Spanos Konstantinos, Nana Petroula, von Kodolitsch Yskert, Behrendt Christian-Alexander, Kouvelos George, Panuccio Giuseppe, Athanasiou Thanos, Matsagkas Miltiadis, Giannoukas Athanasios, Detter Christian, Kölbel Tilo
Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany.
J Endovasc Ther. 2022 Oct;29(5):667-677. doi: 10.1177/15266028211061271. Epub 2021 Dec 7.
Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence.
The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases.
The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited.
In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.
升主动脉和主动脉弓疾病在心血管专科医生中，对于诊断和治疗的关注度日益增加。血管内手术的创新以及开放手术的发展，扩大了先前被认为不适合手术的患者的治疗指征。本系统文献综述的目的是呈现并分析当前心血管指南中关于升主动脉和主动脉弓疾病的建议及其重叠和差异，以及证据评估情况。
使用MEDLINE、EMBASE和Cochrane对照试验中心注册库数据库，检索2009年1月至2020年12月的英文医学文献。分析了关于选定主题的建议，包括最重要的升主动脉和主动脉弓疾病从定义和诊断（影像学和生物标志物）到治疗指征，再到治疗管理（包括手术技术）等方面的问题。
初步检索共识别出2414篇文章。排除重复或不适当的文章后，最终分析纳入了2010年至2019年间多学科心血管学会发表的5篇文章。大多数指南缺乏非A非B型主动脉夹层的定义。对于将升主动脉直径作为治疗指征的推荐类别和证据水平存在分歧。在特定情况下，主动脉疾病的治疗指征可能因人而异，同时生长速度也可能影响决策。除了一个学会外，血管内技术在当前指南中的作用尚未明确。主动脉弓疾病管理中的支持性证据水平仍然有限。
在心血管学会的当前建议中，尽管引入了血管内技术，但升主动脉和主动脉弓仍然是开放手术的领域。纳入学会的建议大多基于专家意见，只有一个学会强调了血管内技术的作用。还应认识到指南之间明显的时间异质性以及证据水平的不一致性。需要更多数据来为升主动脉和主动脉弓疾病制定更可靠的建议。
