AHA: TAA incl hereditary aortopathy & BAV + TEVAR

Question 1

ongoing/subsequent imaging monitoring in BAV with aortic sinuses (root) or asc Ao diameter ≥4.0cm

Answer 1

lifelong TTE/CMR/CTA
interval by rate of progression & fam hx
(2a)

“1. In patients with BAV and a diameter of the aortic sinuses or ascending aorta of ≥4.0 cm, lifelong serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is reasonable, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history.” (2a)

Question 2

ongoing/subsequent imaging monitoring in BAV s/p AVR with aortic sinuses (root) or asc Ao diameter ≥4.0cm

Answer 2

lifelong serial imaging
(2a)

“2. In patients with a BAV who have undergone AVR, continued lifelong serial interval imaging of the aorta is reasonable if the diameter of the aortic sinuses or ascending aorta is ≥4.0 cm.” (2a)

Question 3

aortic root or asc Ao threshold to replace in BAV

Answer 3

\≥5.5cm (1)
\≥5cm with RF(s) for dissxn @ COE (2a) OR pt low-risk @ COE (2b)
\≥4.5cm with concomitant SAVR @ COE (2a)
A:h≥10 @ COE (2a)

Question 4

Do the indications/size threshold to rx/replace aneurysm differ for aortic root v asc Ao in BAV/HTAD/Marfan’s/Loeys-Dietz/Turner?

Answer 4

NO

Question 5

Do the indications to replace root v asc Ao for aneurysm differ for sporadic?

Answer 5

NO

Question 6

How does the mgmt of the asc Ao in setting of root aneurysm differ in Marfan’s compared to other situations (sporadic or other HTAD/syndromes)?

Answer 6

replace the asc Ao WITH the rootkom
even if not aneurysmal / regardless of size

Question 7

indication(s) to replace aortic root or asc Ao in BAV

Answer 7

• >5.5cm (1)
  regardless of sx status
• asx + 5.0-5.5cm + dissxn RF @ CVC (2a)
• asx + 5.0-5.5cm + low-risk @ CVC (2b)
• SAVR + ≥4.5cm @ CVC (2a)

Question 8

Is it OK to spare the valve in a normally-functioning AV when replacing the aortic root or asc Ao in BAV?

Answer 8

YES (@ CVC)
(2b)

“4. In patients with a BAV who meet criteria for replacement of the aortic sinuses, valvesparing surgery may be considered if the surgery is performed at a Comprehensive Valve Center.” (2b)

Question 9

initial mgmt of uncomplicated type B (desc) aortic dissxn

Answer 9

medical tx (1) i.e. anti-impulse tx:
1. IV β-blockade (esmolol) to HR 60-80 (AHA) / HR<60 (SESATS: ∝￬AEs)
2. vasodilators to SBP<120 (AHA)

Question 10

initial mgmt of ANY acute thoracic aortic dissxn OR injury

Answer 10

anti-impulse tx:
1. IV β-blockade (1) (esmolol) > non-dihydropyridine Ca-channel blocker (2a) to HR 60-80
2. ± vasodilators to SBP<120 (1)
a-line in ICU (1)
pain control (1)

except in hypoTN/hypovolemic shock trauma pts (obviously)

Question 11

A:h (Ao cross-sectional area : pt height) ratio threshold for aneurysm rx

Answer 11

≥10 cm²/m
in: sporadic, BAV, Marfan’s

Question 12

Ao landing zones

Answer 12

all vessel landmarks are to the distal end of their origin in the chest & to the prox end of origin in the abdomen

• thoracic
• zone 0 = STJ to innominate artery
• zone 1 = to L carotid
• zone 2 = to L subclv
• zone 3 = to T4 / 2cm distal to L subclv
• zone 4 = to T6 / mid-desc Ao
• zone 5 = to celiac (prox origin)
• abdominal
• zone 6 = celiac to SMA (prox origin)
• zone 7 = SMA to renals (prox origin)
• zone 8 = renals
• zone 9 = infrarenal to Ao bifurc
• zone 10 = CIAs to EIA (prox origin)
• zone 11 = EIAs

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 13

Ao zone 0

Answer 13

asc Ao incl innominate:
STJ through distal origin of innominate artery

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 14

Ao zone 1

Answer 14

L carotid:
end of innominate artery through distal origin of L carotid

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 15

Ao zone 2

Answer 15

L subclavian:
end of L carotid through distal origin of L subclv

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 16

Ao zone 3

Answer 16

1st 2cm desc Ao:
end of L subclv + 2cm distal / through T4

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 17

Ao zone 4

Answer 17

mid-desc Ao:
T4 through T6

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 18

Ao zone 5

Answer 18

low/distal desc Ao:
T6 to prox origin of celiac

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 19

Ao zone 6

Answer 19

celiac axis:
celiac to prox origin of SMA

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 20

Ao zone 7

Answer 20

SMA:
SMA to prox origin of renals

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 21

Ao zone 8

Answer 21

renals:
renals

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 22

Ao zone 9

Answer 22

infarenal Ao:
end of renals to Ao bifurc

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 23

Ao zone 10

Answer 23

CIAs:
Ao bifurc to prox origin of EIAs

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 24

Ao zone 11

Answer 24

EIAs:
from prox origin of EIAs

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

Question 25

aortic root anatomic definition

Answer 25

sinuses of Valsalva = annulus to STJ ## Footnote AHA aortopathy guideline Figure 1. The Anatomy of the Aorta and Its Main Branches https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

Question 26

asc Ao anatomic definition

Answer 26

STJ to prox origin of innominate ## Footnote AHA aortopathy guideline Figure 1. The Anatomy of the Aorta and Its Main Branches https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

Question 27

aortic arch anatomic definition

Answer 27

innominate through L subclv artery (prox origin to distal origin) ## Footnote AHA aortopathy guideline Figure 1. The Anatomy of the Aorta and Its Main Branches https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

Question 28

desc thoracic Ao anatomic definition

Answer 28

end of subclv to diaphragmatic hiatus ## Footnote AHA aortopathy guideline Figure 1. The Anatomy of the Aorta and Its Main Branches https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

Question 29

classifications of Ao dissxn acuity/chronicity: hyperacute | (by SVS/STS 2020 Reporting Standards)

Answer 29

<24h | from sx onset

Question 30

classifications of Ao dissxn acuity/chronicity: acute | (by SVS/STS 2020 Reporting Standards)

Answer 30

2w (1-14d) | from sx onset

Question 31

classifications of Ao dissxn acuity/chronicity: subacute | (by SVS/STS 2020 Reporting Standards)

Answer 31

3mo (15-90d) | from sx onset

Question 32

classifications of Ao dissxn acuity/chronicity: chronic | (by SVS/STS 2020 Reporting Standards)

Answer 32

>3mo (>90d) | from sx onset

Question 33

DeBakey aortic dissxn classification

Answer 33

Type I = asc tear + desc Type II = asc tear only Type IIIa = desc tear thoracic only Type IIIb = desc thoracic tear + abd

Question 34

Stanford aortic dissxn classification

Answer 34

type A = involving asc (± desc) type B = involving desc only *regardless of site of entry tear*

Question 35

recommended measurement of thoracic Ao diameters

Answer 35

inner-edge to inner-edge *unless wall abnormalities e.g. atherosclerosis, discrete wall thickening*: outer-edge to outer-edge

Question 36

recommended measurement of aortic root diameter

Answer 36

maximum sinus to sinus

Question 37

aortic root or asc Ao threshold to replace in non-syndromic HTAD

Answer 37

≥5.0cm (1) **≥4.5cm** with RFs OR concomitant \<3 surg @ COE (2a)

Question 38

risk factors ("high-risk features") for aortic dissxn in BAV

Answer 38

- FH of dissxn @ \<5.0cm - rapid Ao growth (≥0.3cm/y) - Ao CoA - "root phenotype"

Question 39

risk factors ("high-risk features") for aortic dissxn in non-syndromic HTAD

Answer 39

- FH of dissxn @ \<5.0cm - FH unexplained sudden death \<50yo - rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y)

Question 40

risk factors ("high-risk features") for aortic rupture in desc TAA

Answer 40

- rapid Ao growth (≥0.5cm/1y) - +sx - genetic aortopathy - saccular aneurysm - ♀ - infxs/mycotic aneurysm

Question 41

risk factors ("high-risk features") for aortic rupture in TAAA (thoracoabd Ao aneurysm)

Answer 41

- rapid Ao growth (≥0.5cm/1y) - +sx - significant ∆ in appearance/morphology - saccular aneurysm - PAU

Question 42

risk factors ("high-risk features") for aortic dissxn in non-syndromic HTAD

Answer 42

- FH of dissxn @ \<5.0cm - FH unexplained sudden death \<50yo - rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y)

Question 43

risk factors ("high-risk features") for aortic dissxn in Marfan syndrome

Answer 43

- FH of dissxn - rapid Ao growth (>0.3cm/y) - diffuse aortic root & asc Ao dilation - marked vertebral artery tortuosity

Question 44

risk factors ("high-risk features") for aortic dissxn in Loeys-Dietz syndrome

Answer 44

- FH of dissxn (esp @ young age or small Ao diameter) - rapid Ao growth (>0.3cm/y) - severe extra-aortic features - certain pathogenic variants - women with TGFBR2 & small body size

Question 45

risk factors ("high-risk features") for aortic dissxn in Turner syndrome

Answer 45

- Ao CoA - Ao dilation - BAV - HTN

Question 46

imaging surveillance of Marfan syndrome (starting @ dx)

Answer 46

TTE @ dx + 6mo to assess growth rate 🠆 Q1Y (1)

Question 47

postoperative imaging surveillance for Marfan syndrome s/p aortic root replacement

Answer 47

MRI > CTA Q1Y x2y 🠆 Q2Y (for distal TAD)

Question 48

medical mgmt of Marfan syndrome

Answer 48

β-blocker and(2a)/or(1) ARB @ max-tolerated doses

Question 49

medical mgmt of Loeys-Dietz syndrome

Answer 49

β-blocker and/or ARB @ max-tolerated doses (2a)

Question 50

aortic root threshold to replace BOTH root & asc Ao in Marfan syndrome

Answer 50

*replace root AND asc Ao together* ≥5.0cm (1) **≥4.5cm** with RFs @ COE (2a) A:h≥10 @ COE (2a)

Question 51

aortic arch/desc Ao threshold to replace in Marfan syndrome

Answer 51

≥5.0cm (2a)

Question 52

initial imaging w/u of Turner syndrome

Answer 52

TTE + cMRI @ dx to assess for BAV, root/asc dil, CoA, other congen heart defects (1) 🠆 if no dilation or RFs TTE or MRI Q10Y (1) if ASI>2.3 aortic imaging (NOS) Q1Y (1)

Question 53

initial imaging w/u of Loeys-Dietz syndrome

Answer 53

TTE @ dx + 6mo to assess growth rate 🠆 Q1Y (1) MRI or CTA head to pelvis @ dx (1) + Q2Y (2a)

Question 54

aortic root or asc Ao threshold to replace BOTH root & asc Ao in Loeys-Dietz syndrome

Answer 54

*replace root AND asc Ao together* TGFB3: ≥5.0cm else: **≥4.5cm** TGFB**R**1/2 with **R**Fs: **≥4.0cm** else = SMAD3, TGFB2, TGFBR1/2 without RFs

Question 55

aortic arch/desc Ao threshold to replace in Loeys-Dietz syndrome

Answer 55

TGFBR1/2 or SMAD3: ≥4.5cm (2b)

Question 56

aortic root or asc Ao threshold to replace in Ehlers-Danlos syndrome

Answer 56

UNKNOWN "shared decision-making" @ COE

Question 57

ASI (aortic size index)

Answer 57

max Ao diameter (cm) / BSA (m²) (used for Turner syndrome ≥15yo: rx ASI≥2.5)

Question 58

AHI (aortic height index)

Answer 58

max Ao diameter (cm) / height (m) (used for sporadic TAA: rx AHI≥3.21 @ COE)

Question 59

aortic root or asc Ao threshold to replace in Turner syndrome

Answer 59

ASI≥2.5 with RFs (2a) ASI≥2.5 (2b) (without RFs) (aortic size index = max Ao diam / BSA) *can replace root or asc Ao alone, or can do both together*

Question 60

goal BP for medical mgmt of sporadic TAA

Answer 60

SBP<130 DBP<80 ⇒ ￬MACE (1)

Question 61

aortic root or asc Ao threshold to replace in sporadic TAA

Answer 61

_aortic root OR asc Ao:_ \+sx (1) ≥5.5cm (1) rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y) (1) ≥5.0cm @ COE (2a) A:h≥10 if h>1σ above/below μ @ COE (2a) ASI≥3.08 OR AHI≥3.21 @ COE (2b) _asc Ao only:_ ≥5.0cm + concomitant SAVR (2a) OR other concomitant \<3 surg (2b) ≥4.5cm + concomitant SAVR @ COE (2a)

Question 62

aortic arch threshold to replace in sporadic TAA

Answer 62

\+sx (1) ≥5.5cm + low-risk (2a) hemiarch with aTAA rx extending into prox arch (2a) elephant trunk with aortic arch aneurysm rx extending into prox desc Ao (2b) hybrid or endovascular if high-risk for open surgery (2b)

Question 63

desc Ao threshold to replace in sporadic TAA

Answer 63

**≥5.5cm** (1) <5.5cm with RFs (2b) ≥6.0+cm if high-risk for surgery (2b)

Question 64

Ao threshold to replace in h/o repaired dissxn or IMH with residual chronic TAD

Answer 64

≥5.5cm (1)

Question 65

pt risk factors for ￪cxs with open desc TAA rx

Answer 65

age ≥75yo > 65-75yo CKD3 or ESRD/HD COPD with FEV1≤50% h/o stroke

Question 66

pt risk factors for ￪cxs with endovascular desc TAA rx

Answer 66

fxnal status (dependence) thoracoabd extent "pulm dz" need for EIA access (instead of CFA) zone 1/2 landing

Question 67

recommendation for TEVAR v open rx of desc TAA with Marfan, Loeys-Dietz, Ehlers-Danlos syndromes

Answer 67

NONE AHA does not specify so do **open**

Question 68

general/big-picture recommendation for TEVAR v open rx of desc Ao TAA/type B dissxn

Answer 68

**TEVAR** (1) EXCEPT in genetic aortopathy EXCEPT in acute type B dissxn

Question 69

recommendation for TEVAR v open rx of TAAA (thoracoabd Ao aneurysm) with Marfan, Loeys-Dietz, Ehlers-Danlos syndromes

Answer 69

open rx (1) TEVAR with fenestrated or branched stent grafts @ COE (2b)

Question 70

recommendation for TEVAR v open rx of ruptured desc TAA

Answer 70

TEVAR ⇒ ￬periop M&M (1) can cover L subclv and/or celiac (2b)

Question 71

recommendation for TEVAR v open rx of ruptured type B dissxn

Answer 71

TEVAR (1)

Question 72

recommendation for TEVAR v open rx of non-ruptured but complicated type B dissxn

Answer 72

TEVAR (2a)

Question 73

recommendation for TEVAR v open rx of uncomplicated type B dissxn with RFs

Answer 73

may consider TEVAR (2b)

Question 74

risk factors ("high-risk features") in uncomplicated type B aortic dissxn

Answer 74

- _imaging_ - Ao diameter >4cm - false lumen >2cm - entry tear >1cm - entry tear @ lesser curve - ￪∆ Ao diam >0.5cm on serial imaging - bloody pleural effusion - radiographic-only malperfusion - _clinical_ - refrx HTN on max doses of >3 med classes - refrx pain >12h - need for readmission

Question 75

risk factors ("high-risk features") in PAU

Answer 75

- diameter ≥2cm - depth ≥1cm - "significant" ￪ diam or depth - a/w saccular aneurysm - ￪pleural effusion ("increasing")

Question 76

complicated type B IMH (features)

Answer 76

- malperfusion - periaortic hematoma - percardial effusion with tamponade - persistent/refrx/recurrent pain - rupture

Question 77

risk factors ("high-risk features") in uncomplicated type B IMH

Answer 77

*- dissxn - ￪Ao diam - ￪hematoma thickness* - Ao diameter >5cm - hematoma ≥1.3cm - focal intimal disruption i.e. acute phase development of PAU in desc Ao - ￪ or recurrent pleural effusion

Question 78

risk factors ("high-risk features") in uncomplicated type A IMH

Answer 78

*- dissxn - ￪Ao diam - ￪hematoma thickness* - Ao diameter >5cm - hematoma ≥1.0cm - focal intimal disruption i.e. acute phase development of PAU in asc Ao or arch - pericardial effusion @ adm

Question 79

recommendation for TEVAR v open rx of ruptured TAAA (thoracoabd Ao aneurysm)

Answer 79

open rx (1) TEVAR if pt stable @ COE (2b)

Question 80

Ao threshold to replace in TAAA (thoracoabdominal Ao aneurysm)

Answer 80

≥6.0cm (1) **≥5.5cm** @ COE (2a) <5.5cm with RFs (2a)

Question 81

recommendation for SCI (spinal cord injury) ppx in open TAAA (thoracoabd) rx

Answer 81

spinal (CSF) drain ⇒ ￬temp and/or perm SCI (1)

Question 82

recommendation for SCI (spinal cord injury) ppx in open OR endovasc TAAA (thoracoabd) rx

Answer 82

if delayed (≤2w postop) SC dysfxn, "timely measures to optimize SC perfusion & ￬intrathecal pressure" (1), i.e.: - cardioversion of tachyarrhythmias - spinal (CSF) drain (if not already) - MAP>100 - transfuse to Hb>10 - volume resusc - supplemental O₂ SC perfusion pressure = MAP - SC fluid pressure

Question 83

incidence of immediate/early spinal cord dysfxn after TAAA (thoracoabd) rx

Answer 83

~3%? 2-15% depending on extent etc (AHA)

Question 84

incidence of delayed (up to 2w postop) spinal cord dysfxn after TAAA (thoracoabd) rx

Answer 84

5%

Question 85

AHA recommendation for imaging surveillance after TEVAR TAA rx

Answer 85

CT @ 1mo + 1y 🠆 Q1Y (1) or MRI (2a)

Question 86

AHA recommendation for imaging surveillance after open surgery TAA rx

Answer 86

CT or MRI @ 1y 🠆 Q5Y (2a) *if no residual aortopathy* if residual, Q1Y (2a)

Question 87

mgmt of type B aortic dissxn with rupture tamponade

Answer 87

TEVAR ± false lumen embo ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 88

mgmt of type B aortic dissxn with mesenteric or renal malperfusion

Answer 88

endovascular fenestration OR TEVAR ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 89

mgmt of type B aortic dissxn with limb malperfusion (lower extremity ischemia)

Answer 89

TEVAR ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 90

mgmt of type B aortic dissxn with mesenteric or renal malperfusion with persistent ischemia s/p endovascular fenestration

Answer 90

target vessel stenting ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 91

mgmt of type B aortic dissxn with mesenteric or renal malperfusion with persistent ischemia s/p TEVAR

Answer 91

target vessel stenting OR extra-anatomic bypass ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 92

mgmt of type B aortic dissxn with limb malperfusion (lower extremity ischemia) with persistent ischemia s/p TEVAR

Answer 92

extra-anatomic bypass ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 93

mgmt of type A aortic dissxn with rupture tamponade

Answer 93

emergency surgery ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 94

mgmt of type A aortic dissxn with stroke

Answer 94

emergency surgery ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 95

mgmt of type A aortic dissxn with mesenteric or renal malperfusion

Answer 95

emergency aTAA/arch rx surgery ± antegrade TEVAR OR endovascular fenestration 🠆 surgery ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 96

mgmt of type A aortic dissxn with limb malperfusion (lower extremity ischemia)

Answer 96

emergency aTAA/arch rx surgery + antegrade TEVAR ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 97

mgmt of type A aortic dissxn with mesenteric or renal malperfusion with persistent ischemia s/p emergency aTAA/arch rx surgery + antegrade TEVAR

Answer 97

target vessel stenting ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 98

mgmt of type A aortic dissxn with limb malperfusion (lower extremity ischemia) with persistent ischemia s/p emergency aTAA/arch rx surgery + antegrade TEVAR

Answer 98

target vessel stenting ## Footnote AHA aortopathy guideline Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

Question 99

How should you manage the aortic valve in the setting of acute type A aortic dissxn partially involving the root but with a healthy AV?

Answer 99

aortic valve re-suspension preferred (1)

Question 100

How should you manage the aortic valve & root in the setting of acute type A aortic dissxn destroying the root or with root aneurysm or genetic aortopathy but with a healthy AV?

Answer 100

valved conduit Bentall preferred (1) over valve-sparing root @ COE (2b)

Question 101

recommendation for mgmt of dissxn flap extending through the arch into desc Ao in the setting of acute type A aortic dissxn

Answer 101

may consider antegrade TEVAR ⇒ ￬malperfusion & late distal Ao cxs (2b)

Question 102

recommendations for cannulation strategy in acute type A aortic dissxn

Answer 102

axillary > femoral ⇒ ￬stroke & retrograde malperfusion (2a) OR direct Ao or innominate with imaging guidance reasonable alternative (2a)

Question 103

complications of acute type B aortic dissxn

Answer 103

* rupture * branch artery occlusion & malperfusion (complete or patial occlusion of a major branch regardless of clinical e/o ischemia) * dissxn extension prox or distal * Ao enlargement (progressive of true and/or false lumens) during acute phase * intractable pain * uncontrolled/-able? HTN

Question 104

complications of IMH

Answer 104

* malperfusion * periaortic hematoma * pericardial effusion with tamponade * persistent/refrx/recurrent pain * rupture

Question 105

mgmt of complicated type A OR B IMH

Answer 105

*same as dissxn* "urgent" rx (1)

Question 106

mgmt of type A IMH (± complicated)

Answer 106

*same as dissxn* "prompt" open rx (1) medical mgmt in selected high-risk pts withOUT RFs (2b)

Question 107

mgmt of uncomplicated type B IMH

Answer 107

*same as dissxn* medical tx (1)

Question 108

mgmt of uncomplicated type B IMH with RFs

Answer 108

*basically same as dissxn* rx may be reasonable (2b)

Question 109

recommendation for TEVAR v open rx of complicated type B IMH

Answer 109

*basically same as dissxn* TEVAR OR open rx TEVAR if zones 2-5/favorable anatomy (2a) open rx if unfavorable anatomy for TEVAR (2a)

Question 110

mgmt of PAU with rupture

Answer 110

*basically same as dissxn* "urgent" rx (1)

Question 111

mgmt of asc ("type A") PAU with IMH

Answer 111

*basically same as dissxn* "urgent" rx (1)

Question 112

mgmt of arch/desc ("type B") PAU with IMH

Answer 112

"urgent" **rx** (2a)

Question 113

mgmt of isolated PAU (no rupture, IMH, cx)

Answer 113

\+sx ∝ radiologic findings ⇒ rx (1) asx with RFs ⇒ may consider elective rx (2b)

Question 114

recommendation for TEVAR v open rx of asc/prox arch (zones 1-2) PAU

Answer 114

open rx (1)

Question 115

recommendation for TEVAR v open rx of dist arch (zones 2-3)/desc PAU

Answer 115

open rx OR TEVAR (2a)

Question 116

blunt traumatic thoracic aortic injury (BTTAI) grades

Answer 116

1. intimal tear ± flap 2. IMH 3. contained rupture (pseudoaneurysm) 4. free rupture ## Footnote AHA aortopathy guidelines Figure 23. Classification System for BTTAIs https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

Question 117

initial mgmt of blunt traumatic thoracic aortic injury (BTTAI) grade 1 (intimal tear)

Answer 117

non-op with f/u imaging (1) ## Footnote AHA aortopathy guidelines Figure 23. Classification System for BTTAIs https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

Question 118

initial mgmt of blunt traumatic thoracic aortic injury (BTTAI) grade 2 (IMH)

Answer 118

non-op with f/u imaging (2b) OR rx ("intervention") with RFs (2a) ## Footnote AHA aortopathy guidelines Figure 23. Classification System for BTTAIs https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

Question 119

initial mgmt of blunt traumatic thoracic aortic injury (BTTAI) grade 3-4 (contained - free rupture)

Answer 119

rx ("intervention") (1) ## Footnote AHA aortopathy guidelines Figure 23. Classification System for BTTAIs https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

Question 120

risk factors ("high-risk features") in blunt traumatic thoracic aortic injury (BTTAI)

Answer 120

* posterior mediastinal hematoma >1cm * mediastinal hematoma causing mass effect * lesion : normal Ao diameter ratio >1.4 * Ao pseudo-coarctation * lg L HTX * asc Ao/arch/great vessel involvement * arch hematoma

Question 121

recommendation for TEVAR v open rx of blunt traumatic thoracic aortic injury (BTTAI)

Answer 121

TEVAR (1)

Question 122

imaging surveillance for BTTAI s/p medical tx only, aortic dissxn + IMH s/p medical mgmt OR TEVAR or open rx

Answer 122

CT > MRI @ 1mo, 6mo, 12mo 🠆 Q1Y (1)

Question 123

imaging surveillance for PAU s/p medical mgmt only

Answer 123

CT @ 1mo 🠆 Q6mo x2y 🠆 Q1Y (2a)

Question 124

MY postoperative imaging surveillance for any endovascular aortic procedure

Answer 124

before discharge + @ 1mo, 3-6mo, 12mo 🠆 Q1Y

Question 125

all Ao root/asc size thresholds to replace

Answer 125

- **≥5.0cm** (with RFs/concom) in benign (sporadic, BAV) - **≥4.5cm** with excuses (e.g. SAVR @ COE) in benign \+ (with RFs/concom) in nsHTAD, Marfan \+ in OK Loeys-Dietz - **≥4.0cm** in bad Loeys-Dietz - **ASI≥2.5** in Turner **sporadic**: ≥4.5-5.0cm **BAV**: \>4.5-5.0cm **nsHTAD**: ≥4.5cm **Marfan**: \>4.5cm **Loeys-Dietz** TGFB2/3: ≥4.5cm **Loeys-Dietz** TGFBR1/2,SMAD3: ≥4.0cm (2b) **Turner**: ASI≥2.5

Question 126

indication(s) for C-sxn (over vaginal delivery) with aortopathy

Answer 126

h/o chronic dissxn (1) root and/or asc ≥4.5cm (2a) nsHTAD root and/or asc ≥4.0cm (2b)

Question 127

Ao size threshold to replace pre-partum

Answer 127

**≥5.0cm** in benign (sporadic, BAV) **≥4.5cm** in else (nsHTAD, Marfan, Loeys-Dietz) **≥4.0cm** with RFs (Turner: **ASI≥2.5**) **sporadic**: ≥5.0cm (1) **BAV**: ≥5.0cm (1) **nsHTAD**: ≥4.5cm (1) OR ≥4.0cm with RFs **Marfan**: ≥4.5cm (1) OR ≥4.0cm with RFs (2b) **Loeys-Dietz** TGFB2/3: ≥4.5cm **Loeys-Dietz** TGFBR1/2,SMAD3: ≥4.0cm (2b) **Turner**: ASI≥2.5

Question 128

mgmt of acute type A aortic dissxn in 1st or 2nd trimester

Answer 128

urgent surgery with fetal monitoring (1)

Question 129

mgmt of acute type A aortic dissxn in 3rd trimester

Answer 129

urgent C-sxn 🠆 surgery (1)

Question 130

mgmt of acute type B aortic dissxn in pregnancy

Answer 130

*same as usual* medical tx for un-cx / TEVAR or surgery for cx (1)

Question 131

mgmt of significant Ao CoA (either native or recurrent) + HTN

Answer 131

endovascular stent or open rx (1)

Question 132

additional screening imaging after dx of Ao CoA (adult)

Answer 132

CTA/MRI head for intracranial aneurysm (2b)

Question 133

recommended BP measurement in Ao CoA

Answer 133

**all 4 extremities** (BUE + 1 LE)

Question 134

definition of/criteria for "significant" Ao CoA

Answer 134

1. UE HTN (at rest or with pathologic exercise response) 2. LVH 3. 1 of: - UE:LE gradient >20mmHg - peak-to-peak gradient across Coa by cath >20mmHg - mean gradient across CoA by ECHO Doppler >20mmHg

Question 135

indication(s) for rx of Kommerell's diverticulum

Answer 135

diverticulum orifice >3cm and/or divertic + adjacent desc Ao >5cm (2b) ## Footnote "In patients with Kommerell’s diverticulum, depending on patient anatomy and comorbidities, repair may be reasonable when the diverticulum orifice is >3.0 cm, the combined diameter of the diverticulum and adjacent descending aorta is >5.0 cm, or both." (2b) https://drive.google.com/file/d/12C8xFk6pvyp3vCO8PYPCz2Afl9C1YaXr/view

Question 136

rule of thumb for minimum size of access vessels based on sheath/delivery system size

Answer 136

sheath size ÷ 3 (e.g. 24Fr TEVAR sheath ÷ 3 = 8mm access needed)

Question 137

standard TEVAR/interventional wire length

Answer 137

180cm (or 260cm for exchange)

Question 138

typical wire for initial access in TEVAR

Answer 138

Benston Starter (straight floppy tip) 0.035" x 180cm

Question 139

catheter exchange wire length in TEVAR

Answer 139

260-300cm (also usu stiffer)

Question 140

typical wire for TEVAR device delivery/deployment

Answer 140

Amplatz Super Stiff (straight flex tip 6cm) 0.035" x 260cm

Question 141

next step wire for TEVAR delivery/deployment if typical wire does not pass

Answer 141

Lunderquist Extra Stiff (even stiffer than Amplatz) (straight flex tip 4cm) 0.035" x 260cm

Question 142

alternative to typical wire for initial access in TEVAR (e.g. if tortuous, stenotic)

Answer 142

Glidewire (hydrophilic-coated) 0.035" x 180cm \-- others are non-hydrophilic-coated usu with tetrafluoroethylene (TFE) ## Footnote "The hydrophilic-coated Glidewire manufactured by Terumo Medical Corporation features a nitinol mandrel with a polyurethane outer coating instead of a metal coil. The polyurethane material contains tungsten for radiopacity, and this surface is further coated with a hydrophilic polymer; most manufacturers now offer similarly constructed wires. This wire is well-known for its ability to track in tortuous areas and stenoses. However, care must be taken when using this or any hydrophilic-coated wire, as there is greater risk of dissection or perforation due to the little resistance offered by these wires when advanced through vessels (“best friend and greatest enemy!”)."

Question 143

conventional definition of arterial aneurysm (any location)

Answer 143

diameter ≥1.5x nl

Question 144

normal diameter of root/Ao (at sinuses of Valsalva)

Answer 144

3-3.5cm

Question 145

normal diameter of STJ

Answer 145

3cm

Question 146

AHA definition of "enlarged" for root/Ao

Answer 146

\>4cm

Question 147

normal diameter of asc Ao

Answer 147

???

Question 148

normal diameter of aortic arch

Answer 148

???

Question 149

normal diameter of desc Ao

Answer 149

???

Question 150

normal diameter of abd Ao

Answer 150

\<3cm

Question 151

sheath size for TEVAR

Answer 151

20-24Fr ⇒ ≥8mm iliacs (fems?)

Question 152

max available TEVAR stent graft prox diameter

Answer 152

44mm (⇒ usu max Ao size can stent 36-38mm) *tapered stent grafts avail*

Question 153

available TEVAR stent graft lenghts

Answer 153

10-15cm

Question 154

overlap length for TEVAR stent grafts

Answer 154

5cm???

Question 155

cannulae/cannulation strategy for TEVAR

Answer 155

L CFA micropuncture ￫ dilate/upsize to sheath then TEVAR delivery system \+ R CFA 5Fr sheath for pigtail (aortogram)

Question 156

TEVAR stent graft sizing for acute dissxn

Answer 156

0-10% oversize

Question 157

TEVAR stent graft sizing for aneurysm (non-acute)

Answer 157

20% oversize

Question 158

1st choice TEVAR stent graft for acute dissxn

Answer 158

- covered - 8-10cm (shortest: just cover entry tear) - 0-10% oversized diameter (up to 44mm max)

Question 159

indication(s) for spinal drain in TEVAR (or open desc Ao rx)

Answer 159

YES, also: - \>15-20cm covered - prior aortic stents or procedures - covering L subclv - postop sxs of LE ischemia

Question 160

spinal drain mgmt

Answer 160

- drain to CSF pressure (CSFP) \<10mmHg - Q1H, passive drainage, 5mL at a time (then check CSFP before more drainage) - max drainage: 20mL/h - d/c @ 24-48h for TEVAR / 72h for open (asx)

Question 161

TEVAR procedure steps

Answer 161

1. CVC, BUE a-lines, neuro monitoring (SSEP=somatosensory evoked potential), spinal drain, Foley 2. US-guided cannulation of bilat CFA (non-TEVAR side 5Fr sheath for pigtail / TEVAR side wire then stent) 3. heparin (100u/kg) 4. pigtail side soft wire up to arch ￫ pigtail 5. ACT≥250 5. arch aortogram in LAO ￫ fine-tune fluoro position/check landing zones 4. L soft wire (Bentson) up to arch ￫ exchange catheter ￫ super stiff wire (Amplatz) 5. IVUS + TEE to check true lumen 6. upsize/insert TEVAR deployment device 7. pull back pigtail 8. ￬MAP to 60 / ￬SBP to 80 (HR<90) 9. completion aortogram (∅ balloon) 10. close & ￪MAP \>80 (for spinal cord protection)

Question 162

spinal cord protection maneuvers (ppx)

Answer 162

- spinal drain to CSFP ~10 (8-12) - MAP\>80 (80-100) / SBP≥140 - CI≥2.5 - Hb≥8 - O2 to sat\>95% - Q1H NCs

Question 163

spinal cord rescue maneuvers (sx)

Answer 163

- spinal drain if not already - lay flat - drain to CSFP≤5 - MAP\>100 - Hb\>10 - O2 to sat\>95% (100%???) - neuro c/s - L subclv-carotid bypass if covered

Question 164

TAAA (thoracoabdominal aortic aneurysms) extent classification

Answer 164

1. **I = suprarenal desc Ao** = below L subclv to above renals 1. **II = entire desc Ao** = below L subclv to aortic bifurc 1. **III = lower desc Ao** = below 6th ("T6") intercostal space to bifurc 1. **IV = entire abd Ao** = below T12 to bifurc 1. **V = middle desc Ao** = below T6 to above renals

Question 165

2 options for alternative access for CFAs\<8mm for TEVAR

Answer 165

- L lower paramedian retroperitoneal access to sew 8-10mm graft onto L EIA - 10mm endoconduit (covered stent) of entire L EIA

Question 166

potential cx(s) of covering/jailing L subclavian artery with TEVAR

Answer 166

- posterior circulation stroke - LUE ischemia

Question 167

mgmt of type 2 endoleak from L subclavian artery on TEVAR post-placement aortogram

Answer 167

call vascular/IR colleagues and coil/embolize it (can do at interval)

Question 168

What type of endoleak(s) is/are mandatory to address on the table?

Answer 168

- type 1 (prox/dist) - type 3 (porosity)

Question 169

types of endoleak

Answer 169

1. a/b = prox/dist 2. side-branch back-filling 3. overlap between components 4. porosity 5. endotension ("magic")

Question 170

minimum ACT for TEVAR

Answer 170

250