Aortic dimensions as predictors of adverse events

Central MessageCurrent guidelines use aortic diameter as the primary metric guiding management of patients with thoracic aneurysms. Aortic length and, its surrogate volume, may ultimately prove better predictors AAEs.This Invited Expert Opinion provides a perspective on following paper: J Am Coll Cardiol. 2019 Oct 15;74(15):1883-1894. https://doi.org/10.1016/j.jacc.2019.07.078.See Commentaries pages 1198 and 1202. Current AAEs. This https://doi.org/10.1016/j.jacc.2019.07.078. See There is an accumulating body evidence suggesting that relying single measurement, diameter, be too restrictive when advising need for ascending aneurysm repair. As outcomes procedures like composite valve-graft1Gaudino M. Weltert L. Munjal Lau C. Elsayed Salica A. et al.Early clinical outcome after root replacement using biological valved graft without neo-sinuses.Eur Cardiothorac Surg. 2017; 51: 316-321PubMed Google Scholar valve-sparing replacement2Gaudino Avgerinos D. Girardi L.N. Contemporary surgery aneurysms: propensity-matched comparison valve replacement.J Thorac Cardiovasc 2015; 150: 1120-1229Abstract Full Text PDF PubMed Scopus (47) continue to improve, it crucial scrutinize current opportunities offer these increasingly safe durable operations at risk adverse events (AAEs). indexed either surface area (BSA) or height more accurate than alone in predicting rupture, dissection, sudden death. However, most common approach, upon which recommendations are based, relies diameter/radius wall tension, predicted by LaPlace's law,3Li J.K. Comparative cardiac mechanics: Laplace's law.J Theoret Biol. 1986; 118: 339-343Crossref (30) determine surgery. has recently garnished attention another parameter worthy analysis. We examine support predictor AAE contrast this contemporary data base repair Surgeons main measurement recommend intervention aneurysms primarily because only consistently referenced from both cardiothoracic vascular societies. Although regarded Class I (benefit >>> risk, procedure/treatment SHOULD performed) IIa >> additional studies focused objectives needed, IT IS REASONABLE perform procedure), Level Evidence supporting “C,” arising expert consensus, case studies, “standard care.” Irrespective whether arise North American European guidelines, level substantially stronger abdominal aorta compared counterpart. For aneurysms, I, A exists supporting: (1) diameters ?5.5 cm rupture outweighs open (UKSTAT Aneurysm Detection Management Veterans Affairs Cooperative Study [ADAM] trials4Powel J.T. Brady A.R. Brown L.C. Forbes Fowkes F.G.R. Greenhalgh R.M. al.Mortality results randomized controlled trial early elective ultrasonographic surveillance small The UK participants.Lancet. 1998; 352: 1649-1655Abstract (1067) Scholar,5Lederle F.A. Wilson S.E. Johnson G.R. Reinke D.B. Littooy F.N. Acher C.W. al.Immediate aneurysms.N Engl Med. 2002; 346: 1437-1444Crossref (949) Scholar); (2) endovascular does not advantage over smaller 4 5.5 (Comparison versus Endografting Small Repair study [CESAR]6Cao P. De Rango Verzini F. Parlani G. Romano Cieri E. al.Comparison endografting (CAESAR): trial.Eur Endovasc 2011; 41: 13-25Abstract (198) Positive Impact Endovascular Options Treating Aneurysms Early [PIVOTAL] trials7Ouriel K. Clair D.G. Kent K.C. Zarins C.K. (PIVOTAL) InvestigatorsEndovascular aneurysms.J Vasc 2010; 1081-1087Abstract (169) Scholar). Because there no trials evaluating treatment efficacy aorta, argument begins understanding normal distribution each segment. One earliest reports was published 1991.8Johnston K.W. Rutherford R.B. Tilson M.D. Shah D.M. Hollier Stanley J.C. Suggested standards reporting arterial Subcommittee ad hoc committee standards, Society Vascular Surgery Chapter, International Cardiovascular Surgery.J 1991; 13: 452-458Abstract (929) With improvements computed tomography (CT) imaging echocardiography acknowledgment influence age, sex, size indices “normals” were established.9Roman M.J. Devereux Kramer-Fox R. O'Loughlin J. Two-dimensional echocardiographic dimensions children adults.Am 1989; 64: 507-512Abstract (896) Scholar,10Hannuksela Lundqvist S. Carlberg B. Thoracic aorta: dilated not?.Scand 2006; 40: 175-178Crossref (50) mean tubular female male 2.7 3.6 cm, respectively. sinuses Valsalva somewhat larger women men 3.0 3.9 Using baseline dimensions, investigators began quantify occur greater frequency.11Dapunt O.E. Galla J.D. Sadeghi A.M. Lansman S.L. Mezrow de Asla R.A. al.The natural history 1994; 107: 1323-1333Abstract (219) turning point occurred seminal paper Yale group demonstrated significant increase, “hinge point,” incidence once became >6.0 cm.12Coady M.A. Rizzo J.A. Hammond G.L. Mandapati Darr U. Kopf G.S. al.What appropriate criterion resection aneurysms?.J 1997; 113: 476-491Abstract (438) logistic regression analysis measurements AAEs recorded 230 they increase number diameter. To reduce potentially fatal complications, opined should become trigger surgical intervention. Since then, based single, relatively study, benchmark created. “aortic paradox,” however, recognizes flaws establishing benchmark. Pape colleagues13Pape L.A. Tsai T.T. Isselbacher E.M. Oh O'gara P.T. Evangelista al.Aortic > = good type dissection: observations international registry acute dissection (IRAD).Circulation. 2007; 116: 1120-1127Crossref (502) examined 591 dissections (ATAD) enrolled Registry Dissection. those ATAD 5.3 cm. Nearly 60% less 40% dissected 5.0 expands between 16.9% 31.9% Dissection significantly overestimated actual before event.14Rylski Blanke Beyersdorf Desai N.D. Milewski R.K. Siepe al.How geometry change dissects?.J 2014; 63: 1311-1319Crossref (121) Clearly room improvement. explain apparent paradox, analyzed “normal” population 3573 undergoing screening magnetic resonance Multi-Ethnic Atherosclerosis (MESA).15Paruchuri V. Salhab K.F. Kuzmik Gubernikoff Fang H. general population: explaining paradox dissection.Cardiology. 131: 265-272Crossref (49) They found 89-fold 4.0 4.4 346-fold 4.5 Another point” interpretation accompanying call aortas exceeded fairly Unfortunately, measured flaw underestimating largest risk. An update database expanding 3349 allowed granular diameter.16Zafar Li Y. Charilaou Saeyeldin Velasquez C.A. al.Height alone, rather area, suffices estimation aneurysm.J 2018; 155: 1938-1950Abstract (75) actually 2 hinge-points, one 5.75 previously shown 5.25 prompted examination surgeons move “leftward,” toward avoid AAE. do imply refined justifies closer look various patient characteristics. While physics tension reliable decisions prophylactic surgery, concept “one fits all” fallen out favor among surgeons. Indexing BSA, index (ASI) proposed 2006.17Davies R.R. Gallo Coady Tellides Botta Burke al.Novel relative predicts aneurysms.Ann 81: 169-177Abstract (377) In 410 patients, ASI <2.75 cm/m2 deemed low whereas above 4.25 felt reveals limitations form indexing. 6.5-cm BSA 2.40 would considered ASI. recommended. Similarly, someone 1.90, anyone consider 8.0-cm “moderate” against intervention? Critics rightfully pointed BSA/weight variable throughout life heavily influenced factors physiology within. More clearly necessary. Around time, cross-sectional ratio superior method ascribe genetically triggered aortopathy.18Svensson L.G. Khitin area/height timing asymptomatic Marfan syndrome.J 123: 360-361Abstract (92) Scholar,19Svensson Kim K.H. Lytle B.W. Cosgrove Relationship bicuspid valves.J 2003; 126: 892-893Abstract (170) shares other due basic diameter-based calculation area. series examining 771 trileaflet valves >10 cm2/m had reduced long-term survival.20Masri Kalahasti Svensson Roselli E.E. Johnston Hammer aorta.Circulation. 2016; 134: 1724-1737Crossref all-cause mortality end limited widespread acceptance interesting metric. Its still class IIa, C recommendation applicable aortopathy. (AHI) also examined. recommended AHI 3.21 cm/m.16Zafar complex statistical failed demonstrate improvement comparing (concordance ASI, 0.617 vs AHI, 0.645). Therefore, never gained marker intervention, especially connective tissue disorders. have cogent discussion utility (AAL) AAE, needs understand nomenclature values variable. anatomic landmarks used measure AAL heterogeneous but easily calculated. Classical (c-AAL) distance sinotubular junction brachiocephalic trunk. value 7.10 ± 2.80 centerline coronal plane, 6.72 1.70 sagittal plane. effaced, commonly seen involving consistent challenging. overcome this, some prefer extended (e-AAL), represents annulus innominate artery. calculated resulted e-AAL 11.2 1.3 reconstructed flattened aorta.21Krüger T. Forkavets O. Veseli Lausberg Vöhringer Schneider W. al.Ascending elongation dissection.Eur 50: 241-247Crossref (48) Scholar,22Wu Zafar Huang Zhao Ascending events: neglected dimension.J 2019; 74: 1883-1894Crossref (32) increases age regardless BSA. cohort 220 followed CT measurements, 20 80 years, increased 66 mm 59 patients. difference percentage segments: 142%, arch 169%, proximal descending 247%.23Adriaans B.P. Heuts Gerretsen Cheriex E.C. Vos Natour part I: ageing process.Heart. 104: 1772-1777Crossref (45) configuration evolves consequence age-related lengthening. apex migrates distally origin great vessels young (type aorta), distal left subclavian artery elderly II aorta). Increasing tortuosity becomes geometrical byproduct matched somatic growth vertebral column decreases time.24Belvroy V.M. Beaufort H.W.L. van Herwaarden Bismuth Moll F.L. Trimarchi Tortuosity age.PLoS One. 14: e0215549Crossref (9) can quantified (ATI), straight linear endoluminal points. On average, ATI 1.07 (age years) 1.21 years).23Adriaans Scholar,25Chaikof E.L. Blankensteijn Harris P.L. White G.H. Bernhard al.Reporting repair.J 35: 1048-1060Abstract (1364) correlation Krüger colleagues.26Krüger Sandoval Boburg Lescan Oikonomou Tübingen pathoanatomy (TAIPAN) project.Eur 54: 26-33Crossref (18) c-AAL healthy controls (108 84 mm, P .001). risk-adjusted corroboration provided colleagues27Heuts Adriaans II: dissection.Heart. 1778-1782Crossref (31) who, propensity matching, longer (78.6 8.8 68.9 7.2 < Interestingly, independently multivariable analysis.27Heuts done identified thresholds AAL. ?13 associated nearly 5-fold yearly rate <9 regression, odds 12.4 times Two hinge points corresponded rate: 11.5 12.0 12.5 13 Hence, suggested ?11 threshold intervention.22Wu Surrogates (ie, high aorta) been related AAEs, who developed underwent baseline.28Franken El Morabit Waard Timmermans Scholte A.J. den Berg M.P. al.Increased indicates severe phenotype adults syndrome.Int 194: 7-12Abstract (51) >1.95 linked 13-fold probability <1.95. Independent combined (hazard [HR], 12.8; .030) (HR, 1.451; 12.083; .039). Chen colleagues29Chen Liang I.P. Chang H.T. W.Y. I.M. Wu M.H. al.Impact measuring 60: 937-944Abstract (33) dichotomized their groups. endoleaks (odds ratio, 9.95; 95% confidence interval, 2.06-48) lower 5-year survival (63% 86%, .023).29Chen colleagues evaluated prevalence conformational variants frank (diameter >5.5 cm) ATAD, individuals “at risk” ectasia 4.5-5.4 pre-ATAD scanned 24 months occurred). much frequent control (22.7%) pathologic groups: 45.1% group, 60.5% 58.8% 45.2% (P .001).26Krüger Finally, trying estimate ATAD. subset 10 scans within 1.5 years 2.7%, same setting.22Wu reasonable predictive combining provide sensitivity? volumetry (volume ?[diameter/2]2 × length) quantitative useful preoperative postoperative follow-up. absolute volume corresponding diameters. 60 mm-long aneurysm, barely detectable 1 expansion corresponds 10-mL volume.30Parr Jayaratne Buttner Golledge Comparison assessing tomographic angiography.Eur Radiol. 79: 42-47Abstract (60) possibility sensitivity seems obvious. During infrarenal reliance missed 14% 42% changes detected volumetry.30Parr Scholar,31Kauffmann Tang Therasse Giroux M.F. Elkouri Melanson al.Measurements detection growth: accuracy reproducibility segmentation software.Eur 2012; 1688-1694Abstract Similar findings reported Trinh colleagues,32Trinh Dubin I. Rahman Ferreira Botelho Naro N. Carr contrast-enhanced angiography: feasibility sensitive monitoring aortopathy.Invest 52: 216-222Crossref (15) 3.7 After (EVAR), >10% >5-mm endoleak.33Nomura Sugimoto Gotake Yamanaka Sakamoto Muradi volumetric diametric aneurysm.Eur 53-59Abstract (4) endoleak EVAR, 63% volumetry. further investigation necessary confirmed surveillance, harbinger EVAR EVAR. could particularly endoleaks, where consensus lacking timing/need reintervention.34van Keulen J.W. Prehn Prokop Potential sac addition Ther. 2009; 16: 506-513Crossref It noted investigations combine metrics, such length/height index, diameter/height index.22Wu Further needed validate calculations meaningful (Figure 1). aneurysmal remains created Despite indisputable obvious insufficient. below experience life-threatening Clearly, (Table 1).Table 1Aortic interventionParameterCalculationRecommended (without aortopathy)DiameterDiameter5.5 cmAortic indexDiameter/body area>2.75 cm/m2Cross-sectional indexCross-sectional area/height>10 cm2/mAortic indexDiameter/heightHigh >3.21 cm/mSevere >4.06 cm/mClassical lengthLength (sinotubular origin)–Extended (aortic origin)>11 indexCenterline distance/linear distance–Aortic volumetry?[diameter/2]2 length– Open table new tab