ESC 2024 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases
European Society of Cardiology｜循環器 / 血管疾患｜163 ページ｜チャンク 1557｜推奨 740 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.13 | I | B | When managing PAAD, it is recommended to adopt a comprehensive approach that addresses the entirety of arterial circulation. | Table 3 New recommendations |
| p.13 | IIa | C | In patients with AAA, femoro-popliteal aneurysm screening with DUS should be considered. | Table 3 New recommendations |
| p.13 | IIb | C | In patients needing intervention with transfemoral access, screening for iliofemoral artery disease may be considered. | Table 3 New recommendations |
| p.13 | IIb | C | In patients with two or more CVRFs, screening for asymptomatic CS may be considered. | Table 3 New recommendations |
| p.13 | IIa | B | Opportunistic AAA screening with DUS should be considered in symptomatic/asymptomatic PAD patients. | Table 3 New recommendations |
| p.13 | IIa | C | Use of web- or app-based secondary prevention risk calculators should be considered in the shared decision-making to improve patient adherence to treatment and lifestyle changes. | Table 3 New recommendations |
| p.13 | IIb | C | E-cigarettes may be considered as an aid to quitting tobacco smoking, but it is advisable to limit their use and avoid simultaneous use with conventional cigarettes due to unknown long-term effects. | Table 3 New recommendations |
| p.13 | I | A | In patients with atherosclerotic PAAD, lipid-lowering therapy is recommended. | Table 3 New recommendations |
| p.13 | I | A | atherosclerotic PAAD. | Table 3 New recommendations |
| p.13 | I | A | patients with atherosclerotic PAAD, to achieve target values. | Table 3 New recommendations |
| p.13 | I | B | the given target values. | Table 3 New recommendations |
| p.13 | I | B | recommended to add bempedoic acid either alone or in combination with a PCSK9 inhibitor. | Table 3 New recommendations |
| p.13 | IIa | B | Statins for the reduction of growth and rupture of AAA should be considered. | Table 3 New recommendations |
| p.13 | IIb | B | Statins for the reduction of growth and rupture of TAA may be considered. | Table 3 New recommendations |
| p.13 | IIb | B | In high-risk patients with PAAD and triglycerides >1.5 mmol/L despite lifestyle measures and statin therapy, icosapent ethyl 2 g b.i.d. may be considered in addition to a statin. | Table 3 New recommendations |
| p.13 | III | B | Fibrates are not recommended for cholesterol lowering. | Table 3 New recommendations |
| p.13 | I | A | In patients with symptomatic PAD, SET is recommended. | Table 3 New recommendations |
| p.13 | I | A | In those patients undergoing endovascular revascularization, SET is recommended as an adjuvant therapy. | Table 3 New recommendations |
| p.13 | IIa | A | When SET is not available or feasible, a structured and monitored (calls, logbooks, connected devices) HBET programme should be considered. | Table 3 New recommendations |
| p.13 | IIa | A | Walking should be considered as the first-line training modality. When walking exercise is not an option, alternative exercise modes (strength training, arm cranking, cycling, and combinations of different training modes) should also be considered. | Table 3 New recommendations |
| p.13 | IIa | B | weeks should be considered. | Table 3 New recommendations |
| p.13 | IIb | B | improvements are also achievable with lesser claudication pain severities (low-mild pain or pain-free). | Table 3 New recommendations |
| p.13 | IIb | C | Based on patient’s tolerance, a progressive increase (every 1–2 weeks) in exercise training load may be considered. | Table 3 New recommendations |
| p.14 | IIa | A | Treatment with combination rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered for patients with PAD and high ischaemic risk, and non-high bleeding risk. | |
| p.14 | IIa | B | Treatment with combination rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered for patients with PAD and non-high bleeding risk following lower-limb revascularization. | |
| p.14 | IIb | A | Aspirin (75–100 mg) for primary prevention may be considered in patients with asymptomatic PAD and DM, in the absence of contraindications. | |
| p.14 | I | B | In patients with symptomatic PAD, after a 3 month period of OMT and exercise therapy, PAD-related QoL assessment is recommended. | |
| p.14 | I | C | patient condition. | |
| p.14 | IIb | B | may be considered. | |
| p.14 | III | B | In patients with PAD, revascularization is not recommended if the reason is to solely prevent progression to CLTI. | |
| p.14 | III | C | In patients with asymptomatic PAD, revascularization is not recommended. | |
| p.14 | IIa | A | In femoro-popliteal lesions, drug-eluting treatment should be considered as the first-choice strategy. | |
| p.14 | IIa | C | GSV) is available in patients with low surgical risk. | |
| p.14 | IIb | C | same intervention. | |
| p.14 | I | C | adherence, limb symptoms, and CVRFs, with DUS assessment as needed. | |
| p.14 | I | C | Early recognition of CLTI and referral to the vascular team are recommended for limb salvage. | |
| p.14 | I | C | It is recommended that patients with CLTI are managed by a vascular team. | |
| p.14 | I | C | In patients with CLTI and ulcers, offloading mechanical tissue stress is indicated to allow wound healing. | |
| p.14 | III | C | Lower-limb exercise training is not recommended in patients with CLTI and wounds. | |
| p.14 | I | B | In CLTI patients, it is recommended to perform revascularization as soon as possible. | |
| p.14 | I | B | In CLTI, it is recommended to use autologous veins as the preferred conduit for infra-inguinal bypass surgery. | |
| p.14 | I | C | In multilevel vascular disease, it is recommended to eliminate inflow obstructions when treating downstream lesions. | |
| p.14 | IIb | B | inadequate autologous veins. | |
| p.14 | I | C | In patients with CLTI, following revascularization it is recommended to follow-up patients on a regular basis. | |
| p.14 | I | C | At follow-up, it is recommended to assess clinical, haemodynamic and functional status, limb symptoms, treatment adherence, and CVRFs. | |
| p.14 | I | B | It is recommended to use the NASCET method or its non-invasive equivalent to assess ICA stenosis. | |
| p.14 | III | C | It is not recommended to use the ECST method for ICA stenosis assessment. | |
| p.14 | I | B | Bilateral arm BP measurement is recommended for all patients with PAAD. | |
| p.14 | IIb | B | Endovascular revascularization may be considered over surgery, despite similar long-term outcomes, due to lower complication rates. | |
| p.14 | III | C | Routine revascularization in patients with atherosclerotic subclavian artery disease is not recommended. | |
| p.14 | I | B | DUS is recommended as the first-line imaging modality in patients with suspicion of RAS. | |
| p.15 | IIa | B | should be considered after OMT has been established. | |
| p.15 | IIa | B | renal artery revascularization should be considered. | |
| p.15 | IIa | B | In patients with hypertension and/or signs of renal dysfunction due to RAS caused by fibromuscular dysplasia, concomitant high-risk features, and signs of kidney viability, revascularization with primary balloon angioplasty and bailout stenting should be considered. | |
| p.15 | IIa | B | In patients with an indication for renal artery revascularization and complex anatomy, or after failed endovascular revascularization, open surgical revascularization should be considered. | |
| p.15 | III | A | In patients with atherosclerotic unilateral RAS, routine revascularization is not recommended. | |
| p.15 | I | C | In patients with acute or chronic mesenteric ischaemia, assessment by a vascular team is recommended. | |
| p.15 | III | C | Revascularization of asymptomatic atherosclerotic visceral artery stenosis is not recommended. | |
| p.15 | IIa | B | should be considered at a maximum diameter >52 mm. | |
| p.15 | IIa | C | SAPT with low-dose aspirin (75–100 mg/day) should be considered for the first 3 months after valve-sparing aortic surgery when there are no other baseline indications for OAC. | |
| p.15 | IIa | C | In patients undergoing non-aortic-valve cardiac surgery who have concomitant dilatation of the ascending aorta or aortic root with a maximum diameter ≥50 mm, concomitant aortic surgery should be considered. | |
| p.15 | I | C | non-aortic causes, open surgical replacement of the arch is recommended. | |
| p.15 | IIa | C | considered if the aneurysmal disease extends into the proximal descending thoracic aorta. | |
| p.15 | I | B | and every 5 years thereafter is recommended if findings are stable. | |
| p.15 | IIa | B | After 5 post-operative years without complications, continuing long-term follow-up of TEVAR by CCT every 5 years should be considered. | |
| p.15 | IIa | C | the growth rate observed, should be considered. | |
| p.15 | IIa | B | In low-risk patients, from 1 year post-operatively after EVAR, repeating DUS/CEUS every 2 years should be considered. | |
| p.15 | IIa | B | If any abnormality during DUS/CEUS is found, confirmation should be considered using additional CCT or CMR (based on potential artefacts). | |
| p.15 | I | C | accurate, and provides information about the entry tear, extension, and possible complications (malperfusion, dilatation, or rupture). | |
| p.15 | I | C | In patients with suspected AAS, TOE is recommended to guide peri-operative management and detect complications. | |
| p.15 | I | B | In patients with AAS who can be managed conservatively and who achieved haemodynamic targets with i.v. anti-impulse therapy, switching to oral BBs and, if necessary, up-titration of other BP-lowering agents is recommended after 24 h if gastrointestinal transit is preserved. | |
| p.15 | IIa | B | If the patient has a contraindication for BBs, a non-dihydropyridine calcium blocker should be considered. | |
| p.15 | I | B | root replacement is recommended with a mechanical or biological valved conduit. | |
| p.15 | IIa | B | should be considered to improve survival if transfer can be accomplished without significant delay in surgery. | |
| p.15 | IIb | B | In selected patients, a valve-sparing root repair may be considered, when performed by experienced surgeons. | |
| p.16 | I | B | In patients with acute TAAD and a partially dissected aortic root but no significant aortic valve leaflet pathology, aortic valve resuspension is recommended over valve replacement. | |
| p.16 | I | B | In patients with acute TAAD undergoing aortic repair, an open distal anastomosis is recommended to improve survival and increase FL thrombosis rates. | |
| p.16 | I | B | In patients with acute TAAD without an intimal tear in the arch or a significant arch aneurysm, hemi-arch repair is recommended over more extensive arch replacement. | |
| p.16 | I | B | recommended. | |
| p.16 | IIa | B | considered to improve neurological outcome and reduce mortality. | |
| p.16 | IIa | B | patients with high-risk features to prevent aortic complications. | |
| p.16 | I | B | In chronic TBAD and with a descending thoracic aortic diameter ≥60 mm, treatment is recommended in patients at reasonable surgical risk. | |
| p.16 | IIa | C | In patients with chronic TBAD and a descending thoracic aortic diameter ≥55 mm, an indication for intervention should be considered in patients with low procedural risk. | |
| p.16 | IIb | C | In patients with chronic post-dissection thoracoabdominal aortic aneurysms, the use of fenestrated/branched stent grafts may be considered, when treatment is indicated. | |
| p.16 | IIa | C | In uncomplicated type B PAU with high-risk imaging features, endovascular treatment should be considered. | |
| p.16 | I | A | In cases of severe aortic injury (grade 4), immediate repair is recommended. | |
| p.16 | IIa | C | In minimal aortic injury (grades 1 or 2), initial medical therapy under careful clinical and imaging surveillance should be considered. | |
| p.16 | IIa | C | In cases of progression of the IMH (grade 2), semi-elective repair (within 24–72 h) should be considered. | |
| p.16 | I | C | In medically treated type B AAS or IMH, follow-up imaging is recommended at 1, 3, 6, and 12 months after onset, then yearly if imaging findings are stable. | |
| p.16 | I | C | In medically treated PAU, follow-up imaging is recommended at 1 month after diagnosis, then every 6 months if imaging findings are stable. | |
| p.16 | IIa | B | After open surgery for AAS, follow-up imaging by CCT and TTE within 6 months, then CCT at 12 months and then yearly if findings are stable, should be considered. | |
| p.16 | IIa | B | If no complications occur within the first 5 years, CCT every 2 years thereafter should be considered. | |
| p.16 | IIa | C | If no residual patent FL is documented for 3 post-operative years, subsequent surveillance by CCT every 2–3 years should be considered. | |
| p.16 | IIa | C | In the follow-up of medically treated PAU, after 2 years of imaging stability, larger intervals should be considered in low-risk patients. | |
| p.16 | I | C | It is recommended that medical management of patients with HTAD is individualized and based on shared decision-making. | |
| p.16 | I | C | the care of this patient group. | |
| p.16 | IIa | B | In patients with HTAD, guidance of clinical management by the underlying gene/variant, when known, should be considered. | |
| p.17 | I | C | ASI and concomitant lesions. | |
| p.17 | IIb | C | have an ascending ASI >25 mm/m2, an AHI >25 mm/m, a z-score >4, and who do not have associated risk factors for aortic dissection. | |
| p.17 | I | C | In patients with vEDS, regular vascular surveillance of the aorta and peripheral arteries by DUS, CCT, or CMR is recommended. | |
| p.17 | IIa | B | Treatment with celiprolol should be considered in patients with vEDS. | |
| p.17 | I | C | recommended at the first evaluation, and subsequently every 3–5 years if stable. | |
| p.17 | I | A | In patients with MFS, treatment with either a BB or an ARB, in maximally tolerated doses (unless contraindicated), is recommended to reduce the rate of aortic dilatation. | |
| p.17 | IIa | A | In patients with MFS, the use of both a BB and an ARB, in maximally tolerated doses (unless contraindicated), should be considered to reduce the rate of aortic dilatation. | |
| p.17 | I | C | It is recommended that couples in which a partner has or is at risk of HTAD be offered pre-conception genetic counselling. | |
| p.17 | I | C | Imaging of the whole aorta (by CMR/CCT) is recommended prior to pregnancy. | |
| p.17 | I | C | Follow-up during pregnancy is recommended with a frequency determined by aortic diameter and growth. | |
| p.17 | I | C | Intake of BBs during pregnancy is recommended. | |
| p.17 | I | C | Prophylactic aortic root surgery is recommended in women desiring pregnancy with aortic diameters >45 mm. | |
| p.17 | IIb | C | Prophylactic aortic root surgery may be considered in women desiring pregnancy with aortic diameters of 40–45 mm. | |
| p.17 | I | C | pre-existing fitness. | |
| p.17 | I | C | Regular moderate aerobic exercise with a level of intensity informed by aortic diameter is recommended in most patients with MFS. | |
| p.17 | IIa | B | For patients who present with aortic dissection and/or have undergone aortic surgery, post-operative cardiac rehabilitation aiming at improving both physical and mental health should be considered. | |
| p.17 | I | C | recommended. | |
| p.17 | I | C | with CMR or CCT or DUS every 1–3 years is recommended. | |
| p.17 | I | C | Annual monitoring of the aortic root/ascending aorta with TTE to evaluate for aortic root/ascending aorta enlargement is recommended. | |
| p.17 | I | C | Imaging of the aorta with CMR/CCT every 3–5 years is recommended. | |
| p.17 | IIa | C | Prophylactic aortic root surgery should be considered with a diameter ≥45 mm, or lower in cases with other risk factors. | |
| p.18 | I | B | Surgery for bicuspid aortopathy of the root phenotype is recommended when the maximum aortic diameter is ≥50 mm. | |
| p.18 | I | C | Screening by TTE in FDRs of BAV patients with root phenotype aortopathy and/or isolated aortic regurgitation is recommended. | |
| p.18 | IIa | B | diameter is >52 mm. | |
| p.18 | I | B | every 3–5 years (adapted to clinical status and previous imaging findings). | |
| p.18 | I | A | In patients with PVD, an LDL-C reduction by ≥50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) are recommended. | |
| p.18 | IIa | A | rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered. | |
| p.18 | I | A | smoking to reduce the risk of death from ruptured AAA. | Table 4 Revised recommendations |
| p.18 | III | C | familial history. | Table 4 Revised recommendations |
| p.18 | I | C | ≥50, unless an acquired cause can be clearly identified. | Table 4 Revised recommendations |
| p.18 | IIa | B | Targeted screening for AAA with ultrasound should be considered in first-degree siblings of patients with AAA. IIa B Should be considered in men ≥65 years and in women aged ≥75 years during TTE. | Table 4 Revised recommendations |
| p.18 | I | A | towards 120–129 mmHg, if tolerated, is recommended. | Table 4 Revised recommendations |
| p.18 | IIb | B | ACEIs or ARBs should be considered as first-line therapy in patients with PAD and hypertension. IIa B ACEIs/ARBs may be considered in all patients with PAD, regardless of BP levels, in the absence of contraindications. | Table 4 Revised recommendations |
| p.18 | I | C | diagnose ICA stenosis. | Table 4 Revised recommendations |
| p.18 | I | C | Targeted screening for AAA with ultrasound should be Opportunistic AAA screening with DUS In patients with PAD and hypertension, it is recommended In patients with PAD, it is recommended to reduce LDL-C to <1.8 mmol/L (70 mg/dL) or decrease it by >50% if baseline values are 1.8–3.5 mmol/L (70–135 mg/dL). | Table 4 Revised recommendations |
| p.18 | I | B | DUS (as first-line imaging), CTA, and/or MRA are recommended for evaluating the extent and severity of extracranial carotid stenosis. | Table 4 Revised recommendations |
| p.18 | I | A | An ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline are recommended in patients with atherosclerotic PAAD. It is recommended to use DUS as first-line imaging to | Table 4 Revised recommendations |
| p.19 | I | B | experienced centres and durable results are expected. | |
| p.19 | I | B | 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalities are documented. | |
| p.19 | I | C | contrast if feasible) is recommended during the initial evaluation. | |
| p.19 | IIa | B | In patients with acute embolic occlusion of the SMA, both endovascular and open surgery therapy should be considered. | |
| p.19 | IIa | B | In patients with small (30–55 mm) AAA, the following time interval should be considered: • Every 3 years for AAA of 30–39 mm diameter • Every 2 years for AAA of 40–44 mm diameter • Every year for AAA >45 mm diameter. | |
| p.19 | IIa | C | Surgery should be considered in patients who have isolated aortic arch aneurysm with a maximal diameter ≥55 mm. | |
| p.19 | I | C | Aortic valve repair using the reimplantation technique or remodelling with aortic annuloplasty is recommended in young patients with aortic root dilation and tricuspid aortic valves. Lower thresholds for intervention may be considered according to BSA in patients with small stature or in the | |
| p.19 | IIb | C | case of rapid progression, aortic valve regurgitation, planned pregnancy, and patient’s preference. | |
| p.19 | IIb | C | Aortic arch repair may be considered in patients with aortic arch aneurysm who already have an indication for surgery of an adjacent aneurysm located in the ascending or descending aorta. | |
| p.19 | I | C | After TEVAR or EVAR, surveillance is recommended after 1, 6, and 12 months and then yearly. Shorter intervals can be proposed in the event of abnormal findings requiring closer surveillance. | |
| p.19 | IIb | C | Long-term surveillance of open abdominal aortic repair may be considered at loose (5 year) intervals using colour DUS or CCT imaging. | |
| p.19 | IIa | C | If neither endoleak nor AAA sac enlargement is documented during first year after EVAR, then colour DUS, with or without contrast agents, should be considered for annual post-operative surveillance, with non-contrast CT imaging every 5 years. | |
| p.19 | I | C | TTE is recommended as an initial imaging investigation. In stable patients with a suspicion of AAS, the following imaging modalities are recommended (or should be considered according to local availability and expertise): | |
| p.19 | I | B | In patients with acute mesenteric ischaemia due to acute occlusion of the SMA, endovascular revascularization is recommended. DUS surveillance should be considered annually in women with AAA of 40–45 mm and in men with AAA of 40– | |
| p.19 | I | B | Surgery is recommended in patients with dilatation of the aortic root or ascending aorta with a tricuspid aortic valve and a maximum diameter of ≥55 mm. Valve-sparing aortic root replacement is recommended in patients with aortic root dilatation if performed in | |
| p.19 | IIb | B | Ascending aortic or root replacement may be considered at a maximum diameter of ≥50 mm in patients with proximal aorta dilatation who can be offered surgery with low predicted risk and present with any of the following: • Growth of the aortic diameter ≥3 mm per year • Resistant hypertension • Short stature (<1.69 m) • Root phenotype • Aortic length >11 cm • Age <50 years • Desire for pregnancy | |
| p.19 | IIa | C | • Aortic coarctation. In patients undergoing open surgical repair of an ascending aortic aneurysm, concomitant hemi-arch replacement should be considered if the dilatation extends into the proximal aortic arch (>50 mm). After TEVAR, follow-up imaging is recommended at 1 and | |
| p.19 | I | A | After open repair of AAA, first follow-up imaging is recommended within 1 post-operative year, and every 5 years thereafter if findings are stable. | |
| p.19 | I | A | After EVAR, follow-up imaging is recommended with CCT (or CMR) and DUS/CEUS at 1 month and 12 months post-operatively, then, if no abnormalities are documented, DUS/CEUS is recommended every year, repeating CCT or CMR (based on potential artefacts) every 5 years. In patients with suspected AAS, focused TTE (with use of | |
| p.19 | IIa | C | In patients with suspected AAS, CMR should be considered as an alternative imaging technique if CCT is not available. | |
| p.20 | I | C | relief and blood pressure control, is recommended. | |
| p.20 | IIb | C | intervention is recommended. I B In complicated TBAD, surgery may be considered. | |
| p.20 | IIb | C | In complicated TBAD, TEVAR may be recommended. IIb C In patients with complicated acute TBAD, TEVAR is recommended as the first-line therapy. I B In complicated TBAD, surgery may be considered. | |
| p.20 | I | C | In complicated type B IMH, TEVAR should be considered. IIa C In complicated type B IMH, TEVAR is recommended. | |
| p.20 | I | C | In the case of type A PAU, surgery should be considered. IIa C In the case of type A PAU, surgery is recommended. | |
| p.20 | I | C | recommended. | |
| p.20 | I | A | In cases of TAI with suitable anatomy requiring intervention, TEVAR should be preferred to surgery. IIa C In cases of TAI with suitable anatomy requiring intervention, TEVAR is recommended over open surgery. | |
| p.20 | I | C | family mutation/disease. | |
| p.20 | IIa | C | TOE In all patients with AD, medical therapy, including pain | |
| p.20 | I | C | It is recommended to investigate FDRs (siblings and parents) of a subject with TAAD to identify a familial form in which relatives all have a 50% chance of carrying the Cardiac MRI or CT is indicated in patients with BAV when the morphology of the aortic root and the ascending aorta cannot be accurately assessed by TTE. | |
| p.20 | I | C | >3 mm per year measured by echocardiography, confirmation of the measurement is indicated, using another imaging modality (CT or MRI). | |
| p.20 | I | C | In the case of a diameter of the aortic root or the ascending aorta >45 mm or an increase of >3 mm per year measured by echocardiography, annual measurement of aortic diameter is indicated. In cases of BAV, surgery of the ascending aorta is indicated in the case of: | |
| p.20 | I | C | • Aortic root or ascending aortic diameter >50 mm in the presence of other risk factors (coarctation of the aorta, systemic hypertension, family history of dissection, or increase in aortic diameter of >3 mm per year). | |
| p.20 | I | C | In patients with suspected AAS, TOE is recommended to guide peri-operative management and detect complications. | |
| p.20 | I | B | Invasive monitoring with an arterial line and continuous three-lead ECG recording, as well as admission to an intensive care unit, is recommended. | |
| p.20 | IIa | C | Imaging screening of family members of patients with TAD with risk factors for HTAD in whom no (likely) pathogenic variant is identified should be considered starting at age 25, or 10 years below the youngest case, whichever is younger. If the initial screening is normal, continued screening every 5 years until the age of 60 should be considered. CCT or CMR of the entire thoracic aorta is recommended at first diagnosis and when important | |
| p.20 | I | C | discrepancies in measurements are found between subsequent TTE controls during surveillance, or when the diameter of the aorta exceeds 45 mm. Surveillance serial imaging by TTE is recommended in BAV patients with a maximum aortic diameter >40 mm, either with no indication for surgery or after isolated aortic valve surgery, after 1 year, then if stability is observed, every 2–3 years. In patients with low surgical risk and ascending phenotype bicuspid aortopathy, surgery should be considered at a | |
| p.20 | IIa | C | maximum diameter ≥50 mm if any of the following is the case: • Age <50 years • Short stature • Ascending aortic length ≥11 cm • Aortic diameter growth rate >3 mm per year • Family history of acute aortic syndrome • Aortic coarctation • Resistant hypertension • Concomitant non-aortic-valve cardiac surgery • Desire for pregnancy | |
| p.21 | IIa | C | ascending diameter ≥45 mm. | |
| p.21 | I | B | patients with a recent (<6 months) history of TIA/stroke. | |
| p.21 | I | C | In cases of BAV, surgery of the ascending aorta is indicated in the case of: • Aortic root or ascending aortic diameter >45 mm when surgical aortic valve replacement is scheduled. In patients undergoing CABG, DUS is recommended in | |
| p.21 | IIa | B | Surgery for bicuspid aortopathy in patients undergoing aortic valve surgery should be considered at a root or Carotid DUS should be considered for stable patients scheduled for CABG with TIA/stroke within the past 6 months without carotid revascularization. | |
| p.23 | I | B | When managing PAAD, it is recommended to adopt a comprehensive approach that addresses the entirety of the arterial circulation.76 | Recommendation Table 1 — Recommendations for clinical and laboratory, and for functional and quality of life, assessment in patients with peripheral arterial and aortic disease (see also Evidence Table 1) |
| p.23 | I | C | To assess PAAD, it is recommended to perform thorough clinical, vascular, and CVRFs laboratory evaluation.77 | Recommendation Table 1 — Recommendations for clinical and laboratory, and for functional and quality of life, assessment in patients with peripheral arterial and aortic disease (see also Evidence Table 1) |
| p.23 | IIa | B | Overall evaluation of functional (physical functioning) performance with objective tests should be considered in patients with symptomatic and asymptomatic chronic PAD.57,61,63 | Recommendation Table 1 — Recommendations for clinical and laboratory, and for functional and quality of life, assessment in patients with peripheral arterial and aortic disease (see also Evidence Table 1) |
| p.23 | IIa | B | Overall evaluation of self-reported (i.e. by questionnaire) physical and mental/social HRQoL should be considered in patients with PAAD.34–36,38,72 | Recommendation Table 1 — Recommendations for clinical and laboratory, and for functional and quality of life, assessment in patients with peripheral arterial and aortic disease (see also Evidence Table 1) |
| p.25 | I | B | Measurement of the ABI is recommended as the first-line non-invasive test for screening and diagnosis of PAD, using an ABI ≤0.90 as a diagnostic criterion.79,90,130,131 | Recommendation Table 2 — Recommendations for diagnostic tests in patients with peripheral arterial disease |
| p.25 | I | B | In the case of non-compressible ankle arteries or ABI >1.40, additional methods such as TP, TBI or Doppler waveform analysis are recommended.90,91,124,132,133 | Recommendation Table 2 — Recommendations for diagnostic tests in patients with peripheral arterial disease |
| p.28 | I | C | It is recommended that aortic diameters are measured at pre-specified anatomical landmarks, and the largest diameter of the section be perpendicular to the longitudinal axis.134,135 | Recommendation Table 3 — Recommendations for imaging of the aorta (see also Evidence Table 2) |
| p.28 | I | C | It is recommended in cases of serial imaging of the aorta over time to use the same imaging modality with the same measurement method.159 | Recommendation Table 3 — Recommendations for imaging of the aorta (see also Evidence Table 2) |
| p.28 | I | C | It is recommended to consider renal function, pregnancy, age, and history of allergy to contrast media to select the optimal imaging modality with minimal radiation exposure and lowest iatrogenic risk, except for emergency cases.159–161 | Recommendation Table 3 — Recommendations for imaging of the aorta (see also Evidence Table 2) |
| p.28 | IIa | B | Indexing aortic diameters to BSA, along with the use of nomograms, z-scores, or other indexing methods, should be considered for more accurate assessment of aortic size, especially for body sizes at the lower end of the normal distribution.156–158 BSA, body surface area. aClass of recommendation. bLevel of evidence. | Recommendation Table 3 — Recommendations for imaging of the aorta (see also Evidence Table 2) |
| p.29 | I | B | TTE is recommended as the first-line imaging technique in evaluating thoracic aortic diseases.159,165 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | I | C | It is recommended to report aortic diameters using the leading-to-leading edge convention in end-diastole by echocardiography.137,139,140,159 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | I | C | It is recommended to report aortic diameters using the inner-to-inner edge convention in end-diastole by CCT or CMR.137,143,144,159 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | I | C | It is recommended to report aortic diameters from images obtained with the double-oblique technique (not axial images) by CCT or CMR.148 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | I | C | ECG-triggered CCT is recommended for comprehensive diagnosis, follow-up, and pre-invasive treatment assessment of the entire aorta, particularly the root and ascending aorta.159 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | I | C | CMR is recommended for diagnosis and follow-up of thoracic aortic diseases, especially when chronic follow-up is required.166–168 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | IIa | C | The aortic root should be measured using the cusp-to-cusp distance. Also, the presence of asymmetry (>5 mm) among distances should be reported.137,146 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | IIa | C | If an increase of ≥3 mm per year in aortic diameters by TTE is observed, confirmation by CCT/CMR should be considered.137,159 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.29 | IIb | C | Chest X-ray may be considered in cases of low clinical probability of AAS; however, a negative exploration should not delay dedicated aortic imaging in high-risk patients.162–164 | Recommendation Table 4 — Recommendations for thoracic aortic measurements |
| p.31 | IIa | C | for PAD by ABI or TBI should be considered.77,218,219 | Recommendation Table 5 — Recommendations for peripheral arterial disease screening (see also Evidence Table 3) |
| p.31 | IIa | C | screening with DUS should be considered.76 | Recommendation Table 5 — Recommendations for peripheral arterial disease screening (see also Evidence Table 3) |
| p.31 | IIb | C | PAD by ABI or TBI may be considered.220 | Recommendation Table 5 — Recommendations for peripheral arterial disease screening (see also Evidence Table 3) |
| p.31 | IIb | C | In patients with two or more CVRFs, screening for CS may be considered.201,203,210 | Recommendation Table 5 — Recommendations for peripheral arterial disease screening (see also Evidence Table 3) |
| p.31 | IIa | B | PAD patients.233 | Recommendation Table 6 — Recommendations for abdominal aortic aneurysm screening |
| p.31 | IIa | B | women aged ≥75 years during TTE.232 | Recommendation Table 6 — Recommendations for abdominal aortic aneurysm screening |
| p.31 | IIa | B | In patients with diabetes or chronic kidney disease, and normal resting ABI, TBI measurement should be considered. In patients ≥65 years of age with CVRFs, screening In patients with AAA, femoro-popliteal aneurysm | Recommendation Table 5 — Recommendations for peripheral arterial disease screening (see also Evidence Table 3) |
| p.31 | IIb | C | In patients ≥65 years without CVRFs, screening for In patients needing intervention with transfemoral access, screening for iliofemoral artery disease may be considered.198 | Recommendation Table 5 — Recommendations for peripheral arterial disease screening (see also Evidence Table 3) |
| p.31 | I | A | Screening for AAA with DUS: Is recommended in men aged ≥65 years with a history of smoking to reduce the risk of death from ruptured AAA.221–224,234 | Recommendation Table 6 — Recommendations for abdominal aortic aneurysm screening |
| p.31 | IIb | C | May be considered in men aged ≥75 years (irrespective of smoking history) or in women aged ≥75 years who are current smokers, hypertensive, or both.227,228,235–237 | Recommendation Table 6 — Recommendations for abdominal aortic aneurysm screening |
| p.31 | I | C | Family AAA screening with DUS: Is recommended for FDRs of patients with AAA aged ≥50, unless an acquired cause can be clearly identified.231 Opportunistic AAA screening with DUS: Should be considered in symptomatic/asymptomatic © ESC 2024 Should be considered in men aged ≥65 years and in | Recommendation Table 6 — Recommendations for abdominal aortic aneurysm screening |
| p.33 | I | A | In patients with PAAD, cessation and abstinence from smoking of any kind is recommended to reduce the risk of AD, MI, death, and limb ischaemia.119,261–267 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | I | A | A healthy diet rich in legumes, dietary fibre, nuts, fruits, and vegetables, with a high flavonoid intake (Mediterranean diet), is recommended for CV disease prevention in patients with PAAD.239– 241,249,290–293 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | I | A | Low- to moderate-intensity (or high if tolerated)c aerobic activities are recommended in patients with PAD to increase overall and pain-free walking distance.37,294 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | I | B | In patients with PAAD, behavioural counselling to promote healthy diet, smoking cessation, and physical activity is recommended to improve the CV risk profile.241,249,253,295 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | I | C | It is recommended to promote patient and caregivers’ education and empowerment through tailored guidance on lifestyle adjustments and the importance of regular physical activity.276,277,283 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | IIa | C | In patients with PAAD, avoidance of exposure to second-hand smoke and air pollution should be considered.261 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | IIa | C | Physical exercise and sports activities should be considered in patients with aortic diseases based on prior risk stratification (based on the extent of the aneurysm, risk of dissection, and BP control).71 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | IIa | C | Use of web- or app-based secondary prevention risk calculators should be considered in the shared decision-making to improve patient adherence to treatment and lifestyle changes.288,289 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.33 | IIb | C | E-cigarettes may be considered as an aid to quit tobacco smoking, but it is advisable to limit their use and avoid simultaneous use with conventional cigarettes due to unknown long-term effects.119,271,296,297 | Recommendation Table 7 — Recommendations for lifestyle, physical activity, and patient education (see also Evidence Table 4) |
| p.34 | I | A | In patients with PAAD and hypertension an SBP target towards 120–129 mmHg, if tolerated, is recommended.301–305,325 | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | I | B | In unilateral RAS patients, it is recommended that antihypertensive medication include ACEIs/ ARBs.307,320–323 | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | IIa | B | In patients with PAAD and hypertension, ACEIs or ARBs should be considered as first-line antihypertensive therapy.307,312 | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | IIa | B | In RAS-related hypertension, the combination of ACEIs/ARBs with diuretics and/or calcium channel blockers should be considered.324 | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | IIa | C | An individualized, more lenient BP goal (e.g. <140/ 90 mmHg) should be considered in:301 • Age ≥85 years • Residential care • Symptomatic orthostatic hypotension | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | IIb | C | An individualized, more lenient BP goal (e.g. <140/ 90 mmHg) may be considered in:301 • Clinically severe frailty at any age • Limited life expectancy (<3 years) | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | IIb | B | In patients with bilateral RAS, antihypertensive medication including ACEIs/ARBs may be considered if close patient monitoring (renal function) is feasible.321 | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.34 | IIb | B | ACEIs/ARBs may be considered in all patients with PAD, regardless of BP levels, in the absence of contraindications.312,313 | Recommendation Table 8 — Recommendations for antihypertensive therapy in patients with peripheral and aortic disease |
| p.35 | I | A | therapy is recommended.242,334–336 | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.35 | I | A | PAD.328,329,337,371 | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.35 | IIa | B | AAA should be considered.347–349,352,354 | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.35 | IIb | C | In cases where on-treatment SBP is at or below target (120–129 mmHg) but DBP is not at target (≥80 mmHg), intensifying BP-lowering treatment to achieve an on-treatment DBP of 70–79 mmHg may be considered to reduce CVD risk.306 | |
| p.35 | I | A | In patients with atherosclerotic PAAD, lipid-lowering An ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >50% reduction in LDL-C vs. baseline are recommended in patients with atherosclerotic PAAD.19,242,246,300,335 Statins are recommended in all patients with | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.35 | I | A | If the target LDL-C level is not achieved on maximally tolerated statins and ezetimibe, treatment with a PCSK9 inhibitor is recommended in patients with atherosclerotic PAAD, to achieve target values.372,373 | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.35 | I | B | If the target LDL-C level is not achieved, a combination of statins and ezetimibe is indicated in patients with atherosclerotic PAAD, to achieve the given target values.247 | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.35 | I | B | For statin-intolerant patients with atherosclerotic PAAD, at high CV risk, who do not achieve their LDL-C goal on ezetimibe, it is recommended to add bempedoic acid either alone or in combination with a PCSK9 inhibitor.361 Statins for the reduction of growth and rupture of | Recommendation Table 9 — Recommendations for lipid-lowering therapy in patients with peripheral arterial and aortic diseases |
| p.36 | IIb | B | TAA may be considered.350,351,355 | |
| p.36 | III | B | Fibrates are not recommended for cholesterol lowering.367 | |
| p.36 | I | B | patients with PAAD.374,408–412 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.36 | IIb | B | Statins for the reduction of growth and rupture of In high-risk patients with PAAD and triglycerides >1.5 mmol/L despite lifestyle measures and statin therapy, icosapent ethyl 2 g b.i.d. may be considered in addition to a statin.368 | |
| p.36 | I | A | It is recommended to apply tight glycaemic control (HbA1c <53 mmol/mol [7%]) to reduce microvascular complications in patients with PAAD.374,394–397 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.36 | I | A | SGLT2i with proven CV benefit are recommended in patients with T2DM and PAAD to reduce CV events, independent of baseline or target HbA1c and concomitant glucose-lowering medication.382,386,398–402 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.36 | I | A | GLP-1RAs with proven CV benefit are recommended in patients with T2DM and PAAD to reduce CV events, independent of baseline or target HbA1c and concomitant glucose-lowering medication.381,403–407 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.36 | I | C | It is recommended to avoid hypoglycaemia in It is recommended to individualize HbA1c targets according to comorbidities, diabetes duration, and life expectancy.408,411 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.36 | I | C | It is recommended to prioritize the use of glucose-lowering agents with proven CV benefits,c,d followed by agents with proven CV safety,e over agents without proven CV benefit or safety.374 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.36 | IIa | B | If additional glucose control is needed, metformin should be considered in patients with T2DM and PAAD.374,384,393 | Recommendation Table 10 — Recommendations for the medical management of patients with peripheral arterial and aortic diseases and diabetes |
| p.40 | I | C | DUS is recommended as the first-line imaging method to confirm PAD lesions.122,123,447 | Recommendation Table 12 — Recommendations for imaging in patients with peripheral arterial disease |
| p.40 | I | C | Measuring TP or TBI is recommended in patients with diabetes or renal failure if resting ABI is normal.90,91,94,440 | Recommendation Table 11 — Recommendations for diagnostic tests in patients with peripheral arterial disease and diabetes, renal failure, and wounds |
| p.40 | IIa | C | In patients with PAD and chronic wounds, the WIfI classification system should be considered to estimate individual risk of amputation.417,444–446 | Recommendation Table 11 — Recommendations for diagnostic tests in patients with peripheral arterial disease and diabetes, renal failure, and wounds |
| p.40 | I | C | In symptomatic patients with aorto-iliac or multisegmental/complex disease, CTA and/or MRA © ESC 2024 are recommended as adjuvant imaging techniques for preparation of revascularization procedures.448,449 | Recommendation Table 12 — Recommendations for imaging in patients with peripheral arterial disease |
| p.40 | I | C | Analysis of anatomical imaging tests in conjunction with symptoms and haemodynamic tests prior to an invasive procedure is recommended.426 | Recommendation Table 12 — Recommendations for imaging in patients with peripheral arterial disease |
| p.45 | I | A | In patients with symptomatic PAD, SET is recommended.294,453,456–458,462 | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | I | A | In those patients undergoing endovascular revascularization, SET is recommended as an adjuvant therapy.482,483 | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | IIa | A | When SET is not available or feasible, a structured and monitored (calls, logbooks, connected devices) HBET programme should be considered.468,469,471 | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | IIa | A | Walking should be considered as a first-line training modality. When walking exercise is not an option, alternative exercise modes (strength training, arm cranking, cycling, and combinations of different training modes) should also be considered.475 | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | IIa | A | Walking training performed at high intensity (77%– 95% of maximal heart rate or 14–17 self-perceived exertion on Borg’s scale) should be considered to improve walking performance,294 and high-intensity exercise training (various aerobic training modes) should be considered to improve cardiorespiratory | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | IIa | B | fitness.294,457 Training frequency of at least three times per week, training session duration of at least 30 min, and training programme duration of at least 12 weeks should be considered.472 | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | IIb | B | In patients with PAD, exercise training to moderate-severe claudication pain may be considered to improve walking performance.37,454,456,458 However, improvements are also achievable with lesser claudication pain | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | IIb | C | severities (low-mild pain or pain-free).455,460 Based on patient’s tolerance, a progressive increase (every 1–2 weeks) in exercise training load may be considered.37,62 | Recommendation Table 13 — Recommendations for exercise therapy in patients with peripheral arterial disease (see also Evidence Table 5) |
| p.45 | I | A | Use of antiplatelet therapy with aspirin alone (range 75–160 mg o.d.) or clopidogrel alone (75 mg o.d.) is recommended for the reduction of MACE in patients with symptomatic PAD.488–490 | Recommendation Table 14 — Recommendations for antithrombotic therapy in patients with peripheral arterial disease (see also Evidence Table 6) |
| p.45 | IIa | A | Treatment with combination rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered for patients with PAD, high ischaemic risk,c and non-high bleeding risk.d,429,498,499 | Recommendation Table 14 — Recommendations for antithrombotic therapy in patients with peripheral arterial disease (see also Evidence Table 6) |
| p.46 | III | A | Long-term DAPT in patients with PAD is not recommended.489 | |
| p.46 | III | A | Oral anticoagulant monotherapy for PAD (unless for another indication) is not recommended.515 | |
| p.46 | III | A | The routine use of ticagrelor in patients with PAD is not recommended.495 | |
| p.46 | IIa | B | Treatment with combination rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered for patients with PAD and non-high bleeding risk following lower-limb revascularization.490,505 | |
| p.46 | IIb | B | Use of antiplatelet therapy with clopidogrel alone (75 mg o.d.) may be considered over aspirin to reduce MI, stroke, and vascular death.493,494 | |
| p.46 | IIb | A | Aspirin (75–100 mg) for primary prevention may be considered in patients with asymptomatic PAD and DM, in the absence of contraindications.419,487 | |
| p.46 | IIb | B | DAPT for at least 1 month after revascularization may be considered to reduce limb events.500,501,503,513,514 | |
| p.46 | III | B | It is not recommended to systematically treat patients with asymptomatic PAD without any sign of clinically relevant ASCVD with antiplatelet drugs.485 | |
| p.47 | III | C | revascularization is not recommended.119,529 | Recommendation Table 15 — Recommendations for interventional treatment of asymptomatic and symptomatic peripheral arterial disease (general) |
| p.47 | I | B | In patients with symptomatic PAD, after a 3 month period of OMT and exercise therapy, PAD-related QoL assessment is recommended.119 | Recommendation Table 15 — Recommendations for interventional treatment of asymptomatic and symptomatic peripheral arterial disease (general) |
| p.47 | I | C | It is recommended to adapt the mode and type of revascularization options to anatomical lesion location, lesion morphology, and general patient condition.119 | Recommendation Table 15 — Recommendations for interventional treatment of asymptomatic and symptomatic peripheral arterial disease (general) |
| p.47 | IIb | B | In patients with symptomatic PAD and impaired PAD-related quality of life after a 3 month period of OMT and exercise therapy, revascularization may be considered.465,540 | Recommendation Table 15 — Recommendations for interventional treatment of asymptomatic and symptomatic peripheral arterial disease (general) |
| p.47 | III | B | In patients with PAD, revascularization is not recommended if the reason is to solely prevent progression to CLTI.541–544 In patients with asymptomatic PAD, | Recommendation Table 15 — Recommendations for interventional treatment of asymptomatic and symptomatic peripheral arterial disease (general) |
| p.48 | IIa | A | In femoro-popliteal lesions, drug-eluting treatment should be considered as the first-choice strategy.534–537 | Recommendation Table 16 — Recommendations for interventional treatment of patients with symptomatic peripheral arterial disease (per arterial bed) |
| p.48 | IIa | B | In iliac lesions, balloon angioplasty with or without stenting in external iliac arteries, or primary stenting in common iliac arteries, should be considered.545–548 | Recommendation Table 16 — Recommendations for interventional treatment of patients with symptomatic peripheral arterial disease (per arterial bed) |
| p.48 | IIa | B | In femoro-popliteal lesions, if revascularization is indicated, endovascular therapy should be considered.119,529–531 | Recommendation Table 16 — Recommendations for interventional treatment of patients with symptomatic peripheral arterial disease (per arterial bed) |
| p.48 | IIa | C | In femoro-popliteal lesions, if revascularization is indicated, an open surgical approach should be considered when an autologous vein (e.g. GSV) is available in patients with low surgical risk.119,529 | Recommendation Table 16 — Recommendations for interventional treatment of patients with symptomatic peripheral arterial disease (per arterial bed) |
| p.48 | IIb | C | In patients with severe IC undergoing endovascular femoro-popliteal revascularization, treatment of BTK arteries may be considered in the same intervention.549,550 | Recommendation Table 16 — Recommendations for interventional treatment of patients with symptomatic peripheral arterial disease (per arterial bed) |
| p.48 | I | C | It is recommended to regularly, at least once a year, follow up patients with PAD, assessing clinical and functional status, medication adherence, limb symptoms, and CVRFs, with DUS assessment as needed.553,554 | Recommendation Table 17 — Recommendations in patients with peripheral arterial disease: follow-up of patients with peripheral arterial disease |
| p.49 | I | B | revascularization is recommended.564,567 | Recommendation Table 18 — Recommendations for the management of chronic limb-threatening ischaemia |
| p.49 | I | C | team are recommended for limb salvage.417,560 | Recommendation Table 18 — Recommendations for the management of chronic limb-threatening ischaemia |
| p.49 | IIa | C | limb should be considered.560 | Recommendation Table 18 — Recommendations for the management of chronic limb-threatening ischaemia |
| p.49 | I | C | It is recommended that patients with CLTI are managed by a vascular team.568 | Recommendation Table 19 — Recommendations for medical treatment in patients with chronic limbthreatening ischaemia (see also Evidence Table 7) |
| p.49 | I | C | antibiotics.569,570 | Recommendation Table 19 — Recommendations for medical treatment in patients with chronic limbthreatening ischaemia (see also Evidence Table 7) |
| p.49 | III | C | patients with CLTI and wounds.584 | Recommendation Table 19 — Recommendations for medical treatment in patients with chronic limbthreatening ischaemia (see also Evidence Table 7) |
| p.49 | I | C | In patients with CLTI and ulcers, offloading mechanical tissue stress is recommended to allow wound healing.583,584 It is recommended to treat infection with Lower-limb exercise training is not recommended in CLTI, chronic limb-threatening ischaemia. aClass of recommendation. bLevel of evidence. | Recommendation Table 19 — Recommendations for medical treatment in patients with chronic limbthreatening ischaemia (see also Evidence Table 7) |
| p.50 | I | B | revascularization as soon as possible.564 | Recommendation Table 20 — Recommendations for interventional treatment of chronic limb-threatening ischaemia |
| p.50 | I | B | In CLTI patients, it is recommended to perform In CLTI, it is recommended to use autologous veins as the preferred conduit for infra-inguinal bypass surgery.567,593 | Recommendation Table 20 — Recommendations for interventional treatment of chronic limb-threatening ischaemia |
| p.50 | I | C | In multilevel vascular disease, it is recommended to eliminate inflow obstructions when treating downstream lesions. | Recommendation Table 20 — Recommendations for interventional treatment of chronic limb-threatening ischaemia |
| p.50 | I | C | An individual risk assessment (weighing the patient’s individual procedural risk of endovascular vs. surgical revascularization) by a multidisciplinary vascular team is recommended. | Recommendation Table 20 — Recommendations for interventional treatment of chronic limb-threatening ischaemia |
| p.50 | IIb | B | In CLTI patients with good autologous veins and low surgical risk (<5% peri-operative mortality, >50% 2 year survival), infra-inguinal bypass may be considered.564,567,590 | Recommendation Table 20 — Recommendations for interventional treatment of chronic limb-threatening ischaemia |
| p.50 | IIb | B | In CLTI patients, endovascular treatment may be considered as first-line therapy, especially in patients with increased surgical risk or inadequate autologous veins.564,567,590 CLTI, chronic limb-threatening ischaemia. aClass of recommendation. bLevel of evidence. | Recommendation Table 20 — Recommendations for interventional treatment of chronic limb-threatening ischaemia |
| p.50 | I | C | In patients with CLTI, following revascularization it is recommended to follow up patients on a regular basis.552,626,627 | Recommendation Table 21 — Recommendations for follow-up in patients with chronic limb-threatening ischaemia |
| p.50 | I | C | At follow-up, it is recommended to assess clinical, haemodynamic and functional status, limb symptoms, treatment adherence, and CVRFs.552,625–628 © ESC 2024 | Recommendation Table 21 — Recommendations for follow-up in patients with chronic limb-threatening ischaemia |
| p.53 | I | C | Treatment with analgesics is recommended as soon as possible for pain control. | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | IIb | C | heparin may be considered.635,654–656 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | C | diagnose ICA stenosis.77,663 | Recommendation Table 23 — Recommendations for carotid artery stenosis assessment |
| p.53 | III | C | ICA stenosis assessment.77,122,660 | Recommendation Table 23 — Recommendations for carotid artery stenosis assessment |
| p.53 | I | C | In patients with ALI, it is recommended that an urgent evaluation is performed by a vascular clinician with sufficient experience to assess limb viability and implement appropriate therapy.635 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | C | In cases of neurological deficit, urgent revascularization is recommended; diagnostic imaging is recommended to guide treatment, provided it does not delay treatment, or if the need for primary amputation is obvious.422,635,651,652 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | C | In the absence of severe neurological deficit, revascularization is recommended within hours of initial imaging in a case-by-case decision.422,635,652 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | C | It is recommended to monitor for compartment syndrome after revascularization and treat (fasciotomy).637,652 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | C | It is recommended to assess clinical and haemodynamic success following revascularization.627 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | C | In patients with ALI, it is recommended to obtain a comprehensive medical history and determine the cause of thrombosis and/or embolization.650 | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | IIa | C | In patients with ALI, following revascularization if not on anticoagulation for other reasons, DAPT or rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered.514,653 Upon confirmation of ALI diagnosis, treatment with | Recommendation Table 22 — Recommendations for the management of patients presenting with acute limb ischaemia (see also Evidence Table 8) |
| p.53 | I | B | It is recommended to use the NASCET method or its non-invasive equivalent to assess ICA © ESC 2024 stenosis.77,122,660 It is recommended to use DUS as first-line imaging to It is not recommended to use the ECST method for | Recommendation Table 23 — Recommendations for carotid artery stenosis assessment |
| p.55 | I | A | Carotid artery disease In patients with symptomatic CS, not undergoing carotid endarterectomy or stenting, DAPT with low-dose aspirin and clopidogrel (75 mg) is recommended for the first 21 days or longer, followed by clopidogrel 75 mg or long-term aspirin to reduce the risk of stroke.667–669 | Recommendation Table 24 — Recommendations for antithrombotic treatment in patients with carotid stenosis |
| p.55 | IIa | C | In patients with asymptomatic >50% CS, long-term antiplatelet therapy (commonly low-dose aspirin) should be considered if bleeding risk is low.488,497,670,671 CS, carotid artery stenosis; DAPT, dual antiplatelet therapy. aClass of recommendation. bLevel of evidence. | Recommendation Table 24 — Recommendations for antithrombotic treatment in patients with carotid stenosis |
| p.57 | IIa | C | considered following ICA revascularization.667,668 | Recommendation Table 26 — Recommendations for evaluation and medical treatment in patients with symptomatic carotid artery stenosis |
| p.57 | IIa | B | When ICA revascularization is considered, documented peri-operative stroke/death rates should be <3% and the patient’s life expectancy should be considered >5 years after careful consideration of the risks and benefits by a vascular team. 674,709 | Recommendation Table 25 — Recommendations for interventional treatment in patients with asymptomatic carotid artery stenosis |
| p.57 | IIa | B | In ‘average surgical risk’ patients over 75 years of age with a CS of 60%–99%, in the presence of high-risk features, CEA, in addition to OMT, should be considered.674,709 | Recommendation Table 25 — Recommendations for interventional treatment in patients with asymptomatic carotid artery stenosis |
| p.57 | IIb | B | In ‘high surgical risk’ patients with a CS of 60%–99%, in the presence of high-risk features, CAS, in addition to OMT, may be considered.699,701,704 | Recommendation Table 25 — Recommendations for interventional treatment in patients with asymptomatic carotid artery stenosis |
| p.57 | IIb | B | In ‘average surgical risk’ patients with a CS of 60%– 99%, in the presence of high-risk features, CAS, in addition to OMT, may be considered as an alternative to CEA.696,701,702,710 | Recommendation Table 25 — Recommendations for interventional treatment in patients with asymptomatic carotid artery stenosis |
| p.57 | III | A | In asymptomatic patients with ICA stenosis, in the absence of high-risk features and with a life expectancy <5 years, routine revascularization is not recommended.674 | Recommendation Table 25 — Recommendations for interventional treatment in patients with asymptomatic carotid artery stenosis |
| p.57 | I | A | DAPT is recommended in the early phase of minor strokes in patients with ICA stenosis, if not revascularized, for at least 21 days, considering the bleeding risk.667,668 | Recommendation Table 26 — Recommendations for evaluation and medical treatment in patients with symptomatic carotid artery stenosis |
| p.57 | I | C | It is recommended that symptomatic ICA stenosis patients are assessed by a vascular team including a neurologist.667,668 Long-term treatment with SAPT should be | Recommendation Table 26 — Recommendations for evaluation and medical treatment in patients with symptomatic carotid artery stenosis |
| p.57 | IIb | B | © ESC 2024 DAPT may be considered in the early phase of minor stroke in patients with ICA stenosis for up to 90 days, considering the bleeding risk.667,668 | Recommendation Table 26 — Recommendations for evaluation and medical treatment in patients with symptomatic carotid artery stenosis |
| p.59 | I | A | stenosis patients.19 | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | III | A | with ICA lesions <50%.660,719 | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | I | A | CVRFs and treatment compliance.754 | Recommendation Table 28 — Recommendations for follow-up in patients with carotid artery stenosis |
| p.59 | I | B | After ICA revascularization, long-term aspirin or clopidogrel is recommended.746,747 | Recommendation Table 28 — Recommendations for follow-up in patients with carotid artery stenosis |
| p.59 | I | C | recommended within the first month.749,754 | Recommendation Table 28 — Recommendations for follow-up in patients with carotid artery stenosis |
| p.59 | I | A | It is recommended to perform CEA of symptomatic 70%–99% ICA stenosis provided a documented 30 day risk of procedural death/stroke is <6%.660,719 | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | I | B | If indicated, it is recommended to perform CEA within 14 days in symptomatic ICA stenosis patients.734 OMT is recommended for all symptomatic ICA | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | IIa | A | CEA of symptomatic 50%–69% ICA stenosis should be considered provided a documented 30 day risk of procedural death/stroke is <6%.660,719 | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | IIa | B | For symptomatic patients at high risk for CEA with a 70%–99% ICA stenosis, CAS should be considered provided a documented 30 day risk of procedural death/stroke is <6%.703 | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | IIb | A | For symptomatic patients <70 years of age with a 70%–99% ICA stenosis, CAS may be considered provided a documented 30 day risk of procedural death/stroke is <6%.703 Revascularization is not recommended in patients | Recommendation Table 27 — Recommendations for interventions in patients with symptomatic carotid artery stenosis |
| p.59 | I | A | Once-yearly follow-up is recommended to check for After ICA stent implantation, DAPT with aspirin and clopidogrel is recommended for at least 1 month.77,749,750 © ESC 2024 | Recommendation Table 28 — Recommendations for follow-up in patients with carotid artery stenosis |
| p.59 | I | C | During follow-up, it is recommended to assess neurological symptoms, CVRFs, and treatment adherence at least yearly in patients with CS.754 After ICA revascularization, surveillance with DUS is | Recommendation Table 28 — Recommendations for follow-up in patients with carotid artery stenosis |
| p.60 | I | B | all patients with PAAD.32,758 | Recommendation Table 29 — Recommendations for the management of subclavian artery stenosis (see also Evidence Table 9) |
| p.60 | IIa | C | haemodialysis arteriovenous access.778 | Recommendation Table 29 — Recommendations for the management of subclavian artery stenosis (see also Evidence Table 9) |
| p.60 | IIa | B | Bilateral arm BP measurement is recommended for In symptomatic patients with atherosclerotic subclavian artery disease (TIA/stroke, coronary subclavian steal syndrome, ipsilateral haemodialysis access dysfunction, severe ischaemia), both revascularization options (endovascular ± stenting or surgery) should be considered and discussed case by case by a vascular team.776 | Recommendation Table 29 — Recommendations for the management of subclavian artery stenosis (see also Evidence Table 9) |
| p.60 | IIb | B | Endovascular revascularization may be considered over surgery, despite similar long-term outcomes, due to lower complication rates.765 | Recommendation Table 29 — Recommendations for the management of subclavian artery stenosis (see also Evidence Table 9) |
| p.60 | IIa | C | Should be considered in cases of proximal stenosis in patients undergoing CABG using the ipsilateral internal mammary artery.777–781 | Recommendation Table 29 — Recommendations for the management of subclavian artery stenosis (see also Evidence Table 9) |
| p.60 | III | C | Routine revascularization in patients with atherosclerotic subclavian artery disease is not recommended.776 | Recommendation Table 29 — Recommendations for the management of subclavian artery stenosis (see also Evidence Table 9) |
| p.63 | I | B | modality in patients with suspicion of RAS.787,789–791 | Recommendation Table 30 — Recommendations for diagnostic strategies for renal artery disease |
| p.63 | IIb | C | low-dose aspirin may be considered.811 | Recommendation Table 31 — Recommendations for treatment strategies for renal artery disease (see also Evidence Table 10) |
| p.63 | I | B | DUS is recommended as the first-line imaging In cases of DUS-based suspicion of RAS or inconclusive DUS, MRA, or CTA are recommended.789,791 | Recommendation Table 30 — Recommendations for diagnostic strategies for renal artery disease |
| p.63 | I | B | In patients with atherosclerotic RAS, it is recommended to assess clinical high-risk features and kidney viability when evaluating renal artery revascularization.809,810 | Recommendation Table 30 — Recommendations for diagnostic strategies for renal artery disease |
| p.63 | IIa | B | Medical therapy In patients with atherosclerotic RAS the use of Revascularization In patients with atherosclerotic unilateral >70% RAS, concomitant high-risk features, and signs of kidney viability, renal artery revascularization should be considered after OMT has been established.798,809,810 | Recommendation Table 31 — Recommendations for treatment strategies for renal artery disease (see also Evidence Table 10) |
| p.63 | IIa | B | In patients with atherosclerotic bilateral (>70%) RAS or RAS in a solitary kidney, concomitant high risk features, and signs of kidney viability, renal artery revascularization should be considered.800–802 | Recommendation Table 31 — Recommendations for treatment strategies for renal artery disease (see also Evidence Table 10) |
| p.63 | IIa | B | In patients with hypertension and/or signs of renal dysfunction due to RAS caused by fibromuscular dysplasia, concomitant high-risk features, and signs of kidney viability, revascularization with primary balloon angioplasty and bailout stenting should be considered.812,813 | |
| p.63 | IIa | B | In patients with an indication for renal artery revascularization and complex anatomy, or after failed endovascular revascularization, open surgical revascularization should be considered.805,806 | |
| p.63 | III | A | In patients with atherosclerotic unilateral RAS, routine revascularization is not recommended.324,800–804,814 RAS, renal artery stenosis. aClass of recommendation. bLevel of evidence. | |
| p.65 | III | C | visceral artery stenosis is not recommended. | Recommendation Table 32 — Recommendations in patients with visceral artery stenosis |
| p.65 | IIa | C | considered in severe/complex plaques.493,666,861,863 | Recommendation Table 33 — Recommendations for primary and secondary prevention in aortic atheromatous plaques |
| p.65 | I | B | In patients with acute mesenteric ischaemia due to acute occlusion of the SMA, endovascular revascularization is recommended.829–831 | Recommendation Table 32 — Recommendations in patients with visceral artery stenosis |
| p.65 | I | C | In patients with suspected acute or chronic mesenteric ischaemia, CTA is recommended.826,827,845,846 | Recommendation Table 32 — Recommendations in patients with visceral artery stenosis |
| p.65 | I | C | In patients with acute or chronic mesenteric ischaemia, assessment by a vascular team is recommended. Revascularization of asymptomatic atherosclerotic 9 Aorta | Recommendation Table 32 — Recommendations in patients with visceral artery stenosis |
| p.65 | IIa | C | Primary prevention In patients with severe/complex aortic atheromatous plaques, statins should be considered to decrease progression and risk of CV events.862 SAPT with clopidogrel or low-dose aspirin should be | Recommendation Table 33 — Recommendations for primary and secondary prevention in aortic atheromatous plaques |
| p.65 | III | C | Anticoagulation861 or DAPT863 are not © ESC 2024 recommended in aortic plaques since they present no benefit and increase bleeding risk.666 | Recommendation Table 33 — Recommendations for primary and secondary prevention in aortic atheromatous plaques |
| p.65 | I | A | atherosclerosis In patients with an embolic event and evidence of an aortic arch atheroma, intensive lipid management to an LDL-C target <1.4 mmol/L (<55 mg/dL) is recommended to prevent recurrences.242,862,865,868 | Recommendation Table 33 — Recommendations for primary and secondary prevention in aortic atheromatous plaques |
| p.65 | I | C | In patients with an embolic event and evidence of an aortic arch atheroma, SAPT is recommended to prevent recurrences.666,865,866 | Recommendation Table 33 — Recommendations for primary and secondary prevention in aortic atheromatous plaques |
| p.66 | I | C | When a TAA is identified, assessment of the aortic valve (especially for BAV) is recommended.879,880 | Recommendation Table 34 — Recommendations for initial evaluation of thoracic aortic aneurysm and abdominal aortic aneurysm |
| p.66 | I | C | mobile/ulcerated components) © ESC 2024 ulcerated components) When an aortic aneurysm is identified at any location, assessment of the entire aorta is mobile/ulcerated components recommended at baseline and during follow-up.874,875 | Recommendation Table 34 — Recommendations for initial evaluation of thoracic aortic aneurysm and abdominal aortic aneurysm |
| p.66 | IIa | C | When an AAA is identified, evaluation of the presence of aneurysm in the femoro-popliteal arterial segment should be considered.876–878,881 | Recommendation Table 34 — Recommendations for initial evaluation of thoracic aortic aneurysm and abdominal aortic aneurysm |
| p.66 | IIa | C | Patients with aortic aneurysm are at increased risk of CVD, thus general CV prevention should be considered.26,882,883 | Recommendation Table 34 — Recommendations for initial evaluation of thoracic aortic aneurysm and abdominal aortic aneurysm |
| p.70 | I | C | In thoracic aortic dilatation, TTE is recommended at diagnosis to assess aortic valve anatomy and function, aortic root, and ascending aorta diameters. Additionally, a global aortic evaluation using all echocardiographic views is recommended.159 | Recommendation Table 35 — Recommendation for the surveillance of patients with thoracic aortic aneurysms (non-heritable thoracic aortic disease) |
| p.70 | I | C | CMR or CCT is recommended for surveillance of patients with aneurysm at the distal ascending aorta, aortic arch, DTA, or TAAA.70,159,172,912–915 | Recommendation Table 35 — Recommendation for the surveillance of patients with thoracic aortic aneurysms (non-heritable thoracic aortic disease) |
| p.70 | I | C | In thoracic aortic dilatation, CCT or CMR is recommended to confirm TTE measurements, rule out aortic asymmetry, and determine baseline diameters for follow-up.137,143,144 | Recommendation Table 35 — Recommendation for the surveillance of patients with thoracic aortic aneurysms (non-heritable thoracic aortic disease) |
| p.70 | IIa | C | Follow-up imaging with TTE, CCT, or CMR (based on aneurysm location) should be considered annually if there is no expansion/extension or customized according to baseline aortic diameter and the underlying condition.70,159,172 | |
| p.70 | III | C | TTE is not recommended for the surveillance of aneurysms in the distal ascending aorta, aortic arch, or DTA.159,171 | |
| p.72 | I | C | DUS is recommended for AAA surveillance.943 | Recommendation Table 36 — Recommendations for surveillance of patients with abdominal aortic aneurysm |
| p.72 | IIa | B | DUS surveillance every 3 years should be considered in patients with AAA of 30–<40 mm.938 | Recommendation Table 36 — Recommendations for surveillance of patients with abdominal aortic aneurysm |
| p.72 | I | B | DUS surveillance is recommended every 6 months in men with AAA of 50–55 mm and in women with AAA of 45–50 mm.938 | Recommendation Table 36 — Recommendations for surveillance of patients with abdominal aortic aneurysm |
| p.72 | I | B | CCT or CMR is recommended if DUS does not allow adequate measurement of AAA diameter.148,939–942 | Recommendation Table 36 — Recommendations for surveillance of patients with abdominal aortic aneurysm |
| p.72 | IIa | B | DUS surveillance should be considered annually in women with AAA of 40–<45 mm and in men with AAA of 40–<50 mm.938 | Recommendation Table 36 — Recommendations for surveillance of patients with abdominal aortic aneurysm |
| p.72 | IIa | C | DUS surveillance should be considered every 4 years in patients with aortic diameter ≥25 mm and <30 mm and life expectancy >2 years.937,938 | Recommendation Table 36 — Recommendations for surveillance of patients with abdominal aortic aneurysm |
| p.72 | I | C | In patients with aortic aneurysm (TAA and/or AAA), optimal implementation of CV risk management and medical treatment (see detailed recommendations in dedicated Tables of Recommendationsc) are recommended to reduce MACE.936 | Recommendation Table 37 — Recommendations for medical treatment in patients with thoracic aorta or abdominal aortic aneurysms |
| p.72 | IIb | B | Fluoroquinolones, while generally discouraged for patients with aortic aneurysms, may be considered if there is a compelling clinical indication and no other reasonable alternative.951–960 | Recommendation Table 37 — Recommendations for medical treatment in patients with thoracic aorta or abdominal aortic aneurysms |
| p.74 | I | B | a Bentall procedure with an MHV prosthesis.970,971 | Recommendation Table 38 — Recommendations for surgery in aortic root and ascending aorta dilatation associated with tricuspid aortic valve (see also Evidence Table 11) |
| p.74 | I | B | Surgery is recommended in patients with dilatation of the aortic root or ascending aorta with a tricuspid aortic valve and a maximum diameter of ≥55 mm.172,894,899,904 | Recommendation Table 38 — Recommendations for surgery in aortic root and ascending aorta dilatation associated with tricuspid aortic valve (see also Evidence Table 11) |
| p.74 | I | B | Valve-sparing aortic root replacement is recommended in patients with aortic root dilatation if performed in experienced centres and durable results are expected.961–965 VKAs are recommended lifelong for all patients with | Recommendation Table 38 — Recommendations for surgery in aortic root and ascending aorta dilatation associated with tricuspid aortic valve (see also Evidence Table 11) |
| p.74 | IIa | B | In patients with dilatation of the tubular ascending aorta who can be offered surgery with low predicted risk,c ascending aortic replacement should be considered at a maximum diameter >52 mm.153,981,983 | Recommendation Table 38 — Recommendations for surgery in aortic root and ascending aorta dilatation associated with tricuspid aortic valve (see also Evidence Table 11) |
| p.74 | IIa | B | In patients undergoing surgery for tricuspid aortic valve disease who have concomitant dilatation of the aortic root or ascending tubular aorta, and low predicted surgical risk, ascending aorta or root replacement should be considered at a maximum diameter ≥45 mm, otherwise ≥50 mm.70,987–989 | Recommendation Table 39 — Recommendations for surgery in aortic arch aneurysms |
| p.74 | IIa | C | SAPT with low-dose aspirin (75–100 mg per day) should be considered for the first 3 months after valve-sparing aortic surgery when there are no other baseline indications for OAC. | |
| p.74 | IIa | C | In patients undergoing non-aortic-valve cardiac surgery who have concomitant dilatation of the ascending aorta or aortic root with a maximum diameter ≥50 mm, concomitant aortic surgery should be considered.70,990,991 Ascending aortic or root replacement may be considered at a maximum diameter of ≥50 mm in | |
| p.74 | IIb | B | patients with proximal aorta dilatation who can be offered surgery with low predicted riskc and present with any of the following:153–155,891,892 • Growth of the aortic diameter ≥3 mm per year • Resistant hypertensiond • Short stature <1.69 m • Root phenotype • Aortic lengthe >11 cm • Age <50 years • Desire for pregnancy • Aortic coarctation | |
| p.74 | I | C | In patients with low or intermediate operative risk with an aortic arch aneurysm and recurrent episodes of chest pain not attributable to non-aortic causes, open surgical replacement of the arch is recommended.70,172 Continued | Recommendation Table 39 — Recommendations for surgery in aortic arch aneurysms |
| p.75 | IIa | B | In patients with an isolated aortic arch aneurysm who are asymptomatic and have low operative risk, open surgical replacement should be considered at an arch diameter of ≥55 mm.70,172,899 | |
| p.75 | IIa | C | In patients undergoing open surgical repair of an ascending aortic aneurysm, concomitant hemi-arch replacement should be considered if the dilatation extends into the proximal aortic arch (>50 mm).70,172,1000 | |
| p.75 | IIa | C | In patients undergoing open surgical repair of an aortic arch aneurysm, an elephant trunk or frozen elephant trunk procedure should be considered if the aneurysmal disease extends into the proximal descending thoracic aorta.70,172,997,1001 | |
| p.75 | IIb | C | In patients undergoing open surgical repair of an ascending aortic aneurysm, concomitant hemi-arch or arch replacement may be considered in experienced centres if the dilatation extends into the aortic arch (>45 mm).70,172,1001 | |
| p.75 | IIb | C | In patients with an aortic arch aneurysm who meet criteria for intervention but have high surgical risk, a hybrid or endovascular approach may be considered.70,172 For heritable thoracic aortic disease refer to Section 10. aClass of recommendation. bLevel of evidence. | |
| p.76 | I | B | In patients with unruptured DTA aneurysm (without HTAD), elective repair is recommended if diameter ≥55 mm.902,1002 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | I | B | In patients without HTAD with unruptured DTA aneurysm, when elective repair is indicated and anatomy is suitable, TEVAR is recommended over open repair.1006,1019,1020 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | I | B | In patients with DTA aneurysm who undergo TEVAR with planned LSA coverage, it is recommended to revascularize the LSA before TEVAR to reduce the risk of SCI and stroke.1026,1028,1029 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | I | B | In patients with unruptured degenerative TAAA, elective repair is recommended when the diameter is ≥60 mm.902,1002,1033 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | IIa | B | In patients without significant comorbidities and with unruptured DTA aneurysm, when elective repair is indicated and anatomy is unsuitable for TEVAR, open repair should be considered if life expectancy exceeds 2 years.1013 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | IIa | B | In TAAA, surgical repair should be considered at diameters ≥55 mm if patients present with high-risk features, are at very low risk, and are under the care of experienced surgeons in a multidisciplinary aorta team.1004,1033,1034 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | IIa | B | In patients with unruptured degenerative TAAA and suitable anatomy, when elective repair is indicated, endovascular repair using fenestrated and/or branched endografts should be considered in experienced centres.1051,1052,1055–1059 Biological age and life expectancy quality of life approach | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.76 | IIb | B | be considered if the diameter is <55 mm.904,1003,1004,1033,1034 | Recommendation Table 40 — Recommendations for the management of patients presenting with descending thoracic aortic and thoracoabdominal aortic aneurysms |
| p.78 | I | A | ≥55 mm in men or ≥50 mm in women.1064–1067 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | IIb | C | aneurysm ≥45 mm may be considered.1144 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | I | B | Elective repair is recommended if AAA diameter is In ruptured AAA with suitable anatomy, endovascular repair is recommended over open repair to reduce peri-operative morbidity and mortality.1116–1118 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | IIa | B | Prior to AAA repair, DUS assessment of the femoro-popliteal segment, to detect concomitant aneurysms, should be considered.1091,1092 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | IIa | B | In patients with AAA with suitable anatomy and reasonable life expectancy (>2 years), EVAR should be considered as the preferred therapy, based on shared decision-making.910,1096,1141–1143 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | IIb | C | In patients with unruptured AAA and aneurysm growth ≥5 mm in 6 months or ≥10 mm per year, repair may be considered.1064,1065 Elective repair for patients presenting with a saccular | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | III | B | In patients with AAA and limited life expectancy (<2 years), elective AAA repair is not recommended.1098,1099 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.78 | III | C | Prior to AAA repair, routine evaluation with coronary angiography and systematic revascularization in patients with chronic coronary syndromes is not recommended.1080,1081 | Recommendation Table 41 — Recommendations for the management of patients presenting with abdominal aortic aneurysm |
| p.80 | I | B | It is recommended to perform 30 day imaging after TEVAR/EVAR, by CCT and DUS/CEUS, to assess the success of intervention.1096 | Recommendation Table 42 — Recommendations for the management of patients presenting with endoleaks |
| p.80 | I | B | It is recommended to re-intervene to achieve a seal in patients with type I endoleak after TEVAR/ EVAR.1137,1148 | Recommendation Table 42 — Recommendations for the management of patients presenting with endoleaks |
| p.80 | I | B | It is recommended to re-intervene, principally by endovascular means, to achieve a seal in patients with type III endoleak after TEVAR/EVAR.1139 | Recommendation Table 42 — Recommendations for the management of patients presenting with endoleaks |
| p.80 | IIa | C | Re-intervention, principally with an endovascular approach or embolization, should be considered in patients with type II or V endoleak and significant sac expansion ≥10 mm or significantly decreasing proximal or distal seal.1096,1149 | Recommendation Table 42 — Recommendations for the management of patients presenting with endoleaks |
| p.81 | I | B | Thoracic aortic aneurysm After open repair of TAA, an early CCT is recommended within 1 month, and then yearly CCT follow-up for the first 2 post-operative years and every 5 years thereafter is recommended if findings are stable.c,70,1153,1159 | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | I | B | After TEVAR, follow-up imaging is recommended at 1 and 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalitiesd are documented.70,1153,1158 | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | IIa | B | After 5 post-operative years without complications, continuing long-term follow-up of TEVAR by CCT every 5 years should be considered.70,1153,1158 | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | IIa | C | If growth of the excluded aneurysm is observed, without evidence of type I or III endoleak, repeating CCT every 6–12 months, depending on the growth rate observed, should be considered.1150 When frequent controls are required in TAA | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | IIa | C | patients treated either by open or endovascular repair, CMR should be considered instead of CCT after the first year of follow-up. However, the choice between these imaging modalities should be based on individual patient factors, the potential for artefacts, and the local availability and expertise in | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | I | A | specific imaging techniques.1155 Abdominal aortic aneurysm After open repair of AAA, first follow-up imaging is recommended within 1 post-operative year, and every 5 years thereafter if findings are stable.1079,1096 After EVAR, follow-up imaging is recommended with | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | I | A | CCT (or CMR) and DUS/CEUS at 1 month and 12 months post-operatively, then, if no abnormalitiesd are documented, DUS/CEUS is recommended every year, repeating CCT or CMR (based on potential artefacts) every 5 years.70,1079,1100,1163–1165,1167 | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | IIa | B | In higher-risk patients, i.e. with inadequate sealing or type II endoleak at first CCT control, more frequent DUS/CEUS imaging should be considered.e,1096,1161,1164,1165,1167 | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | IIa | B | In low-riskf patients, from 1 year post-operatively after EVAR, repeating DUS/CEUS every 2 years should be considered.1096 | Recommendation Table 43 — Recommendations for follow-up after treatment of aortic aneurysms (see also Evidence Table 12) |
| p.81 | IIa | B | If any abnormality during DUS/CEUS is found, confirmation should be considered using additional CCT or CMR (based on potential artefacts).1163,1166 | |
| p.81 | IIa | C | In post-treatment surveillance, administration of OMT (see 8.1.2.2 and 8.2.4) and assessment of aneurysm development/growth in other arterial segments should be considered. | |
| p.85 | I | B | In unstable patients who cannot be transferred to CCT, TOE is recommended for diagnosis1204,1208,1209 and evaluation of the coeliac trunk and mesenteric artery.1210 | Recommendation Table 44 — Recommendations for diagnostic work-up of acute aortic syndromes |
| p.85 | I | B | In patients presenting with clinical features compatible with possible AAS, a multiparametric algorithm for ruling in or out AAS using the ADD-RS is recommended.1196–1200 | Recommendation Table 44 — Recommendations for diagnostic work-up of acute aortic syndromes |
| p.85 | I | C | ECG-gated CCT from neck to pelvis is recommended as the first-line imaging technique in patients with a suspected AAS since it is widely available, accurate, and provides information about the entry tear, extension, and possible complications (malperfusion, dilatation, or rupture).170 | Recommendation Table 44 — Recommendations for diagnostic work-up of acute aortic syndromes |
| p.85 | I | C | In patients with suspected AAS, focused TTE (with use of contrast if feasible) is recommended during the initial evaluation.170 | Recommendation Table 44 — Recommendations for diagnostic work-up of acute aortic syndromes |
| p.85 | I | C | In patients with suspected AAS, TOE is recommended to guide peri-operative management and detect complications.170 | Recommendation Table 44 — Recommendations for diagnostic work-up of acute aortic syndromes |
| p.85 | IIa | C | In patients with suspected AAS, CMR should be considered as an alternative imaging technique if CCT is not available.170 | Recommendation Table 44 — Recommendations for diagnostic work-up of acute aortic syndromes |
| p.86 | I | C | Adequate pain control to achieve haemodynamic targets is recommended.174 | Recommendation Table 45 — Recommendation for medical treatment in acute aortic syndromes |
| p.86 | I | B | In patients with AAS, immediate anti-impulse treatment targeting SBP <120 mmHg and heart rate ≤60 b.p.m. is recommended. In cases of spinal ischaemia or concomitant brain injury, maintaining higher MAP is recommended.1214–1216 | Recommendation Table 45 — Recommendation for medical treatment in acute aortic syndromes |
| p.86 | I | B | Intravenous BBs (e.g. labetalol or esmolol) are recommended as first-line agents. If necessary, i.v. vasodilators (e.g. dihydropyridine calcium blockers or nitrates) could be added.174,1224 | Recommendation Table 45 — Recommendation for medical treatment in acute aortic syndromes |
| p.86 | I | B | Invasive monitoring with an arterial line and continuous three-lead ECG recording, as well as admission to an intensive care unit, is recommended.1205,1217,1218,1225 | Recommendation Table 45 — Recommendation for medical treatment in acute aortic syndromes |
| p.86 | I | B | In patients with AAS who can be managed conservatively and who achieved haemodynamic targets with i.v. anti-impulse therapy, switching to oral BBs and, if necessary, up-titration of other BP-lowering agents, is recommended after 24 h if gastrointestinal transit is preserved.174,1216 | Recommendation Table 45 — Recommendation for medical treatment in acute aortic syndromes |
| p.86 | IIa | B | If the patient has a contraindication for BBs, a non-dihydropyridine calcium blocker should be considered.174,1224 Rate/pressure control 1 | Recommendation Table 45 — Recommendation for medical treatment in acute aortic syndromes |
| p.87 | I | B | In patients with acute TAAD, emergency surgical consultation and evaluation and immediate surgical intervention is recommended.1182,1250 | Recommendation Table 46 — Recommendations for intervention in type A acute aortic dissection |
| p.87 | I | B | In patients with acute TAAD who have extensive destruction of the aortic root, a root aneurysm, or a known genetic aortic disorder, aortic root replacement is recommended with a mechanical or biological valved conduit.1251–1255 | Recommendation Table 46 — Recommendations for intervention in type A acute aortic dissection |
| p.87 | IIa | B | In patients presenting with acute TAAD, transfer from a low- to a high-volume aortic centre with the presence of a multidisciplinary team should be considered to improve survival if transfer can be accomplished without significant delay in | Recommendation Table 46 — Recommendations for intervention in type A acute aortic dissection |
| p.87 | IIb | B | surgery.1256,1257 In selected patients, a valve-sparing root repair may be considered, when performed by experienced surgeons.1251,1258,1259 TAAD, type A aortic dissection. aClass of recommendation. bLevel of evidence. | Recommendation Table 46 — Recommendations for intervention in type A acute aortic dissection |
| p.87 | I | B | In patients with acute TAAD and a partially dissected aortic root but no significant aortic valve leaflet pathology, aortic valve resuspension is recommended over valve replacement.1251–1255 | Recommendation Table 47 — Recommendations for aortic repair strategies in type A acute aortic dissection |
| p.87 | I | B | In patients with acute TAAD undergoing aortic repair, an open distal anastomosis is recommended to improve survival and increase FL thrombosis rates. 1266–1269 | Recommendation Table 47 — Recommendations for aortic repair strategies in type A acute aortic dissection |
| p.87 | I | B | In patients with acute TAAD without an intimal tear in the arch or a significant arch aneurysm, hemi-arch repair is recommended over more extensive arch replacement.1270–1272 In patients with acute TAAD and a secondary intimal | Recommendation Table 47 — Recommendations for aortic repair strategies in type A acute aortic dissection |
| p.87 | IIb | C | tear in the arch or proximal DTA, an extended aortic repair with stenting of the proximal DTA (e.g. by using the frozen elephant trunk technique) may be considered to reduce late distal aortic complications (e.g. aneurysm evolution of the remaining dissected descending aorta).1273,1274 | Recommendation Table 47 — Recommendations for aortic repair strategies in type A acute aortic dissection |
| p.91 | I | B | In patients with acute TAAD presenting with malperfusion (cerebral, mesenteric, lower limb, or renal), immediate aortic surgery is recommended.1275,1277 | Recommendation Table 48 — Recommendations for the management of malperfusion in the setting of acute aortic dissection |
| p.91 | IIa | B | In patients with acute TAAD presenting with cerebral malperfusion or non-haemorrhagic stroke, immediate aortic surgery should be considered to improve neurological outcome and reduce mortality.1255,1276,1278 | Recommendation Table 48 — Recommendations for the management of malperfusion in the setting of acute aortic dissection |
| p.91 | IIa | C | In patients with acute TAAD presenting with clinically significant mesenteric malperfusion syndrome, immediate invasive angiographic diagnostics to evaluate percutaneous malperfusion repair before or directly after aortic surgery, in aortic centres with expertise, should be considered.1278–1280 TAAD, type A aortic dissection. aClass of recommendation. bLevel of evidence. | Recommendation Table 48 — Recommendations for the management of malperfusion in the setting of acute aortic dissection |
| p.92 | I | B | In patients with complicated acute TBAD, TEVAR is recommended as the first-line therapy.c,910,1288–1293 | Recommendation Table 49 — Recommendations for the management of patients presenting with acute type B aortic dissection |
| p.92 | IIa | B | In patients with acute TBAD, BBs should be considered as the first-line medical therapy.1216,1312 | Recommendation Table 49 — Recommendations for the management of patients presenting with acute type B aortic dissection |
| p.92 | I | B | Antihypertensive therapy is recommended in all patients with chronic TBAD.1331–1333 | Recommendation Table 50 — Recommendations for the management of patients presenting with chronic type B aortic dissection |
| p.92 | I | B | Medical therapy including pain relief and blood pressure control is recommended in all patients with acute TBAD.1215,1219,1310,1311 | Recommendation Table 49 — Recommendations for the management of patients presenting with acute type B aortic dissection |
| p.92 | I | B | In patients with complicated acute TBAD, emergency intervention is recommended.1193,1250,1284,1285,1288,1289,1291–1293 | Recommendation Table 49 — Recommendations for the management of patients presenting with acute type B aortic dissection |
| p.92 | IIa | B | In patients with uncomplicated acute TBAD, TEVAR in the subacute phase (between 14 and 90 days) should be considered in selected patients with high-risk featuresd to prevent aortic complications.1219,1226,1295,1297,1298,1308,1309 | Recommendation Table 49 — Recommendations for the management of patients presenting with acute type B aortic dissection |
| p.92 | I | C | In chronic TBAD with acute symptoms of malperfusion, rupture, or progression of disease, emergency intervention is recommended.1302,1313,1314 | Recommendation Table 50 — Recommendations for the management of patients presenting with chronic type B aortic dissection |
| p.92 | I | B | In patients with chronic TBAD and a descending thoracic aortic diameter ≥60 mm, treatment is recommended in patients at reasonable surgical risk.1302,1315,1334 | Recommendation Table 50 — Recommendations for the management of patients presenting with chronic type B aortic dissection |
| p.92 | IIa | C | In patients with chronic TBAD and a descending thoracic aortic diameter ≥55 mm, an indication for intervention should be considered in patients with low procedural risk.1302,1316 | Recommendation Table 50 — Recommendations for the management of patients presenting with chronic type B aortic dissection |
| p.92 | IIb | C | In patients with chronic post-dissection thoracoabdominal aortic aneurysms, the use of fenestrated/branched stent grafts may be considered, when treatment is indicated.1062,1327–1329 TBAD, type B aortic dissection. aClass of recommendation. bLevel of evidence. | Recommendation Table 50 — Recommendations for the management of patients presenting with chronic type B aortic dissection |
| p.94 | I | C | In type A IMH, urgent surgery is recommended.172,1175,1192 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | I | C | In type B IMH, initial medical therapy under careful surveillance is recommended.1175,1192,1347,1350,1353 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | I | C | In uncomplicatedc type B IMH, repetitive imaging (CCT or CMR) is indicated.1175,1192,1347,1350,1353 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | I | C | In complicatedc type B IMH, TEVAR is recommended.1175,1192,1347,1350,1353 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | I | C | In cases of type A PAU, surgery is recommended.172 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | I | C | In cases of type B PAU, initial medical therapy under careful surveillance is recommended.1347,1350 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | I | C | In uncomplicated type B PAU, repetitive imaging (CMR, CCT, or TOE) is recommended.1347,1350 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | I | C | (TEVAR) is recommended.1347,1350,1357 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | I | C | In patients with IMH, medical therapy including pain relief and blood pressure control is recommended.24,172 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | IIa | C | In uncomplicatedc type B IMH but with high-risk imaging featuresd, TEVAR should be considered.1347,1350 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | IIb | C | In complicatedc type B IMH, surgery may be considered in patients with anatomy unfavourable for TEVAR.1175,1192,1347,1350,1353 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | IIb | C | In selected patients with increased operative risk and uncomplicatedc type A IMH without high-risk imaging featuresd, a ‘wait and see’ strategy may be considered.1348,1354–1356 | Recommendation Table 51 — Recommendations for the management of intramural haematoma |
| p.94 | I | C | In all patients with PAU, medical therapy including pain relief and blood pressure control is recommended.24,172 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | IIa | C | In complicated type B PAU, endovascular treatment In uncomplicated type B PAU with high-risk imaging features,c endovascular treatment should be considered.1347,1350 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | IIb | C | In complicated type B PAU, surgery may be considered based on anatomy and medical comorbidities.1347,1350 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.94 | IIb | C | In isolated, asymptomatic, small PAUs with no high-risk features,c conservative management with regular surveillance and medical treatment may be considered.24,1361 | Recommendation Table 52 — Recommendations for the management of penetrating atherosclerotic ulcer |
| p.96 | I | A | repair is recommended.24,1373,1374 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | I | C | recommended.159,172 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | I | C | recommended.24,1373 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | IIa | C | considered.159,172 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | I | A | In cases of severe aortic injury (grade 4), immediate In cases of TAI with suitable anatomy requiring intervention, TEVAR is recommended over open surgery.24,1373,1374 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | I | C | In all TAI patients, medical therapy including pain relief, and blood pressure and heart rate control, is recommended.24,172 In cases of TAI suspicion, CCT is In cases of moderate aortic injury (grade 3), repair is | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | IIa | C | If CCT is not available, TOE should be In minimal aortic injury (grades 1 or 2), initial medical therapy under careful clinical and imaging surveillance should be considered.24,1374 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.96 | IIa | C | In cases of progression of the IMH (grade 2), semi-elective repair (within 24–72 h) should be considered.24,1374 | Recommendation Table 53 — Recommendations for traumatic aortic injury |
| p.100 | I | C | 6 months if imaging findings are stable.70,1350,1384 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | I | B | After TEVAR for AAS, follow-up imaging is recommended at 1, 6, and 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalitiesc are documented.1159,1378,1382 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | I | C | In medically treated type B AAS or IMH, follow-up imaging is recommended at 1, 3, 6, and 12 months after onset, then yearly if imaging findings are stable.1301,1383 In medically treated PAU, follow-up imaging is | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | IIa | B | recommended at 1 month after diagnosis, then every After open surgery for AAS, follow-up imaging by CCT and TTE within 6 months, then CCT at 12 months and then yearly if findings are stable,d should be considered.1153,1159,1383 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | IIa | B | If no complicationsc occur within the first 5 years, CCT every 2 years thereafter should be considered.1159,1378 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | IIa | C | If no residual patent FL is documented for 3 post-operative years, subsequent surveillance by CCT every 2–3 years should be considered.1153,1159,1383 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | IIa | C | If abnormalitiesc are documented at any time of follow-up after TEVAR for AAS, then CCT should be considered every 3–6 months.1159,1378,1382 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | IIa | C | When frequent controls are required in AAS patients treated either by open or endovascular repair, CMR should be considered instead of CCT after the first-year follow-up.70,1153 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | IIa | C | In the follow-up of medically treated PAU, after 2 years of imaging stability, larger intervals should be considered in low-risk patientse.70,1350,1384 | Recommendation Table 54 — Recommendations for follow-up after treatment of acute aortic syndrome |
| p.100 | I | C | It is recommended that medical management of patients with HTAD is individualized and based on shared decision-making.1386 | Recommendation Table 55 — Recommendations for the management of patients with heritable thoracic aortic disease |
| p.100 | I | C | It is recommended that patients with known or suspected syndromic or non-syndromic HTAD are evaluated in a centre with experience in the care of this patient group.888 HTAD, heritable thoracic aortic disease. aClass of recommendation. bLevel of evidence. © ESC 2024 | Recommendation Table 55 — Recommendations for the management of patients with heritable thoracic aortic disease |
| p.101 | I | B | Genetic testing In patients with aortic root/ascending aneurysms or thoracic aortic dissection, gathering family history information for at least three generations about TAD, unexplained sudden deaths, and peripheral and intracranial aneurysms is recommended.880,1396–1402 | Recommendation Table 56 — Recommendations for genetic testing and aortic screening in aortic disease |
| p.101 | I | B | In patients with aortic root/ascending aortic aneurysms or thoracic aortic dissection and risk factors for HTAD,c genetic counselling at an expert centre and subsequent testing, if indicated, is recommended.1399,1403–1408 | Recommendation Table 56 — Recommendations for genetic testing and aortic screening in aortic disease |
| p.101 | I | C | In patients with HTAD who have a pathogenic/likely pathogenic variant, genetic testing of at-risk biological relatives (i.e. cascade testing) is recommended, irrespective of age.70,1407,1409 | Recommendation Table 56 — Recommendations for genetic testing and aortic screening in aortic disease |
| p.101 | IIa | B | In patients with HTAD, guidance of clinical management by the underlying gene/variant, when known, should be considered.70,1391,1410–1416 Aortic imaging screening | Recommendation Table 56 — Recommendations for genetic testing and aortic screening in aortic disease |
| p.101 | I | B | In patients with TAD with risk factors for HTAD,c with a negative family history of TAD and in whom no (likely) pathogenic variant is identified, TTEd screening aortic imaging of FDRse is recommended.1396,1402 | Recommendation Table 57 — Recommendations for imaging in women with Turner syndrome |
| p.101 | IIa | C | Imaging screening of family members of patients with TAD with risk factors for HTADc in whom no (likely) pathogenic variant is identified should be considered starting at age 25, or 10 years below the youngest case, whichever is younger. If the initial screening is normal, continued screening every 5 years until the age of 60 should be considered.25 | |
| p.101 | I | C | To take the smaller body size of women (≥15 years) with TS into account, the use of the ascending ASI (ratio of aortic diameter [mm] to BSA [m2]), AHI (ratio of aortic diameter [mm] to height [m]), or aortic z-score is recommended to define the degree of aortic dilatation and assess the risk of aortic dissection.153,1417,1421,1423,1428,1429 | Recommendation Table 57 — Recommendations for imaging in women with Turner syndrome |
| p.101 | I | C | It is recommended to define imaging and clinical surveillance intervals according to the estimated risk for dissection, based on the ascending ASI and concomitant lesions.c,1420,1421 | Recommendation Table 57 — Recommendations for imaging in women with Turner syndrome |
| p.103 | IIa | C | Elective surgery for aneurysms of the aortic root and/ or ascending aorta should be considered in women with TS who are ≥15 years of age, have an ascending ASI >23 mm/m2, an AHI >23 mm/m, a z-score >3.5, and have associated risk factors for aortic dissectionc or are planning pregnancy.70,1417,1421 | Recommendation Table 58 — Recommendations for aortic surgery in women with Turner syndrome |
| p.103 | IIb | C | Elective surgery for aneurysms of the aortic root and/ or ascending aorta may be considered for women with TS who are ≥15 years of age, have an ascending ASI >25 mm/m2, an AHI >25 mm/m, a z-score >4, and who do not have associated risk factors for aortic dissectionc.70,1417,1421 | |
| p.104 | IIa | B | patients with vEDS.1441,1444,1445 | Recommendation Table 59 — Recommendations for medical treatment in patients with vascular Ehlers– Danlos syndrome (see also Evidence Table 13) |
| p.104 | I | C | In patients with vEDS, regular vascular surveillance of the aorta and peripheral arteries by DUS, CCT, or CMR is recommended.1439,1443 Treatment with celiprolol should be considered in | Recommendation Table 59 — Recommendations for medical treatment in patients with vascular Ehlers– Danlos syndrome (see also Evidence Table 13) |
| p.105 | I | C | In patients with MFS, TTE is recommended:70,171,1458,1459 • At least annually in patients with an aortic root diameter <45 mm in the absence of additional risk factorsc • At least every 6 months in patients with an aortic root diameter <45 mm in the presence of additional risk factorsc • At least every 6–12 months in patients with an | Recommendation Table 60 — Recommendations for vascular imaging in Marfan syndrome |
| p.105 | I | C | aortic root diameter ≥45 mm in the absence of additional risk factorsc In patients without previous aortic surgery, complete peripheral vascular and thoracoabdominal aorta imaging by CMR or CCT and DUS is recommended at the first evaluation, and subsequently every 3–5 years if stable.70,1455,1459 | Recommendation Table 60 — Recommendations for vascular imaging in Marfan syndrome |
| p.105 | I | C | In patients with MFS who have undergone aortic root replacement, surveillance imaging of the thoracic aorta by CMR (or CCT) is recommended at least every 3 years.70,1458 | Recommendation Table 60 — Recommendations for vascular imaging in Marfan syndrome |
| p.105 | I | A | In patients with MFS, treatment with either a BB or an ARB, in maximally tolerated doses (unless contraindicated), is recommended to reduce the rate of aortic dilatation.1461,1462 | Recommendation Table 61 — Recommendations for medical treatment in Marfan syndrome (see also Evidence Table 14) |
| p.105 | IIa | A | In patients with MFS, the use of both a BB and an ARB, in maximally tolerated doses (unless contraindicated), should be considered to reduce the rate of aortic dilatation.1463,1464 | Recommendation Table 61 — Recommendations for medical treatment in Marfan syndrome (see also Evidence Table 14) |
| p.105 | I | B | Surgery is indicated in patients with MFS who have aortic root disease with a maximal aortic sinus diameter ≥50 mm.70,172,1466–1468 Surgery to replace the aortic root and ascending | Recommendation Table 62 — Recommendations for aortic surgery in Marfan syndrome |
| p.105 | I | B | aorta, using the valve-sparing surgery technique, is recommended in patients with MFS or related © ESC 2024 HTAD with aortic root dilatation when anatomical features of the valve allow its preservation and the surgeon has specific expertise.70,1466,1469 | Recommendation Table 62 — Recommendations for aortic surgery in Marfan syndrome |
| p.105 | IIa | C | Surgery should be considered in patients with MFS who have an aortic root aneurysm with a maximal aortic sinus diameter ≥45 mm and additional risk factors.c,1467,1469 | Recommendation Table 62 — Recommendations for aortic surgery in Marfan syndrome |
| p.105 | IIa | C | In patients with MFS and an aneurysm of the ascending aorta, aortic arch, descending thoracic aorta, or abdominal aorta of ≥50 mm, surgical replacement of the aneurysmal segment by a surgeon with specific expertise should be considered.1467,1469 | Recommendation Table 62 — Recommendations for aortic surgery in Marfan syndrome |