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

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HomeCirculationVol. 121, No. 132010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUB2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic DiseaseA 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 WRITING GROUP MEMBERS Loren F. Hiratzka, MD, Chair, George L. Bakris, MD, Joshua A. Beckman, MD, MS, Robert M. Bersin, MD, Vincent F. Carr, DO, Donald E. CaseyJr, MD, MPH, MBA, Kim A. Eagle, MD, Luke K. Hermann, MD, Eric M. Isselbacher, MD, Ella A. Kazerooni, MD, MS, Nicholas T. Kouchoukos, MD, Bruce W. Lytle, MD, Dianna M. Milewicz, MD, PhD, David L. Reich, MD, Souvik Sen, MD, MS, Julie A. Shinn, RN, MA, CCRN, Lars G. Svensson, MD, PhD and David M. Williams, MD WRITING GROUP MEMBERS Search for more papers by this author , Loren F. HiratzkaLoren F. Hiratzka Search for more papers by this author , George L. BakrisGeorge L. Bakris Search for more papers by this author , Joshua A. BeckmanJoshua A. Beckman Search for more papers by this author , Robert M. BersinRobert M. Bersin Search for more papers by this author , Vincent F. CarrVincent F. Carr Search for more papers by this author , Donald E. CaseyJrDonald E. CaseyJr Search for more papers by this author , Kim A. EagleKim A. Eagle Search for more papers by this author , Luke K. HermannLuke K. Hermann Search for more papers by this author , Eric M. IsselbacherEric M. Isselbacher Search for more papers by this author , Ella A. KazerooniElla A. Kazerooni Search for more papers by this author , Nicholas T. KouchoukosNicholas T. Kouchoukos Search for more papers by this author , Bruce W. LytleBruce W. Lytle Search for more papers by this author , Dianna M. MilewiczDianna M. Milewicz Search for more papers by this author , David L. ReichDavid L. Reich Search for more papers by this author , Souvik SenSouvik Sen Search for more papers by this author , Julie A. ShinnJulie A. Shinn Search for more papers by this author , Lars G. SvenssonLars G. Svensson Search for more papers by this author and David M. WilliamsDavid M. Williams Search for more papers by this author Originally published16 Mar 2010https://doi.org/10.1161/CIR.0b013e3181d4739eCirculation. 2010;121:e266–e369is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 16, 2010: Previous Version 1 Preamble……e2701. Introduction…e270 1.1. Methodology and Evidence Review…e270 1.2. Organization of the Writing Committee…e271 1.3. Document Review and Approval…e271 1.4. Scope of the Guideline…e272 1.4.1. Critical Issues…e274 1.5. Glossary of Terms and Abbreviations Used Throughout Guideline…e2742. The Thoracic Aorta…e275 2.1. The Normal Aorta…e275 2.2. Normal Thoracic Aortic Diameter…e2753. Thoracic Aortic Histopathology…e276 3.1. Atherosclerosis…e276 3.2. Aneurysms and Dissections…e276 3.3. Vasculitis and Inflammatory Diseases…e2774. Imaging Modalities…e278 4.1. Recommendations for Aortic Imaging Techniques to Determine the Presence and Progression of Thoracic Aortic Disease…e278 4.2. Chest X-Ray…e279 4.3. Computed Tomographic Imaging…e279 4.3.1. Computed Tomographic Imaging Technique…e281 4.4. Magnetic Resonance Imaging…e281 4.4.1. Magnetic Resonance Imaging Technique …e282 4.4.2. Black Blood Imaging…e282 4.4.3. Noncontrast White Blood Imaging…e282 4.4.4. Contrast-Enhanced Magnetic Resonance Angiography…e282 4.4.5. Phase Contrast Imaging…e282 4.5. Standards for Reporting of the Thoracic Aorta on Computed Tomography and Magnetic Resonance Imaging…e282 4.6. Angiography…e283 4.7. Echocardiography…e284 4.7.1. Echocardiographic Criteria for Thoracic Aortic Aneurysms…e284 4.7.2. Echocardiographic Criteria for Aortic Dissection…e284 4.7.2.1. Diagnostic Accuracy of Echocardiography for Aortic Dissection…e285 4.7.2.2. Diagnostic Accuracy of Echocardiography for Acute Intramural Hematoma…e285 4.7.2.3. Role of Echocardiography in Following Patients With Chronic Aortic Disease…e2865. Genetic Syndromes Associated With Thoracic Aortic Aneurysms and Dissections…e286 5.1. Recommendations for Genetic Syndromes…e286 5.1.1. Marfan Syndrome…e287 5.1.2. Loeys-Dietz Syndrome…e288 5.1.3. Ehlers-Danlos Syndrome, Vascular Form or Type IV…e288 5.1.4. Turner Syndrome…e288 5.1.5. Other Genetic Syndromes With Increased Risk for Thoracic Aortic Aneurysms and Dissections…e289 5.1.6. Recommendations for Familial Thoracic Aortic Aneurysms and Dissections…e289 5.2. Summary…e2906. Other Cardiovascular Conditions Associated With Thoracic Aortic Aneurysm and Dissection…e291 6.1. Recommendations for Bicuspid Aortic Valve and Associated Congenital Variants in Adults…e291 6.2. Aberrant Right Subclavian Artery…e292 6.3. Coarctation of the Aorta…e292 6.4. Right Aortic Arch…e2927. Inflammatory Diseases Associated With Thoracic Aortic Disease…e292 7.1. Recommendations for Takayasu Arteritis and Giant Cell Arteritis…e292 7.2. Takayasu Arteritis…e293 7.3. Giant Cell Arteritis…e295 7.4. Behçet Disease…e296 7.5. Ankylosing Spondylitis (Spondyloarthropathies) …e296 7.6. Infective Thoracic Aortic Aneurysms…e2968. Acute Aortic Syndromes…e297 8.1. Aortic Dissection…e297 8.1.1. Aortic Dissection Definition…e297 8.1.2. Anatomic Classification of Aortic Dissection…e297 8.1.3. Risk Factors for Aortic Dissection…e299 8.1.4. Clinical Presentation of Acute Thoracic Aortic Dissection…e300 8.1.4.1. Symptoms of Acute Thoracic Aortic Dissection…e300 8.1.4.2. Perfusion Deficits and End-Organ Ischemia…e301 8.1.5. Cardiac Complications…e303 8.1.5.1. Acute Aortic Regurgitation…e303 8.1.5.2. Myocardial Ischemia or Infarction…e303 8.1.5.3. Heart Failure and Shock…e303 8.1.5.4. Pericardial Effusion and Tamponade…e303 8.1.6. Syncope…e303 8.1.7. Neurologic Complications…e304 8.1.8. Pulmonary Complications…e304 8.1.9. Gastrointestinal Complications…e304 8.1.10. Blood Pressure and Heart Rate Considerations…e304 8.1.11. Age and Sex Considerations…e304 8.2. Intramural Hematoma…e304 8.3. Penetrating Atherosclerotic Ulcer…e306 8.4. Pseudoaneurysms of the Thoracic Aorta…e306 8.5. Traumatic Rupture of the Thoracic Aorta…e306 8.6. Evaluation and Management of Acute Thoracic Aortic Disease…e307 8.6.1. Initial Evaluation and Management…e307 8.6.1.1. Recommendations for Estimation of Pretest Risk of Thoracic Aortic Dissection…e307 8.6.1.2. Laboratory Testing…e307 8.6.1.3. Recommendations for Screening Tests…e308 8.6.1.4. Recommendations for Diagnostic Imaging Studies…e308 8.6.1.5. Recommendations for Initial Management…e308 8.6.1.6. Recommendations for Definitive Management…e308 8.6.2. Evaluation and Management Algorithms…e309 8.6.3. Initial Management…e310 8.6.3.1. Blood Pressure and Rate Control Therapy…e311 8.6.3.2. Additional Antihypertensive Therapy…e312 8.6.3.3. Pain Control…e312 8.6.3.4. Hypotension…e312 8.6.3.5. Determining Definitive Management…e312 8.6.4. Recommendation for Surgical Intervention for Acute Thoracic Aortic Dissection…e312 8.6.5. Endovascular Interventions…e313 8.6.6. Principles of Treatment for Intramural Hematoma and Penetrating Atherosclerotic Ulcer…e313 8.6.6.1. Intimal Defect Without Intramural Hematoma…e313 8.6.6.2. Intimal Defect With Intramural Hematoma…e313 8.6.6.3. Recommendation for Intramural Hematoma Without Intimal Defect…e313 8.7. Treatment for the Management of Traumatic Aortic Rupture…e3139. Thoracic Aortic Aneurysms…e314 9.1. General Approach to the Patient…e315 9.1.1. Recommendation for History and Physical Examination for Thoracic Aortic Disease…e315 9.1.1.1. Coronary Artery Disease…e316 9.1.1.2. Emboli…e317 9.1.1.3. Associated Renal Ischemia…e317 9.1.1.4. Associated Mesenteric Ischemia…e317 9.1.1.5. Associated Peripheral Ischemia…e317 9.1.2. Differential Diagnosis…e317 9.1.2.1. Symptoms…e317 9.1.2.2. Physical Findings…e317 9.1.3. Considerations for Imaging…e318 9.2. General Medical Treatment and Risk Factor Management for Patients With Thoracic Aortic Disease…e318 9.2.1. Recommendation for Medical Treatment of Patients With Thoracic Aortic Diseases…e318 9.2.1.1. Recommendations for Blood Pressure Control…e319 9.2.1.2. Recommendation for Dyslipidemia…e319 9.2.1.3. Recommendation for Smoking Cessation…e319 9.2.2. Surgical and Endovascular Treatment by Location of Disease…e320 9.2.2.1. Ascending Aorta and Aortic Sinuses…e320 9.2.2.1.1. Recommendations for Asymptomatic Patients With Ascending Aortic Aneurysm…e320 9.2.2.1.2. Recommendation for Symptomatic Patients With Thoracic Aortic Aneurysm…e320 9.2.2.1.3. Endovascular Grafting for Ascending Aortic Aneurysm…e321 9.2.2.1.4. Recommendations for Open Surgery for Ascending Aortic Aneurysm…e321 9.2.2.2. Recommendations for Aortic Arch Aneurysms…e323 9.2.2.2.1. Open Surgery…e323 9.2.2.3. Descending Thoracic Aorta and Thoracoabdominal Aorta…e324 9.2.2.3.1. Recommendations for Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms…e324 9.2.2.3.2. Endovascular Versus Open Surgical Approach…e324 9.2.2.3.3. End-Organ Preservation During Thoracic Endograft Implantation…e325 9.2.2.3.4. Periprocedural Complications of Endograft Procedures…e326 9.2.2.3.5. Open Surgical…e327 9.2.2.3.6. End-Organ Preservation During Open Thoracoabdominal Repairs…e328 9.2.2.3.7. Aortic Dissection With Malperfusion…e32810. Special Considerations in Pregnant Patients With Aortic Disease…e328 10.1. Effects of Pregnancy on the Aorta…e328 10.2. Epidemiology of Chronic and Acute Aortic Conditions in Pregnancy…e328 10.3. Counseling and Management of Chronic Aortic Diseases in Pregnancy…e328 10.3.1. Recommendations for Counseling and Management of Chronic Aortic Diseases in Pregnancy…e328 10.4. Evaluation and Management of Acute Aortic Syndromes During Pregnancy…e32911. Aortic Arch and Thoracic Aortic Atheroma and Atheroembolic Disease…e329 11.1. Recommendations for Aortic Arch and Thoracic Aortic Atheroma and Atheroembolic Disease…e329 11.2. Clinical Description…e329 11.3. Risk Factors…e330 11.4. Diagnosis…e330 11.5. Treatment…e330 11.5.1. Anticoagulation Versus Antiplatelet Therapy…e330 11.5.2. Lipid-Lowering Agent…e331 11.5.3. Surgical and Interventional Approaches…e33112. Porcelain Aorta…e33113. Tumors of the Thoracic Aorta…e33114. Perioperative Care for Open Surgical and Endovascular Thoracic Aortic Repairs…e332 14.1. Recommendations for Preoperative Evaluation…e332 14.1.1. Preoperative Risk Assessment…e333 14.2. Recommendations for Choice of Anesthetic and Monitoring Techniques…e334 14.2.1. Temperature Monitoring…e334 14.2.2. Hemodynamic Monitoring…e334 14.2.3. Transesophageal Echocardiography…e334 14.2.4. Transesophageal Echocardiography for Endovascular Repairs of the Descending Thoracic Aorta…e335 14.3. Airway Management for Descending Thoracic Aortic Repairs…e335 14.4. Recommendation for Transfusion Management and Anticoagulation in Thoracic Aortic Surgery…e335 14.5. Organ Protection…e336 14.5.1. Recommendations for Brain Protection During Ascending Aortic and Transverse Aortic Arch Surgery…e336 14.5.2. Recommendations for Spinal Cord Protection During Descending Aortic Open Surgical and Endovascular Repairs…e337 14.5.2.1. Monitoring of Spinal Cord Function in Descending Thoracic Aortic Repairs…e337 14.5.2.2. Maintenance of Spinal Cord Arterial Pressure…e338 14.5.2.3. Cerebrospinal Fluid Pressure and Drainage…e338 14.5.2.4. Hypothermia…e339 14.5.2.5. Glucocorticoids and Mannitol…e339 14.5.3. Recommendations for Renal Protection During Descending Aortic Open Surgical and Endovascular Repairs…e339 14.6. Complications of Open Surgical Approaches…e339 14.7. Mortality Risk for Thoracic Aortic Surgery…e340 14.8. Postprocedural Care…e341 14.8.1. Postoperative Risk Factor Management…e341 14.8.2. Recommendations for Surveillance of Thoracic Aortic Disease or Previously Repaired Patients…e34115. Nursing Care and Patient/Family Education…e342 15.1. Nursing Care of Medically Managed Patients…e342 15.2. Preprocedural Nursing Care…e342 15.3. Postprocedural Nursing Care…e342 15.4. Nursing Care of Surgically Managed Patients…e34316. Long-Term Issues…e344 16.1. Recommendation for Employment and Lifestyle in Patients With Thoracic Aortic Disease…e34417. Institutional/Hospital Quality Concerns…e345 17.1. Recommendations for Quality Assessment and Improvement for Thoracic Aortic Disease…e345 17.2. Interinstitutional Issues…e34518. Future Research Directions and Issues…e346 18.1. Risks and Benefits of Current Imaging Technologies…e346 18.2. Mechanisms of Aortic Dissection…e346 18.3. Treatment of Malperfusion and Reperfusion Injury…e346 18.4. Gene-Based Mechanisms and Models…e347 18.4.1. Aortic Disease Management Based on the Underlying Genetic Defects…e347 18.4.2. Biomarkers for Acute Aortic Dissection…e347 18.4.3. Genetic Defects and Molecular Pathway Analyses…e347 18.4.4. Clinical Trials for Medical Therapy for Aortic Aneurysms…e347 18.5. Aortic Atheroma and Atherosclerosis Identification and Treatment…e347 18.6. Prediction Models of Aortic Rupture and the Need for Preemptive Interventions…e347 18.7. National Heart, Lung, and Blood Institute Working Group Recommendations…e347Appendix 1. Author Relationships With Industry and Other Entities…e365Appendix 2. Reviewer Relationships With Industry and Other Entities…e367Appendix 3. Abbreviation List…e369References…e348PreambleIt 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 that, 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 choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and clinical outcomes constitute the primary basis for recommendations in these guidelines.The ACCF/AHA Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all current relationships and those 24 months prior to initiation of the writing effort that may be perceived as relevant. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the members voting. Members who were recused from voting are noted on the title page of this document. Members must recuse themselves from voting on any recommendation where their relationships with industry (RWI) apply. If a writing committee member develops a new relationship with industry during his/her tenure, he/she is required to notify guideline staff in writing. These statements are reviewed by the Task Force on Practice Guidelines and all members during each conference call and/or meeting of the writing committee, updated as changes occur, and ultimately published as an appendix to the document. For detailed information regarding guideline policies and procedures, please refer to the methodology manual for ACCF/AHA Guideline Writing Committees.1 RWI and other entities pertinent to this guideline for authors and peer reviewers are disclosed in Appendixes 1 and 2, respectively. Disclosure information for the ACCF/AHA Task Force on Practice Guidelines is also available online at (http://www.acc.org/about/overview/ ClinicalDocumentsTaskForces.cfm).These practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for diagnosis, management, and prevention of specific diseases or conditions. Clinicians should consider the quality and availability of expertise in the area where care is provided. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The recommendations reflect a consensus after a thorough review of the available current scientific evidence and are intended to improve patient care. The Task Force recognizes that situations arise where additional data are needed to better inform patient care; these areas will be identified within each respective guideline when appropriate.Patient adherence to prescribed and agreed upon medical regimens and lifestyles is an important aspect of treatment. Prescribed courses of treatment in accordance with these recommendations are effective only if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles.If these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care and aligned with the patient’s best interest. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and the patient in light of all of the circumstances presented by that patient. Consequently, there are circumstances in which deviations from these guidelines are appropriate.The guidelines will be reviewed annually by the ACCF/AHA Task Force on Practice Guidelines and considered current unless they are updated, revised, or withdrawn from distribution.Alice K. Jacobs, MD, FACC, FAHAChair, ACCF/AHA Task Force on Practice GuidelinesSidney C. Smith, Jr, MD, FACC, FAHAImmediate Past Chair, ACCF/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe writing committee conducted a comprehensive search of the medical and scientific literature through the use of PubMed/MEDLINE. Searches were limited to publications written in the English language. Compiled reports were reviewed and additional articles were provided by committee members. Specifically targeted searches were conducted on the following subtopics: acute aortic dissection, ankylosing spondylitis, aortic dissection and litigation, aortic neoplasm, aortic tumors, Behçet disease, bicuspid aortic valve, calcified aorta, chronic dissection, coarctation of the aorta, D-dimer, dissecting aneurysm, Ehlers-Danlos syndrome, endovascular and aortic aneurysms, medial degeneration, porcelain aorta, giant cell arteritis, imaging and thoracic aortic disease, inflammatory disease, intramural hematoma, Loeys-Dietz syndrome, Marfan syndrome, Noonan syndrome, penetrating aortic ulcer, polycystic kidney disease, thoracic and aortic aneurysms, thoracic aortic disease and patient care, thoracic aortic disease and surgery, thoracic aorta and Kawasaki disease, Takayasu arteritis, thoracoabdominal and aorta or aortic disease, and Turner syndrome. More than 850 references were reviewed, with 830 used as the primary evidence base for the final guideline. The ACCF/AHA Task Force on Practice Guidelines methodology processes were followed to write the text and recommendations. In general, published manuscripts appearing in journals listed in Index Medicus were used as the evidence base. Published abstracts were used only for emerging information but were not used in the formulation of recommendations.The committee reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from multiple randomized clinical trials or meta-analyses. The committee ranked available evidence as Level B when data were derived from a single randomized trial or nonrandomized studies. Evidence was ranked as Level C when the primary source of the recommendation was consensus opinion, case studies, or standard of care. In the narrative portions of these guidelines, evidence is generally presented in chronological order of development. Studies are identified as observational, retrospective, prospective, or randomized. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as Level C. An analogous example is the use of penicillin for pneumococcal pneumonia, where there are no randomized trials and treatment is based on clinical experience. When recommendations at Level C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues where sparse data are available, a survey of current practice among the clinicians on the writing committee formed the basis for Level C recommendations and no references are cited. The schema for classification of recommendations and level of evidence is summarized in Table 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. Download figureDownload PowerPointTable 1. Applying Classification of Recommendations and Level of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACCF/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.To provide clinicians with a comprehensive set of data, whenever possible, the exact event rates in various treatment arms of clinical trials are presented to permit calculation of the absolute risk difference (ARD), number needed to harm (NNH); the relative treatment effects are described either as odds ratio (OR), relative risk (RR), or hazard ratio (HR) depending on the format in the original publication. Along with all other point statistics, confidence intervals (CIs) for those statistics are added when available.The writing committee recognized that the evidence base for this guideline is less robust in terms of randomized clinical trials than prior ACCF/AHA guidelines, particularly those focused on coronary artery disease (CAD) and heart failure. As the reader will discern, much of the evidence base for this topic consists of cohort studies and retrospective reviews, which largely emanate from centers with a specialized interest in specific types of thoracic aortic disease. The writing committee attempted to focus on providing the practitioner with recommendations for evaluation and treatment wherever possible and where controversy exists, identified as such in the text.The writing committee acknowledges the expertise of the highly experienced and effective practice guidelines staff of the ACCF and AHA. The writing committee chair also acknowledges the commitment and dedication of the diverse writing committee members who were able to put aside issues of specialty “turf” and focus on providing the medical community with a guideline aimed at optimal patient care.1.2. Organization of the Writing CommitteeThe guideline was written by a committee comprised of experts in cardiovascular medicine, surgery, radiology, and nursing. For many of the previous ACCF/AHA practice guidelines, writing expertise has been available within these 2 organizations. Because of the broad scope and diversity of thoracic aortic diseases, as well as the specialists who treat such patients, the ACCF and AHA sought greater involvement from many specialty organizations. Most, but not all, specialty organizations that represent the major stakeholders caring for patients with thoracic aortic diseases provided writing committee members and financial support of the project, and they are recognized as marquee level partners with the ACCF and AHA. These organizations included the American Association for Thoracic Surgery (AATS), American College of Radiology (ACR), American Stroke Association (ASA), Society of Cardiovascular Anesthesiologists (SCA), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Interventional Radiology (SIR), Society of Thoracic Surgeons (STS), and Society for Vascular Medicine (SVM). The American College of Emergency Physicians (ACEP) and the American College of Physicians (ACP) were also represented on the writing committee. Where additional expertise was needed, the scientific councils of the AHA were contacted for writing committee representatives. Representation was provided or facilitated by the Councils on Cardiovascular Nursing, Cardiovascular Surgery and Anesthesia, Cardiovascular Radiology and Intervention, and Clinical Cardiology, Council for High Blood Pressure Research, and Stroke Council.1.3. Document Review and ApprovalThis document was reviewed by 3 outside reviewers nominated by the ACCF and 2 outside reviewers nominated by the AHA, as well as 1 or 2 reviewers from each of the following organizations: the AATS, ACP, ACEP, ACR, ASA, SCA, SCAI, SIR, STS, and the SVM. It was also reviewed by 6 individual content reviewers—2 content reviewers from the ACCF Catherization Committee and 1 content reviewer from the ACCF Interventional Council. All reviewer RWI information was collected and distributed to the writing committee and is published in this document (see Appendix 2).This document was approved for publication by the governing bodies of the ACCF and the AHA and the AATS, ACEP, ACR, ASA, SCA, SCAI, SIR, STS, and SVM and was endorsed by the North American Society for Cardiovascular Imaging.1.4. Scope of the GuidelineThe term “thoracic aortic disease” encompasses a broad range of degenerative, structural, acquired, genetic-based, and traumatic disease states and presentations. According to the Centers for Disease Control and Prevention death certificate data, diseases of the aorta and its branches account for 43 000 to 47 000 deaths annually in the United States.2 The precise number of deaths attributable to thoracic aortic diseases is unclear. However, autopsy studies suggest that the presentation of thoracic aorti