external diameter). (LOE: C)

48

Figure 6. 

Ascending Aortic Aneurysm of Degenerative Etiology.

CABG indicates coronary artery bypass graft surgery; CAD, coronary artery disease; CT, computed 

tomographic imaging; and MR, magnetic resonance imaging.

49

Figure 7. 

Ascending Aortic Aneurysms Associated  

With Genetic Disorder.

*Depends on specific genetic condition. †See Recommendations for Asymptomatic Patients With Ascending 

Aortic Aneurysm (Section 13), and Recommendations for Bicuspid Aortic Valve and Associated Congenital 

Variants in Adults (Section 6). CABG indicates coronary artery bypass graft surgery; CAD, coronary artery 

disease; CT, computed tomographic imaging; and MR, magnetic resonance imaging.

50

14. Recommendation for Symptomatic Patients With 

Thoracic Aortic Aneurysm

Class I 

1. 

Patients with symptoms suggestive of expansion 

of a thoracic aneurysm should be evaluated for 

prompt surgical intervention unless life expectancy 

from comorbid conditions is limited or quality of life 

is substantially impaired. (LOE: C) 

51

15. Recommendations for Open Surgery for 

Ascending Aortic Aneurysm

Class I 

1. 

Separate valve and ascending aortic replacement 

are recommended in patients without significant 

aortic root dilatation, in elderly patients, or in young 

patients with minimal dilatation who have aortic 

valve disease. (LOE: C)

2. 

Patients with Marfan, Loeys-Dietz, and Ehlers-

Danlos syndromes and other patients with dilatation 

of the aortic root and sinuses of Valsalva should 

undergo excision of the sinuses in combination with 

a modified David reimplantation operation if 

technically feasible or, if not, root replacement with 

valved graft conduit. (LOE: B)

52

16. Recommendations for Aortic Arch 

Aneurysms

Class IIa 

1. 

For thoracic aortic aneurysms also involving the 

proximal aortic arch, partial arch replacement to-

gether with ascending aorta repair using right sub-

clavian/axillary artery inflow and hypothermic cir-

culatory arrest is reasonable. (LOE: B)

2. 

Replacement of the entire aortic arch is 

reasonable for acute dissection when the arch is 

aneurysmal or there is extensive aortic arch 

destruction and leakage. (LOE: B)

3. 

Replacement of the entire aortic arch is 

reasonable for aneurysms of the entire arch, for 

chronic dissection when the arch is enlarged, and 

for distal arch aneurysms that also involve the 

proximal descending thoracic aorta, usually with the 

elephant trunk procedure. (LOE: B)

53

4. 

For patients with low operative risk in whom an 

isolated degenerative or atherosclerotic aneurysm of 

the aortic arch is present, operative treatment is 

reasonable for asymptomatic patients when the 

diameter of the arch exceeds 5.5 cm. (LOE: B)

5. 

For patients with isolated aortic arch aneurysms 

less than 4.0 cm in diameter, it is reasonable to 

reimage using computed tomographic imaging or 

magnetic resonance imaging, at 12-month intervals, 

to detect enlargement of the aneurysm. (LOE: C)

6. 

For patients with isolated aortic arch aneurysms 

4.0 cm or greater in diameter, it is reasonable to 

reimage using computed tomographic imaging or 

magnetic resonance imaging, at 6-month intervals, 

to detect enlargement of the aneurysm. (LOE: C)

54

17. Recommendations for Descending 

Thoracic Aorta and Thoracoabdominal 

Aortic Aneurysms

Class I 

1. 

For patients with chronic dissection, particularly if 

associated with a connective tissue disorder, but 

without significant comorbid disease, and a de-

scending thoracic aortic diameter exceeding 5.5 cm, 

open repair is recommended. (LOE: B)

2. 

For patients with degenerative or traumatic 

aneurysms of the descending thoracic aorta 

exceeding 5.5 cm, saccular aneurysms, or 

postoperative pseudoaneurysms, endovascular stent 

grafting should be strongly considered when 

feasible. (LOE: B)

3. 

For patients with thoracoabdominal aneurysms, in 

whom endovascular stent graft options are limited 

and surgical morbidity is elevated, elective surgery is 

recommended if the aortic diameter exceeds 6.0 cm, 

or less if a connective tissue disorder such as Marfan 

or Loeys-Dietz syndrome is present. (LOE: C) 

4. 

For patients with thoracoabdominal aneurysms 

and with end-organ ischemia or significant stenosis 

from atherosclerotic visceral artery disease, an 

additional revascularization procedure is 

recommended. (LOE: B)

55

Table 7. 

Summary of Society of Thoracic Surgeons 

Recommendations for Thoracic Stent Graft Insertion

Entity/Subgroup

Classification

Level of Evidence

Penetrating ulcer/intramural 

hematoma

   Asymptomatic

III

C

   Symptomatic

IIa

C

Acute traumatic                 

I

B

Chronic traumatic

IIa

C

Acute Type B dissection

   Ischemia

I

A

   No ischemia

IIb

C

Subacute dissection

IIb

B

Chronic dissection

IIb

B

Degenerative descending

   >5.5 cm, comorbidity

IIa

B

   >5.5 cm, no comorbidity

IIb

C

   <5.5 cm

III

C

Arch

   Reasonable open risk

III

A

   Severe comorbidity

IIb

C

Thoracoabdominal/Severe 

comorbidity

IIb

C

Reprinted from Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on 

the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann 

Thorac Surg. 2008;85:S1–41.

56

18. Recommendations for Counseling and 

Management of Chronic Aortic Diseases in 

Pregnancy 

Class I 

1. 

Women with Marfan syndrome and aortic dilata-

tion, as well as patients without Marfan syndrome 

who have known aortic disease, should be coun-

seled about the risk of aortic dissection as well as 

the heritable nature of the disease prior to pregnan-

cy. (LOE: C)

2. 

For pregnant women with known thoracic aortic 

dilatation or a familial or genetic predisposition for 

aortic dissection, strict blood pressure control, 

specifically to prevent Stage II hypertension, is 

recommended. (LOE: C)

3. 

For all pregnant women with known aortic root or 

ascending aortic dilatation, monthly or bimonthly 

echocardiographic measurements of the ascending 

aortic dimensions are recommended to detect aortic 

expansion until birth. (LOE: C)

57

4. 

For imaging of pregnant women with aortic arch, 

descending, or abdominal aortic dilatation, magnetic 

resonance imaging (without gadolinium) is 

recommended over computed tomographic imaging to 

avoid exposing both the mother and fetus to ionizing 

radiation. Transesophageal echocardiogram is an 

option for imaging of the thoracic aorta. (LOE: C) 

5. 

Pregnant women with aortic aneurysms should be 

delivered where cardiothoracic surgery is available. 

(LOE: C)

Class IIa 

1. 

Fetal delivery via cesarean section is reasonable 

for patients with significant aortic enlargement, dis-

section, or severe aortic valve regurgitation. (LOE: C)

Class IIb 

1. 

If progressive aortic dilatation and/or advancing 

aortic valve regurgitation are documented, prophy-

lactic surgery may be considered. (LOE: C) 

58

19. Recommendations for Aortic Arch and 

Thoracic Aortic Atheroma and 

Atheroembolic Disease 

Class IIa 

1. 

Treatment with a statin is a reasonable option for 

patients with aortic arch atheroma to reduce the risk 

of stroke. (LOE: C) 

Class IIb 

1. 

Oral anticoagulation therapy with warfarin (INR 

2.0 to 3.0) or antiplatelet therapy may be considered 

in stroke patients with aortic arch atheroma 4.0 mm 

or greater to prevent recurrent stroke. (LOE: C) 

59

20. Periprocedural and Perioperative 

Management

20.1. Recommendations for Brain Protection During Ascending 

Aortic and Transverse Aortic Arch Surgery

Class I 

1. 

A brain protection strategy to prevent stroke and 

preserve cognitive function should be a key element 

of the surgical, anesthetic, and perfusion techniques 

used to accomplish repairs of the ascending aorta 

and transverse aortic arch. (LOE: B)  

Class IIa 

1. 

Deep hypothermic circulatory arrest, selective an-

tegrade brain perfusion, and retrograde brain perfu-

sion are techniques that alone or in combination are 

reasonable to minimize brain injury during surgical 

repairs of the ascending aorta and transverse aortic 

arch. Institutional experience is an important factor 

in selecting these techniques. (LOE: B)  

60

Class III 

1. 

Perioperative brain hyperthermia is not recom-

mended in repairs of the ascending aortic and trans-

verse aortic arch as it is probably injurious to the 

brain. (LOE: B) 

20.2. Recommendations for Spinal Cord Protection During 

Descending Aortic Open Surgical and Endovascular Repairs

Class I 

1. 

Cerebrospinal fluid drainage is recommended as a 

spinal cord protective strategy in open and endovas-

cular thoracic aortic repair for patients at high risk of 

spinal cord ischemic injury. (LOE: B)

Class IIa 

1. 

Spinal cord perfusion pressure optimization using 

techniques, such as proximal aortic pressure main-

tenance and distal aortic perfusion, is reasonable as 

an integral part of the surgical, anesthetic, and per-

fusion strategy in open and endovascular thoracic 

aortic repair patients at high risk of spinal cord isch-

emic injury. Institutional experience is an important 

factor in selecting these techniques. (LOE: B)

2. 

Moderate systemic hypothermia is reasonable for 

protection of the spinal cord during open repairs of 

the descending thoracic aorta. (LOE: B)

61

Class IIb 

1. 

Adjunctive techniques to increase the tolerance of 

the spinal cord to impaired perfusion may be consid-

ered during open and endovascular thoracic aortic 

repair for patients at high risk of spinal cord injury. 

These include distal perfusion, epidural irrigation 

with hypothermic solutions, high-dose systemic glu-

cocorticoids, osmotic diuresis with mannitol, intra-

thecal papaverine, and cellular metabolic suppres-

sion with anesthetic agents. (LOE: B)

2. 

Neurophysiological monitoring of the spinal cord 

(somatosensory evoked potentials or motor evoked 

potentials) may be considered as a strategy to detect 

spinal cord ischemia and to guide reimplantation of 

intercostal arteries and/or hemodynamic 

optimization to prevent or treat spinal cord 

ischemia. (LOE: B)

62

21. Recommendations for Surveillance of 

Thoracic Aortic Disease or Previously 

Repaired Patients 

Class IIa 

1. 

Computed tomographic imaging or magnetic reso-

nance imaging of the thoracic aorta is reasonable 

after a Type A or B aortic dissection or after prophy-

lactic repair of the aortic root/ascending aorta.  

(LOE: C)  

2. 

Computed tomographic imaging or magnetic 

resonance imaging of the aorta is reasonable at 1, 3, 

6, and 12 months postdissection and, if stable, 

annually thereafter so that any threatening 

enlargement can be detected in a timely fashion.  

(LOE: C) 

3. 

When following patients with imaging, utilization 

of the same modality at the same institution is 

reasonable, so that similar images of matching 

anatomic segments can be compared side by side.  

(LOE: C)  

4. 

If a thoracic aortic aneurysm is only moderate in 

size and remains relatively stable over time, 

magnetic resonance imaging instead of computed 

tomographic imaging is reasonable to minimize the 

patient’s radiation exposure. (LOE: C) 

5. 

Surveillance imaging similar to classic aortic 

dissection is reasonable in patients with intramural 

hematoma. (LOE: C) 

63

Table 8. 

Suggested Follow-up of Aortic Pathologies  

After Repair or Treatment

Pathology

Interval

Study

Acute dissection

Before discharge, 1 mo, 6 

mo, yearly

CT or MR, chest plus 

abdomen TTE

Chronic dissection

Before discharge, 1 y, 2 to 

3 y

CT or MR, chest plus 

abdomen TTE

Aortic root repair

Before discharge, yearly

TTE

AVR plus 

ascending 

Before discharge, yearly

TTE

Aortic arch

Before discharge, 1 y, 2 to 

3 y

CT or MR, chest plus 

abdomen

Thoracic aortic 

stent

Before discharge, 1 mo, 2 

mo, 6 mo, yearly

Or 30 days*

CXR, CT, chest plus 

abdomen

Acute IMH/PAU

Before discharge, 1 mo, 3 

mo, 6 mo, yearly

CT or MR, chest plus 

abdomen

*US Food and Drug Administration stent graft studies usually required before discharge or at 30-day CT 

scan to detect endovascular leaks. If there is concern about a leak, a predischarge study is recommended; 

however, the risk of renal injury should be borne in mind. All patients should be receiving beta blockers 

after surgery or medically managed aortic dissection, if tolerated. Adapted from Erbel R, Alfonso F, Boileau 

C, et al. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22:1642–81.

AVR indicates aortic valve replacement; CT, computed tomographic imaging; CXR, chest X-ray; IMH, 

intramural hematoma; MR, magnetic resonance imaging; PAU, penetrating atherosclerotic ulcer; and TTE, 

transthoracic echocardiography.

64

22. Recommendation for Employment and 

Lifestyle in Patients With Thoracic Aortic 

Disease

Class IIa 

1. 

For patients with a current thoracic aortic aneu-

rysm or dissection, or previously repaired aortic dis-

section, employment and lifestyle restrictions are 

reasonable, including the avoidance of strenuous 

lifting, pushing or straining that would require a 

Valsalva maneuver. (LOE: C) 

65