An international panel of experts has released a series of consensus statements on the management and follow-up of acute type B intramural haematoma (IMH) and penetrating aortic ulcer (PAU), with findings recently published as an article in press in the European Journal of Vascular and Endovascular Surgery (EJVES).
Key findings include a clearer definition of complications, the weakened significance of certain morphological criteria as sole indicators for thoracic endovascular aortic repair (TEVAR), and the importance of strict imaging follow-up in the early period to assess for high-risk features. In addition, the panel provides specific recommendations regarding the planning and technical aspects of TEVAR.
In order to develop the consensus document, a team of researchers employed a modified Delphi consensus process involving multiple rounds of anonymous questionnaires. The team—consisting of principal investigator Michele Piazza, first author Francesco Squizzato (both University of Padua, Padua, Italy) and three external facilitators including Mario D’Oria (University Hospital of Cattinara, Trieste, Italy)—sent surveys to international experts practicing in high-volume aortic centres worldwide.
Piazza and Squizzato specify in their EJVES paper that a series of statements—prompted and refined from currently available guidelines or the best available evidence on the standard of care—were voted on using a four-point Linkert scale in a three-round Delphi process. Statements achieving grade A (full agreement 75%) or B (overall agreement 80%, full disagreement <5%) were included as expert recommendations.
A total of 83 experts from across Europe, North America, Latin America, Asia, and Oceania were included in the final analysis.
The authors state that 25 statements achieved a consensus, with 18 (72%) receiving a grade B strength and seven (28%) a grade A strength. They note that most statements (97%) had a high consistency classified as grade I or II.
In EJVES, this panel of international experts summarise that they agreed on the indication for TEVAR for complicated IMH and PAU, defined by rupture or refractory pain/hypertension. They add that uncomplicated IMH and PAU should be managed conservatively and followed with serial computed tomography (CT) imaging during the acute phase.
Furthermore, the experts agreed that high-risk uncomplicated IMH is identified by increased haematoma thickness, new onset or increased size of ulcer-like projections, or transition to aortic dissection, while high-risk uncomplicated PAU is defined by new associated haematoma, PAU width/depth increase, or total aortic diameter increase.
The authors continue that the expert panel agreed uncomplicated high-risk IMH and PAU may be considered for TEVAR. In performing TEVAR, they add, a proximal sealing length >20mm in a site free from haematoma should be achieved, eventually extending in zone 2, with a 0–10% oversize, and that patency of the left subclavian artery should be maintained.
In the discussion of their findings, Piazza and Squizzato stress that currently available guidelines on the management of IMHs and PAUs are characterised by a low level of evidence and lack of consistency on important clinical aspects, such as definitions of complications, characterisation of high-risk features, indications for TEVAR, and technical aspects of the surgical treatment.
While the authors state that the international expert panel achieved a consensus on several of these unsolved topics, they underscore a lack of consensus on the timing of endovascular treatment. “While it is well established that complicated patients should undergo urgent/emergent TEVAR,” the authors write, “the situation is more nuanced in uncomplicated, high-risk IMH/PAU.” They note that clinical guidelines do not mention the suggested timing of intervention in this clinical setting.
Regardless of the timing of TEVAR, the expert panel were in agreement that a postoperative CT angiogram should be obtained within three to seven days to assess for technical success and potential complications, such as dissection at the level of the proximal or distal landing site.
The panel of experts advise that certain limitations of the present study should be taken into account when interpreting the results. “Delphi studies reflect the opinions and practice patterns of selected experts and cannot be considered as a substitute for traditional scientific literature or guidelines,” they state.
Furthermore, the authors emphasise that different opinions and lack of agreement “do not necessarily reflect an incorrect practice, but may be the result of different available options, institutional setting, local regulations, and geographical habits, in topics where there is a low level of evidence”.
Overall, the authors conclude that the consensus statements resulting from the Delphi process offer “valuable insights” for current clinical practice and “may be considered for updated guidelines”.
Closing their paper, Piazza and Squizzato write that additional research is warranted to further investigate the topics of recommendations.
