<ul><li><p>ESC GUIDELINES</p><p>2014 ESC Guidelines on the diagnosis andtreatment of aortic diseasesDocument covering acute and chronic aortic diseases of the thoracicand abdominal aorta of the adult</p><p>The Task Force for the Diagnosis and Treatment of Aortic Diseasesof the European Society of Cardiology (ESC)</p><p>Authors/Task Force members: Raimund Erbel* (Chairperson) (Germany),Victor Aboyans* (Chairperson) (France), Catherine Boileau (France),Eduardo Bossone (Italy), Roberto Di Bartolomeo (Italy), Holger Eggebrecht(Germany), Arturo Evangelista (Spain), Volkmar Falk (Switzerland), Herbert Frank(Austria), Oliver Gaemperli (Switzerland), Martin Grabenwoger (Austria),Axel Haverich (Germany), Bernard Iung (France), Athanasios John Manolis (Greece),Folkert Meijboom (Netherlands), Christoph A. Nienaber (Germany), Marco Roffi(Switzerland), Herve Rousseau (France), Udo Sechtem (Germany), Per Anton Sirnes(Norway), Regula S. von Allmen (Switzerland), Christiaan J.M. Vrints (Belgium).</p><p>ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach(Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Hector Bueno (Spain), Veronica Dean(France), Christi Deaton (UK), etin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai(Israel), Arno Hoes (The Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh</p><p>* Corresponding authors: Raimund Erbel, Department of Cardiology, West-German Heart Centre Essen, University Duisburg-Essen, Hufelandstrasse 55, DE-45122 Essen, Germany.Tel: +49 201 723 4801; Fax: +49 201 723 5401; Email: erbel@uk-essen.de.Victor Aboyans, Department of Cardiology, CHRU Dupuytren Limoges, 2 Avenue Martin Luther King, 87042 Limoges, France. Tel: +33 5 55 05 63 10; Fax: +33 5 55 05 63 84;Email: vaboyans@live.fr</p><p>Other ESC entities having participated in the development of this document:</p><p>ESC Associations:Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous CardiovascularInterventions (EAPCI).</p><p>ESC Councils: Council for Cardiology Practice (CCP).</p><p>ESC Working Groups: Cardiovascular Magnetic Resonance, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Hypertension and the Heart, Nuclear Cardiology andCardiac Computed Tomography, Peripheral Circulation, Valvular Heart Disease.</p><p>The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESCGuidelinesmay be translated or reproduced in any formwithoutwritten permission from the ESC. Permission can beobtained upon submission of awritten request toOxfordUniversityPress, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.</p><p>Disclaimer: The ESCGuidelines represent the views of the ESC andwere produced after careful consideration of the scientific andmedical knowledge and the evidence available at thetime of their dating.</p><p>The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESCGuidelines and any other official recommendations or guidelines issued bythe relevant public health authorities, in particular in relation to good use of health care or therapeutic strategies.Health professionals are encouraged to take the ESCGuidelines fully intoaccount when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESCGuidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patientshealth condition and in consultation with that patient and, where appropriate and/or necessary, the patients caregiver. Nor do the ESC Guidelines exempt health professionals fromtaking full and careful consideration of the relevant official updated recommendations or guidelines issued by the competent public health authorities in order to manage each patientscase in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professionals responsibility to verify the applicable rulesand regulations relating to drugs and medical devices at the time of prescription.</p><p>National Cardiac Societies document reviewers: listed in the Appendix.</p><p>&amp; The European Society of Cardiology 2014. All rights reserved. For permissions please email: journals.permissions@oup.com.</p><p>European Heart Journal (2014) 35, 28732926doi:10.1093/eurheartj/ehu281</p><p>by guest on March 16, 2015</p><p>Dow</p><p>nloaded from </p></li><li><p>(Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK),Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain),Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), and Stephan Windecker (Switzerland).</p><p>Document reviewers: Petros Nihoyannopoulos (CPG Review Coordinator) (UK), Michal Tendera (CPG ReviewCoordinator) (Poland), Martin Czerny (Switzerland), John Deanfield (UK), Carlo Di Mario (UK), Mauro Pepi (Italy),Maria Jesus Salvador Taboada (Spain), Marc R. van Sambeek (The Netherlands), Charalambos Vlachopoulos (Greece),and Jose Luis Zamorano (Spain).</p><p>The disclosure forms provided by the experts involved in the development of these guidelines are available on the ESC websitewww.escardio.org/guidelines</p><p>- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Keywords Guidelines Aortic diseases Aortic aneurysm Acute aortic syndrome Aortic dissection Intramural</p><p>haematoma Penetrating aortic ulcer Traumatic aortic injury Abdominal aortic aneurysm Endovasculartherapy Vascular surgery Congenital aortic diseases Genetic aortic diseases Thromboembolic aorticdiseases Aortitis Aortic tumours</p><p>Table of ContentsAbbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . .2876</p><p>1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2876</p><p>2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2878</p><p>3. The normal and the ageing aorta . . . . . . . . . . . . . . . . . . . .2879</p><p>4. Assessment of the aorta . . . . . . . . . . . . . . . . . . . . . . . . .2880</p><p>4.1 Clinical examination . . . . . . . . . . . . . . . . . . . . . . . .2880</p><p>4.2 Laboratory testing . . . . . . . . . . . . . . . . . . . . . . . . .2880</p><p>4.3 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2880</p><p>4.3.1 Chest X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . .2880</p><p>4.3.2 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . .2881</p><p>4.3.2.1 Transthoracic echocardiography . . . . . . . . . . .2881</p><p>4.3.2.2 Transoesophageal echocardiography . . . . . . . .2881</p><p>4.3.2.3 Abdominal ultrasound . . . . . . . . . . . . . . . . . .2881</p><p>4.3.3 Computed tomography . . . . . . . . . . . . . . . . . . .2881</p><p>4.3.4 Positron emission tomography/computed</p><p>tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2883</p><p>4.3.5 Magnetic resonance imaging . . . . . . . . . . . . . . . .2883</p><p>4.3.6 Aortography . . . . . . . . . . . . . . . . . . . . . . . . . .2883</p><p>4.3.7 Intravascular ultrasound . . . . . . . . . . . . . . . . . . .2884</p><p>4.4 Assessment of aortic stiffness . . . . . . . . . . . . . . . . . .2884</p><p>5. Treatment options . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2884</p><p>5.1 Principles of medical therapy . . . . . . . . . . . . . . . . . . .2884</p><p>5.2 Endovascular therapy . . . . . . . . . . . . . . . . . . . . . . .2885</p><p>5.2.1 Thoracic endovascular aortic repair . . . . . . . . . . .2885</p><p>5.2.1.1 Technique . . . . . . . . . . . . . . . . . . . . . . . . .2885</p><p>5.2.1.2 Complications . . . . . . . . . . . . . . . . . . . . . . .2885</p><p>5.2.2 Abdominal endovascular aortic repair . . . . . . . . . .2885</p><p>5.2.2.1 Technique . . . . . . . . . . . . . . . . . . . . . . . . .2885</p><p>5.2.2.2 Complications . . . . . . . . . . . . . . . . . . . . . . .2886</p><p>5.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2887</p><p>5.3.1 Ascending aorta . . . . . . . . . . . . . . . . . . . . . . . .2887</p><p>5.3.2 Aortic arch . . . . . . . . . . . . . . . . . . . . . . . . . . .2887</p><p>5.3.3 Descending aorta . . . . . . . . . . . . . . . . . . . . . . .2888</p><p>5.3.4 Thoraco-abdominal aorta . . . . . . . . . . . . . . . . . .2888</p><p>5.3.5 Abdominal aorta . . . . . . . . . . . . . . . . . . . . . . . .2888</p><p>6. Acute thoracic aortic syndromes . . . . . . . . . . . . . . . . . . . .2889</p><p>6.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2889</p><p>6.2 Pathology and classification . . . . . . . . . . . . . . . . . . . .2890</p><p>6.3 Acute aortic dissection . . . . . . . . . . . . . . . . . . . . . .2890</p><p>6.3.1 Definition and classification . . . . . . . . . . . . . . . . .2890</p><p>6.3.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . .2890</p><p>6.3.3 Clinical presentation and complications . . . . . . . . .2890</p><p>6.3.3.1 Chest pain . . . . . . . . . . . . . . . . . . . . . . . .2890</p><p>6.3.3.2 Aortic regurgitation . . . . . . . . . . . . . . . . . .2890</p><p>6.3.3.3 Myocardial ischaemia . . . . . . . . . . . . . . . . .2890</p><p>6.3.3.4 Congestive heart failure . . . . . . . . . . . . . . .2890</p><p>6.3.3.5 Large pleural effusions . . . . . . . . . . . . . . . .2891</p><p>6.3.3.6 Pulmonary complications . . . . . . . . . . . . . .2891</p><p>6.3.3.7 Syncope . . . . . . . . . . . . . . . . . . . . . . . . .2891</p><p>6.3.3.8 Neurological symptoms . . . . . . . . . . . . . . .2891</p><p>6.3.3.9 Mesenteric ischaemia . . . . . . . . . . . . . . . . .2891</p><p>6.3.3.10. Renal failure . . . . . . . . . . . . . . . . . . . . . .2891</p><p>6.3.4 Laboratory testing . . . . . . . . . . . . . . . . . . . . . . .2891</p><p>6.3.5 Diagnostic imaging in acute aortic dissection . . . . . .2892</p><p>6.3.5.1 Echocardiography . . . . . . . . . . . . . . . . . . . .2892</p><p>6.3.5.2 Computed tomography . . . . . . . . . . . . . . . . .2892</p><p>6.3.5.3 Magnetic resonance imaging . . . . . . . . . . . . . .2893</p><p>6.3.5.4 Aortography . . . . . . . . . . . . . . . . . . . . . . . .2893</p><p>6.3.6 Diagnostic work-up . . . . . . . . . . . . . . . . . . . . . .2893</p><p>6.3.7 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .2895</p><p>6.3.7.1 Type A aortic dissection . . . . . . . . . . . . . . . .2895</p><p>6.3.7.2 Treatment of Type B aortic dissection . . . . . . .2895</p><p>6.3.7.2.1 Uncomplicated Type B aortic dissection: . . .2895</p><p>6.3.7.2.1.1 Medical therapy . . . . . . . . . . . . . . . . .2895</p><p>6.3.7.2.1.2 Endovascular therapy . . . . . . . . . . . . .2896</p><p>6.3.7.2.2 Complicated Type B aortic dissection:</p><p>endovascular therapy. . . . . . . . . . . . . . . . . . . . . . .2896</p><p>6.3.7.2.2.1 TEVAR . . . . . . . . . . . . . . . . . . . . . .2896</p><p>6.3.7.2.2.2 Surgery . . . . . . . . . . . . . . . . . . . . . .2896</p><p>6.4 Intramural haematoma . . . . . . . . . . . . . . . . . . . . . . .2897</p><p>6.4.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . .2897</p><p>6.4.2 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .2897</p><p>6.4.3 Natural history, morphological changes,</p><p>and complications . . . . . . . . . . . . . . . . . . . . . . . . . . .2897</p><p>ESC Guidelines2874</p><p>by guest on March 16, 2015</p><p>Dow</p><p>nloaded from </p></li><li><p>6.4.4 Indications for surgery and thoracic endovascular</p><p>aortic repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2897</p><p>6.4.4.1 Type A intramural haematoma . . . . . . . . . . . .2897</p><p>6.4.4.2 Type B intramural haematoma . . . . . . . . . . . .2897</p><p>6.5 Penetrating aortic ulcer . . . . . . . . . . . . . . . . . . . . . .2898</p><p>6.5.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . .2898</p><p>6.5.2 Diagnostic imaging . . . . . . . . . . . . . . . . . . . . . .2898</p><p>6.5.3 Management . . . . . . . . . . . . . . . . . . . . . . . . . .2898</p><p>6.5.4 Interventional therapy . . . . . . . . . . . . . . . . . . . .2898</p><p>6.6 Aortic pseudoaneurysm . . . . . . . . . . . . . . . . . . . . . .2899</p><p>6.7 (Contained) rupture of aortic aneurysm . . . . . . . . . . . .2899</p><p>6.7.1 Contained rupture of thoracic aortic aneurysm . . . .2899</p><p>6.7.1.1 Clinical presentation . . . . . . . . . . . . . . . . . . .2899</p><p>6.7.1.2 Diagnostic work-up . . . . . . . . . . . . . . . . . . .2899</p><p>6.7.1.3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . .2899</p><p>6.8 Traumatic aortic injury . . . . . . . . . . . . . . . . . . . . . . .2900</p><p>6.8.1 Definition, epidemiology and classification . . . . . . .2900</p><p>6.8.2 Patient presentation and diagnosis . . . . . . . . . . . .2900</p><p>6.8.3 Indications for treatment in traumatic aortic injury . .2900</p><p>6.8.4 Medical therapy in traumatic aortic injury . . . . . . . .2900</p><p>6.8.5 Surgery in traumatic aortic injury . . . . . . . . . . . . .2900</p><p>6.8.6 Endovascular therapy in traumatic aortic injury . . . .2901</p><p>6.8.7 Long-term surveillance in traumatic aortic injury . . .2901</p><p>6.9 Latrogenic aortic dissection . . . . . . . . . . . . . . . . . . .2901</p><p>7. Aortic aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2902</p><p>7.1 Thoracic aortic aneurysms . . . . . . . . . . . . . . . . . . . .2902</p><p>7.1.1 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .2902</p><p>7.1.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2902</p><p>7.1.3 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . .2902</p><p>7.1.4 Natural history . . . . . . . . . . . . . . . . . . . . . . . . .2903</p><p>7.1.4.1 Aortic growth in familial thoracic aortic aneurysms 2903</p><p>7.1.4.2 Descending aortic growth . . . . . . . . . . . . . . .2903</p><p>7.1.4.3 Risk of aortic dissection . . . . . . . . . . . . . . . . .2903</p><p>7.1.5 Interventions . . . . . . . . . . . . . . . . . . . . . . . . . .2903</p><p>7.1.5.1 Ascending aortic aneurysms . . . . . . . . . . . . . .2903</p><p>7.1.5.2 Aortic arch aneuryms . . . . . . . . . . . . . . . . . .2903</p><p>7.1.5.3 Descending aortic aneurysms . . . . . . . . . . . . .2904</p><p>7.2 Abdominal aortic aneurysm . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.2 Risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.3 Natural history . . . . . . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.4 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.4.1 Presentation . . . . . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.4.2 Diagnostic imaging . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.4.3 Screening abdominal aortic aneurysm in high-risk</p><p>populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2905</p><p>7.2.5 Management of small abdominal aortic aneurysms . .2906</p><p>7.2.5.1 Management of risk factors . . . . . . . . . . . . . .2906</p><p>7.2.5.2 M..</p></li></ul>