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Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation. 2022;146(24):e334-e482. PMID 36322642

One-paragraph summary

Comprehensive US practice guideline replacing the 2010 thoracic aortic document, covering diagnosis, genetics/family screening, imaging standards, medical therapy, open and endovascular repair, and surveillance across the whole aorta. Core operative thresholds: sporadic root/ascending aneurysm ≥5.5 cm (1, B-NR); ≥5.0 cm at experienced Multidisciplinary Aortic Team centers (2a, B-NR); growth ≥0.3 cm/yr ×2 yr or ≥0.5 cm/yr (1, C-LD); Marfan ≥5.0 cm (1, B-NR) or ≥4.5 cm with risk features (2a); indexed criteria enter formally (area/height ≥10 cm²/m 2a; ASI ≥3.08 / AHI ≥3.21 cm/m 2b); descending TAA ≥5.5 cm with TEVAR preferred in non-syndromic anatomy-suitable patients (1, B-NR). Measurement conventions standardized (CT/MRI inner-edge, ECG-gated, orthogonal planes; echo leading-edge end-diastolic). High-volume centers defined as ≥30–40 aortic procedures/yr.

Key findings

  • Nearly all operative-threshold recommendations carry LOE B-NR or C; LOE A appears for Marfan beta-blocker/ARB therapy and CSF drainage in open TAAA repair.
  • New institutional constructs: Multidisciplinary Aortic Team (urgent decisions: 1, C-EO; referral of complex cases: 2a, C-LD).
  • Family screening: imaging of first-degree relatives of root/ascending aneurysm or dissection patients (1, C-LD); cascade genetic testing (1); BAV relative screening (2a, B-NR).
  • Surveillance intervals: baseline TTE + CT/MRI, re-image at 6–12 months, then every 6–24 months by size; post-TEVAR CT at 1 and 12 months then annually (1, B-NR); post-open at 1 year then every 5 years (2a, B-NR).
  • Explicitly flags unresolved issues: thresholds in women, prospective validation of all beyond-diameter predictors, fluoroquinolone association (research gap only), exercise limits (C-EO).

Limitations

  • Threshold recommendations rest on referral-center natural-history cohorts (Yale) and registry data; no RCT informs any diameter cut-point (TITAN:SvS pending).
  • Multidisciplinary Aortic Team / 5.0 cm pathway rests on volume-outcome observational data; auditability of "experienced" is undefined.
  • Full-text tables (e.g., gene-specific thresholds) require the source document; extraction from PMC drops italicized gene symbols.

Why it matters

The operative reference document for all TAA management in North America and the anchor for this knowledge base's clinical pages; its COR/LOE distribution is itself the clearest statement of how thin the evidence under aortic surgery thresholds remains.

Cited by wiki pages

  • guidelines
  • imaging-and-surveillance
  • risk-stratification-and-size-thresholds
  • medical-therapy
  • surgical-and-endovascular-repair