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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Pape LA, Awais M, Woznicki EM, et al. Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: 17-Year Trends From the International Registry of Acute Aortic Dissection. Journal of the American College of Cardiology. 66(4):350-8, 2015 Jul 28. Observational-Dx 4,428 patients To examine 17-year trends in the presentation, diagnosis, and hospital outcomes of Acute Aortic Dissection (AAD) from the International Registry of Acute Aortic Dissection (IRAD). There was no change in the presenting complaints of severe or worst-ever pain for type A and type B AAD (93% and 94%, respectively), nor in the incidence of chest pain (83% and 71%, respectively). Use of computed tomography (CT) for diagnosis of type A increased from 46% to 73% (p < 0.001). Surgical management for type A increased from 79% to 90% (p < 0.001). Endovascular management of type B increased from 7% to 31% (p < 0.001). Type A in-hospital mortality decreased significantly (31% to 22%; p < 0.001), as surgical mortality (25% to 18%; p ¼ 0.003). There was no significant trend in in-hospital mortality in type B (from 12% to 14%). 3
2. Sidloff D, Choke E, Stather P, Bown M, Thompson J, Sayers R. Mortality from thoracic aortic diseases and associations with cardiovascular risk factors. Circulation. 130(25):2287-94, 2014 Dec 23. Review/Other-Dx N/A To examine trends in mortality from thoracic aortic aneurysm (TAA) and aortic dissection (AD) with the aim of identifying associations with trends in established cardiovascular risk factors. Eighteen World Health Organization member states were included (Europe=13, Australasia=2, North America=2, Asia=1). Ecological regression was performed of temporal trends in cardiovascular risk factors (1946–2010) and independent correlations to mortality trends. TAA and AD mortality trends show substantial heterogeneity but are generally declining. TAA mortality has increased in Hungary, Romania, Japan, and Denmark, and AD mortality has increased in Romania and Japan; therefore, the mortality decline is not universal. A linear relationship exists between trends in systolic blood pressure, cholesterol, and body mass index and mortality from TAA. Body mass index demonstrated a negative linear association with female AD mortality, whereas trends in systolic blood pressure demonstrated a positive linear relationship with male AD mortality. Trends in smoking prevalence were not associated with TAA or AD mortality trends. 4
3. Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation. 2003;108(5):628-635. Review/Other-Dx N/A Review etiology, natural history, and classification (with vascular staging) of aortic wall disease and diagnostic strategies. Modern imaging techniques can reliably identify variants of dissection such as IMH, plaque ulceration, or traumatic aortic injury. 4
4. Romano L, Pinto A, Gagliardi N. Multidetector-row CT evaluation of nontraumatic acute thoracic aortic syndromes. [Review] [85 refs]. Radiol Med (Torino). 112(1):1-20, 2007 Feb. Review/Other-Dx N/A To evaluate acute thoracic nontraumatic aortic syndromes to illustrate the examination technique and the key imaging findings related to each disease. The role of MDCT for planning specific treatment is also highlighted. Acute thoracic aortic syndromes encompass a spectrum of emergencies presenting with acute chest pain and marked by a high risk of aortic rupture and sudden death. These include nontraumatic disease entities of the thoracic aorta, namely, dissection, intramural haematoma, penetrating atherosclerotic ulcer and aneurysm rupture. In clinical practice, the most frequent imaging procedure used in the diagnostic assessment of these diseases is CT, which, thanks to recent technological developments (ie, MDCT), affords important diagnostic possibilities and very interesting future perspectives. 4
5. Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. [Review]. JAMA. 316(7):754-63, 2016 Aug 16. Review/Other-Dx 82 Studies describing 57,311 patients To systematically review the current evidence on diagnosis and treatment of AAS. Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n?=?876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n?=?61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P?<?.001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias. 4
6. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection. Eur Heart J. 2001;22(18):1642-1681. Review/Other-Dx N/A Review diagnosis and treatment of AAD. CT is often used for patients with suspected AD. MRI has the highest accuracy and sensitivity as well as specificity (nearly 100%) for detection of all forms of dissection except subtle forms. MRI provides excellent visualization of tear localization, aortic regurgitation, side branch involvement and complications. 4
7. Pelzel JM, Braverman AC, Hirsch AT, Harris KM. International heterogeneity in diagnostic frequency and clinical outcomes of ascending aortic intramural hematoma. J Am Soc Echocardiogr 2007;20:1260-8. Meta-analysis 42 studies To perform a complete review of the published literature and thereby to compare the diagnostic, treatment, and outcome data for type-A intramural hematoma (IMH) between these two geographic locales. MH, as a percentage of aortic dissection, occurs more frequently in Japan/Korea versus NA/Europe (31.7% vs 10.9%, P < .0001). The proportion of patients treated with early medical therapy is greater in Japanese/Korean studies (77.9% vs 48.8% in NA/Europe, P < .0001). However, the overall mortality is significantly lower in Japan/Korea compared with NA/Europe (9.4% vs 20.6%, odds ratio = 2.80, P = .003) in part because of the lower mortality with early medical therapy (7.8% vs 33.3%, P < .0001). Good
8. Macura KJ, Corl FM, Fishman EK, Bluemke DA. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol 2003;181:309-16. Review/Other-Dx N/A No abstract available. No abstract available. 4
9. American College of Radiology. ACR Appropriateness Criteria®: Nontraumatic Aortic Disease. Available at: https://acsearch.acr.org/docs/3082597/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
10. Coady MA, Rizzo JA, Goldstein LJ, Elefteriades JA. Natural history, pathogenesis, and etiology of thoracic aortic aneurysms and dissections. Cardiol Clin. 1999;17(4):615-635; vii. Review/Other-Dx N/A To review the history, pathogenesis and etiology of aortic aneurysms. The natural history of thoracic aortic aneurysms and dissections is diverse, reflecting a broad spectrum of etiologies which include increasing aortic size, hypertension, and genetic factors. The pathogenesis is related to defects or degeneration in structural integrity of the adventitia, not the media, which is required for aneurysm formation. The ascending and descending aorta appear to have separate underlying disease processor that lead to a weakened vessel wall and an increased susceptibility for dissection. Etiologic factors for aortic aneurysms and dissections are multifactorial, reflecting genetic, environmental, and physiologic influences. 4
11. Lempel JK, Frazier AA, Jeudy J, et al. Aortic arch dissection: a controversy of classification. Radiology. 271(3):848-55, 2014 Jun. Observational-Dx 205 patients To determine the frequency of acute aortic arch dissections at our institution. No results stated in the abstract. 3
12. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
13. Chirillo F, Cavallini C, Longhini C, et al. Comparative diagnostic value of transesophageal echocardiography and retrograde aortography in the evaluation of thoracic aortic dissection. Am J Cardiol. 1994;74(6):590-595. Observational-Dx 64 patients Prospective study to assess the comparative diagnostic value of TEE and retrograde aortography for morphologic evaluation and anatomic mapping of AD. For detection of AD, aortography showed lower sensitivity (87.5% vs 97.5%) and NPV (85.3% vs 96.7%; For the epiphenomena of AD, aortography was significantly more accurate (97.2% vs 78%; P<0.05) in assessing the site of entry, and TEE was more accurate in identifying thrombus formation (90% vs 65%; P<0.05). In elective patients, combining both techniques seems the best approach; in unstable patients, TEE may be preferential because it is less invasive, requires no contrast injection, and provides accurate diagnosis in a short time at the bedside. 3
14. Andresen J, Baekgaard N, Allermand H. Evaluation of patients with thoracic aortic dissection by intraarterial digital subtraction angiography. Vasa. 1992;21(2):167-170. Review/Other-Dx 17 patients, 11 patients Determine quantity of information obtainable with arterial subtraction angiography in planning treatment of thoracic AD. In 17 patients, a thoracic AD could be revealed by intra-arterial digital-subtraction angiography with exact delineation of the proximal and distal extent. In 11 patients the entry was seen over a longer area. Arterial digital-subtraction angiography provided accurate diagnosis with visualization of all pathophysiological aspect including flow into supra aortic and infradiaphragmatic arteries. 4
15. Lovy AJ, Rosenblum JK, Levsky JM, et al. Acute aortic syndromes: a second look at dual-phase CT. AJR Am J Roentgenol. 200(4):805-11, 2013 Apr. Observational-Dx 2,868 patients To assess the diagnostic performance of the unenhanced and contrast-enhanced phases separately in patients imaged with CT for suspected acute aortic syndromes. 45 patients had one or more CT findings of acute aortic syndrome: AD (n = 32), IMH (n = 27), aortic rupture (n = 10), impending rupture (n = 4), and penetrating atherosclerotic ulcer (n = 2). Unenhanced CT was 89% (40/45) sensitive and 100% (45/45) specific for acute aortic syndrome. Unenhanced CT was 94% (17/18) and 71% (10/14) sensitive for type A and type B dissection, respectively (P=0.142). Contrast-enhanced CTA was 100% (8/8) sensitive for isolated IMH. Mean radiation effective dose was 43 +/- 20 mSv. 2
16. Vantine PR, Rosenblum JK, Schaeffer WG, et al. Can non-contrast-enhanced CT (NECT) triage patients suspected of having non-traumatic acute aortic syndromes (AAS)?. EMERG. RADIOL.. 22(1):19-24, 2015 Feb. Observational-Dx 117 patients To determine whether non-contrast-enhanced CT (NECT) of patients with suspected acute aortic syndrome (AAS) can identify patients with a very low likelihood of a positive diagnosis. In the derivation phase, patients who received both NECT and contrast-enhanced CT angiography (CTA) for suspected AAS were identified. Two readers blinded to CTA results analyzed NECTs from AAS positive and negative cases, recording maximal aortic diameters and qualitative findings of aortic disease. Logistic regression analysis was performed to identify independent positive predictors for AAS; those predictors were then used to create a decision rule. For the validation phase, NECTs from patients evaluated for AAS at a second institution were reviewed by two independent readers who recorded the presence of decision rule predictors while blinded to CTA results. In the derivation phase, 34 CTA positive and 83 CTA negative cases were reviewed. Measurements of aortic diameter alone achieved mean sensitivity and specificity of 82 % and of 83 %, respectively. Logistic regression identified aortic diameter, displaced calcifications, high attenuation aortic wall and abnormal aortic contour as independent predictors of AAS. The decision rule incorporating these findings achieved higher mean sensitivity (93 %), negative predictive value (96 %), and moderate reader agreement (kappa = 0.59). For the validation phase, application of the decision rule to 35AAS positive and 45 AAS negative cases at the second institution yielded sensitivity of 100 % and specificity of 74 % for both readers. 2
17. Lemos AA, Pezzullo JC, Fasani P, et al. Can the unenhanced phase be eliminated from dual-phase CT angiography for chest pain? Implications for diagnostic accuracy in acute aortic intramural hematoma. AJR. American Journal of Roentgenology. 203(6):1171-80, 2014 Dec. Observational-Dx 306 patients To retrospectively assess the frequency of acute aortic intramural hematoma and evaluate whether the elimination of the unenhanced imaging acquisition series from the dual-phase MDCT angiography (CTA) protocol for chest pain might affect diagnostic accuracy in detecting intramural hematoma and justify the reduced radiation dose. Thirty-six patients were suspected of having intramural hematoma; 16 patients underwent both surgery and transesophageal echocardiography (TEE), and the remaining 20 underwent TEE. Single-phase CTA showed a higher number of false-negative and false-positive results than dual-phase CTA. With intramural hematoma frequency of 12% (95% CI, 8.38-15.91%), sensitivity, specificity, and accuracy were 94.4% (81.3-99.3%), 99.3% (97.4-99.9%), and 98.7% (96.7-99.6%) for combined dual-phase CTA and 68.4% (51.4-82.5%), 96.3% (93.2-98.2%), and 92.8% (89.3-95.4%) for single-phase CTA. Dual-phase was significantly better than single-phase CTA with respect to sensitivity (p=0.002), specificity (p=0.008), overall accuracy (p<0.001), and interrater agreement (p=0.001). 2
18. Shaida N, Bowden DJ, Barrett T, et al. Acceptability of virtual unenhanced CT of the aorta as a replacement for the conventional unenhanced phase. Clin Radiol. 67(5):461-7, 2012 May. Observational-Dx 49 patients To evaluate whether virtual unenhanced CT images generated of the aorta were of sufficient quality to replace the conventional unenhanced images. The attenuation was significantly higher in the virtual unenhanced images compared to the conventional unenhanced images within the thoracic aorta (P<0.01) but not within the abdominal aorta (P=0.15). Overall the virtual unenhanced images of the abdominal aorta were deemed acceptable as replacements for the conventional unenhanced images in 93% of cases. For the thoracic aorta, the virtual unenhanced images were deemed acceptable in only 12% of cases, primarily due to pulsation artifact. 4
19. Vlahos I, Chung R, Nair A, Morgan R. Dual-energy CT: vascular applications. AJR Am J Roentgenol. 2012;199(5 Suppl):S87-97. Review/Other-Dx N/A To describe the current status, potential advantages, and limitations of dual-energy CT. No results stated in abstract. 4
20. Vlahos I, Godoy MC, Naidich DP. Dual-energy computed tomography imaging of the aorta. [Review]. J Thorac Imaging. 25(4):289-300, 2010 Nov. Review/Other-Dx N/A To review dual-energy CT imaging of the thoracic aorta. There are 2 inseparable and complimentary technical advantages of dual-energy CT imaging of the thoracic aorta. One advantage stems from the simultaneous availability of low and high peak kVp spectra data and, in particular, the benefits conferred by the improved conspicuity of iodinated contrast media at lower kVp CT imaging. This, in turn, permits improved aortic visualization or, alternatively, reduction in the volume or rate of contrast administration. Image noise at low kVp does not appear to be a significant issue, with the backup availability of simultaneously acquired high kVp images a distinct advantage over single, low kVp imaging techniques. The second advantage of dual-energy CT imaging stems from the potential to calculate material-specific images derived mathematically from the simultaneous availability of attenuation measurements at 2 distinct energies. These material-specific data sets include virtual noncontrast images, virtual contrast, or “bone-subtracted” angiographic-like images. These techniques may confer significant advantages in the evaluation of patients with aortic disease, improving interpretation and reducing reconstruction time, while potentially reducing the need for, and associated radiation burden of, precontrast or postcontrast multiphasic imaging. 4
21. Moore AG, Eagle KA, Bruckman D, et al. Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD). Am J Cardiol. 89(10):1235-8, 2002 May 15. Observational-Dx 628 patients Comparative study to assess the current status of diagnostic imaging in AAD at several cardiovascular referral centers throughout the world by analyzing data on test preference and performance gathered in the IRAD. For AAD, CT is selected most frequently worldwide as the initial test, followed by TEE. Aortography and MRI are performed much less often. More than two-thirds of the patient’s required second imaging tests. 3
22. Yoshida S, Akiba H, Tamakawa M, et al. Thoracic involvement of type A aortic dissection and intramural hematoma: diagnostic accuracy--comparison of emergency helical CT and surgical findings. Radiology. 228(2):430-5, 2003 Aug. Observational-Dx 57 patients To assess the accuracy of various findings at emergency HCT for the evaluation of thoracic involvement of type A AD and type A IMH and to compare these findings with those at surgical confirmation. For the detection of AD or IMH of the thoracic aorta, the accuracy of HCT was 100%. The sensitivity, specificity, and accuracy, respectively, were 82%, 100%, and 84% for an entry tear; 95%, 100%, and 98% for arch branch vessel involvement; and 83%, 100%, and 91% for pericardial effusion. These values were all 100% for aortic arch anomalies. 2
23. Ballal RS, Nanda NC, Gatewood R, et al. Usefulness of transesophageal echocardiography in assessment of aortic dissection. Circulation. 1991;84(5):1903-1914. Observational-Dx 61 patients To clarify role of TEE (36% biplane) in evaluation of AD with attention to type of dissection and associated complications and in assessment of immediate postoperative repair. TEE results compared to CT, angiography, surgery, or autopsy. TEE made correct diagnosis of dissection in 33/34 patients (sensitivity 97%; specificity 100%). CT made correct diagnosis in only 67% and misclassified the type of dissection in 33%. TEE identified coronary artery involvement by dissection in 6/7 with dissection; detected entry sites, thrombi in false lumen and false aneurysm formation. Sensitivity and specificity calculations suspect as group II patients were not suspected of having dissection and 16 patients had intraoperative TEE. 3
24. Laissy JP, Blanc F, Soyer P, et al. Thoracic aortic dissection: diagnosis with transesophageal echocardiography versus MR imaging. Radiology. 1995;194(2):331-336. Observational-Dx 41 patients Retrospective study to compare TEE and MRI in diagnosis of dissection of thoracic aorta. Imaging results compared at independent double-blind readings. MRI depicted intimal flap in 95% ADs; TEE in 86% (P<0.05). Sensitivity for MRI for detection of residual dissection 100% vs 86% with TEE. Inferior extent dissection seen only with MRI. MRI superior to TEE in follow-up thoracic AD. However, because of limited MRI availability, TEE should remain standard modality for diagnosis. 2
25. Nienaber CA, von Kodolitsch Y, Nicolas V, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med. 1993;328(1):1-9. Observational-Dx 110 patients Comparative study to assess reliability and safety of TTE, single plane TEE, contrast enhanced CT and MRI as compared to contrast angiography in patients with clinically suspected AD. MRI, TEE and x-ray CT have similar sensitivities for detecting dissection; 98.3%, 97.7% and 93.8% respectively. Specificities of both TTE (83%) and TEE (76.9%) were lower than those of CT (87.1%) and MRI (97.8%) mainly as a result of false positive findings in the ascending aorta. A noninvasive diagnostic strategy using MRI and TEE in unstable patients should be considered optimal approach to dissection of thoracic aorta. 1
26. Sommer T, Fehske W, Holzknecht N, et al. Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging. Radiology. 1996;199(2):347-352. Observational-Dx 49 patients Prospective study to compare usefulness of spiral CT, multiplanar TEE and MRI in the diagnosis of thoracic AD and arch vessel involvement. Sensitivity in detection thoracic AD was 100% for all techniques, specificity 100%, 94% and 94% for spiral CT, multiplanar TEE and MRI, respectively. For assessment of aortic arch vessel involvement, sensitivity 93%, 60% and 67% respectively and specificity was 97%, 85%, and 88% respectively. In the assessment of the supra aortic branches, spiral CT is superior (P<.05). 2
27. Sailer AM, van Kuijk SM, Nelemans PJ, et al. Computed Tomography Imaging Features in Acute Uncomplicated Stanford Type-B Aortic Dissection Predict Late Adverse Events. Circulation. Cardiovascular imaging. 10(4), 2017 Apr.Circ Cardiovasc Imaging. 10(4), 2017 Apr. Observational-Dx 207 patients To determine the association of clinical and imaging-based morphologic and functional features obtained during the index hospitalization with late adverse events in patients with initially uncomplicated type B aortic dissection, and to derive a model for prediction of individual risk for late adverse events. The association of CT imaging features with late adverse events was retrospectively assessed in 83 patients with acute uncomplicated Stanford type-B aortic dissection, followed over a median of 850 (IQR 247–1824) days. Adverse events were defined as fatal or non-fatal aortic rupture, rapid aortic growth (>10 mm/year), aneurysm formation (=6 cm), organ or limb ischemia, or new uncontrollable hypertension or pain. Five significant predictors were identified using multivariable Cox regression analysis: connective tissue disease (HR 2.94, 95%CI: 1.29–6.72, p=0.01), circumferential extent of false lumen in angular degrees (HR 1.03 per degree, 95%CI: 1.01–1.04, p=0.003), maximum aortic diameter (HR 1.10 per mm, 95%CI: 1.02–1.18, p=0.015), false lumen outflow (HR 0.999 per mL, 95%CI: 0.998–1.000, p=0.055), and number of intercostal arteries (HR 0.89 per n, 95%CI: 0.80–0.98, p=0.024). A prediction model constructed to calculate patient specific risk at 1, 2 and 5 years and to stratify patients into high, intermediate, and low risk groups. The model was internally validated by bootstrapping and showed good discriminatory ability with an optimism-corrected c-statistic of 70.1%. 3
28. Knollmann FD, Lacomis JM, Ocak I, Gleason T. The role of aortic wall CT attenuation measurements for the diagnosis of acute aortic syndromes. Eur J Radiol. 82(12):2392-8, 2013 Dec. Observational-Dx 1206 patients To determine if measurements of aortic wall attenuation can improve the CT diagnosis of acute aortic syndromes. The term “aortic dissection” was identified in 1206, and IMH in 124 patients’ reports. IMH was confirmed in 31 patients, 21 of whom had both unenhanced and contrast enhanced images. All 21 had pathologic CTA findings, and no CTA with IMH was normal. Attenuation of the aortic wall was greater than 45 HUs on the CTA images in all patients with IMH. When this threshold was applied to the new group, sensitivity for diagnosing AAS was 100% (19/19), and specificity 94% (16/17). Addition of unenhanced images did not improve accuracy. 3
29. Moral S, Cuellar H, Avegliano G, et al. Clinical Implications of Focal Intimal Disruption in Patients With Type B Intramural Hematoma. Journal of the American College of Cardiology. 69(1):28-39, 2017 Jan 03. Observational-Dx 43 patients To evaluate the short- and long-term evolution of medically treated patients with type B intramural hematomas (IMH) with and without focal intimal disruption (FID). There were 43 patients (40%) who developed an FID with larger basal maximum aortic diameter and hematoma thickness. Patients with acute FID had a higher risk of aorta-related events than those without FID (hazard ratio: 24.43; 95% confidence interval: 7.65 to 78.04; p < 0.001). Of the 94 discharged patients, 33 (35%) developed an FID within the first 6 months of follow-up: 19 evolved with mild (<1 mm/year), 8 with moderate (1 to 2 mm/year), and 6 with severe (>2 mm/year) aortic enlargement. Chronic FID was not associated with aorta-related events (hazard ratio: 0.98; 95% confidence interval: 0.22 to 4.34; p = 0.987). 2
30. Cho KR, Stanson AW, Potter DD, Cherry KJ, Schaff HV, Sundt TM, 3rd. Penetrating atherosclerotic ulcer of the descending thoracic aorta and arch. J Thorac Cardiovasc Surg 2004;127:1393-9; discussion 99-401. Observational-Dx 105 patients To review the clinical behavior of penetrating atherosclerotic ulcers of the aorta is controversial during a 25 year interval. One hundred five patients with penetrating atherosclerotic ulcers of the descending thoracic aorta or arch with (n = 85) or without (n = 20) associated intramural hematoma were confirmed. Two patients with ulcers in the ascending aorta were excluded. There were 73 men and 32 women with a mean age of 72 +/- 9 years. Comorbidities included hypertension in 97 (92%), tobacco use in 81 (77%), and coronary artery disease in 48 (46%). Of nonoperated patients with follow-up studies, the mean thickness of the intramural hematoma decreased at 1 month in 89% and completely resolved at 1 year in 85%. There were 3 deaths (4%) within 30 days among 76 patients treated medically and 6 deaths (21%) among 29 patients treated surgically (P <.05). Failure of medical therapy defined as surgery or death was predicted by rupture at presentation (odds ratio = 20.6) and era of treatment (before 1990, odds ratio 9.9) but not aortic diameter, ulcer size, or extent of hematoma. 3
31. McMahon MA, Squirrell CA. Multidetector CT of Aortic Dissection: A Pictorial Review. [Review] [64 refs]. Radiographics. 30(2):445-60, 2010 Mar. Review/Other-Dx N/A To review the benefits of MDCT of AD. Modern MDCT is a fast, widely available imaging modality with high sensitivity and specificity. MDCT allows the early recognition and characterization of AD as well as determination of the presence of any associated complications, findings that are essential for optimizing treatment and improving clinical outcomes. 4
32. Rogg JG, De Neve JW, Huang C, et al. The triple work-up for emergency department patients with acute chest pain: how often does it occur?. J Emerg Med. 40(2):128-34, 2011 Feb. Observational-Dx 622 patients To measure the degree of overlap and diagnostic yield for evaluations of acute coronary syndrome, pulmonary embolism, and AD among emergency department patients. Over a 2-week period, 626 patient encounters among 622 unique patients were identified. Among these 626 visits, 139 (22%) included diagnostic tests for more than 1 of the 3 diagnoses of interest. The majority of these multiple tests were for acute coronary syndrome plus pulmonary embolism (n = 121, 87% of all multiple tests), whereas a minority of patients received tests for acute coronary syndrome plus AD (n = 14, 10% of all multiple tests) or for the “triple workup” of acute coronary syndrome plus pulmonary embolism plus AD (n = 4, 2.9% of all multiple tests). 4
33. Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain and possible acute coronary syndrome. Radiology. 2009;252(2):332-345. Review/Other-Dx N/A To evaluate triple-rule-out CTA for the evaluation of acute chest pain and possible acute coronary syndrome. Triple-rule-out CTA can provide a cost-effective evaluation of the coronary arteries, aorta, pulmonary arteries, and adjacent intrathoracic structures for the patient with acute chest pain. Triple-rule-out CTA is most appropriate for the patient who is judged to be at low-risk to intermediate-risk for acute coronary syndrome and whose symptoms may also be attributed to acute pathologic conditions of the aorta or pulmonary arteries. When performed with appropriate attention to timing and technique, triple-rule-out CTA provides coronary image quality equal to that of dedicated coronary CTA and pulmonary arterial images that are free of motion artifact related to cardiac pulsation. In an appropriately selected emergency department patient population, triple-rule-out CT can safely eliminate the need for further diagnostic testing in over 75% of patients. 4
34. Rubin GD. MDCT imaging of the aorta and peripheral vessels. Eur J Radiol. 2003;45 Suppl 1:S42-49. Review/Other-Dx N/A To describe how MDCT technology has substantially improved imaging of the aorta and peripheral vessels. Discusses advantages of MDCT for evaluating a variety of aortic pathologies including AD. Discusses strengths and limitations of TEE, CT and MRI in AD and makes recommendations on efficient use of MDCT. 4
35. Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. [Review] [27 refs]. Arch Intern Med. 166(13):1350-6, 2006 Jul 10. Meta-analysis 1,139 patients from 16 studies Systematic review of the diagnostic accuracy of imaging techniques: TEE, CT, MRI in patients with suspected thoracic AD. TEE, HCT, and MRI, yield clinically equally reliable diagnostic values for confirming or ruling out thoracic AD. M
36. Krishnam MS, Tomasian A, Malik S, Desphande V, Laub G, Ruehm SG. Image quality and diagnostic accuracy of unenhanced SSFP MR angiography compared with conventional contrast-enhanced MR angiography for the assessment of thoracic aortic diseases. Eur Radiol. 20(6):1311-20, 2010 Jun. Observational-Dx 50 patients To determine the image quality and diagnostic accuracy of 3-D unenhanced SSFP MRA for the evaluation of thoracic aortic diseases. Abnormal aortic findings, including aneurysm (n = 47), coarctation (n = 14), dissection (n = 12), aortic graft (n = 6), IMH (n = 11), mural thrombus in the aortic arch (n = 1), and penetrating aortic ulcer (n = 9), were confidently detected on both datasets. Sensitivity, specificity, and diagnostic accuracy of SSFP MRA for the detection of aortic disease were 100% with contrast enhanced-MRA serving as a reference standard. Image quality of the aortic root was significantly higher on SSFP MRA (P<0.001) with no significant difference for other aortic segments (P>0.05). Signal-to-noise ratio and contrast-to-noise ratio values were higher for all segments on SSFP MRA (P<0.01). 3
37. Pereles FS, McCarthy RM, Baskaran V, et al. Thoracic aortic dissection and aneurysm: evaluation with nonenhanced true FISP MR angiography in less than 4 minutes. Radiology. 2002;223(1):270-274. Observational-Dx 29 patients To retrospectively evaluate single-shot true FISP and cine true FISP MR imaging of the thoracic aorta for the diagnosis of aortic dissection or aneurysm. Nonenhanced true fast imaging with steady-state precession MRI alone was 100% accurate for determining the presence or absence of dissection or aneurysm. 3
38. Barron DJ, Livesey SA, Brown IW, Delaney DJ, Lamb RK, Monro JL. Twenty-year follow-up of acute type a dissection: the incidence and extent of distal aortic disease using magnetic resonance imaging. J Card Surg. 1997;12(3):147-159. Observational-Dx 87 patients To report findings of 20-year follow-up in patients who have undergone surgical repair of type A dissection with all survivors undergoing MRI. For dissection extending beyond arch, the choice of surgical technique does not prevent persistence of a distal false lumen. MRI gives ideal assessment of distal aortic disease and provides surgeon with all necessary information to plan timing and indications for further surgery. 3
39. Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA. Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N Engl J Med. 1993;328(1):35-43. Review/Other-Dx N/A To discuss the strengths, weaknesses and relative merits of the 4 imaging techniques: CT, echocardiography (especially TEE), MRI, and angiography available for evaluating patients with suspected AD. MRI and TEE are the most sensitive studies. Specificity of aortography CT and MRI quite high, but TEE specificity high only when strict definition is positive study applied. Selection of imaging technique depends on hospital resources. 4
40. Nienaber CA, Spielmann RP, von Kodolitsch Y, et al. Diagnosis of thoracic aortic dissection. Magnetic resonance imaging versus transesophageal echocardiography. Circulation. 1992;85(2):434-447. Observational-Dx 53 consecutive patients To prospectively assess reliability of ECG triggered MRI and monoplanar TEE for diagnosis of AD. Patients were subjected to a protocol in random order; imaging results were compared and validated against “gold standard” of intraoperative findings (n=27), necropsy (n=7), and/or contrast angiography (n=53). Both MRI and monoplanar TEE had sensitivity of 100%. TEE had lower specificity of 68% vs 100% for MRI resulting mainly from false positive findings confined to ascending segment of aorta. 3
41. Eyler WR, Clark MD. Dissecting aneurysms of the aorta: roentgen manifestations including a comparison with other types of aneurysms. Radiology. 1965;85(6):1047-1057. Review/Other-Dx 46 cases of dissecting aneurysms, 34 cases of arteriosclerotic, luetic, thoracic aneurysms Comparison of radiographic findings in patients with AD and other types of aneurysms. Radiographic and angiographic manifestations in a series of 46 patients with dissecting aneurysm of the aorta reviewed and classified. Classification can be radiographic changes on radiographs or on contrast studies. 4
42. Lovy AJ, Bellin E, Levsky JM, Esses D, Haramati LB. Preliminary development of a clinical decision rule for acute aortic syndromes. American Journal of Emergency Medicine. 31(11):1546-50, 2013 Nov. Observational-Dx 1,465 patients To explore whether history, physical examination, and simple diagnostic tests can be used to establish pretest probability for acute aortic syndrome (AAS) in emergency department (ED) patients. Of the patients who underwent CT, 2.7% (40/1465) had an AAS; 2 additional cases were diagnosed after admission (ED miss rate, 5% [2/42]). Patients with AAS were significantly older than controls (66 vs 59 years; P = .008). Risk factors included abnormal chest radiograph (sensitivity, 79% [26/33]; specificity, 82% [113/137]) and acute chest pain (sensitivity, 83% [29/35]; specificity, 71% [111/157]). None of the 19 patients with resolved pain upon ED presentation had AAS. These data support a 2-step rule: first screen for ongoing pain; if present, screen for acute chest pain or an abnormal chest radiograph. This approach achieves a 54% (84/155) reduction in CT usage with a sensitivity for AAS of 96% (95% confidence interval, 89%-100%), negative predictive value of 99.8% (99.4%-100%), and a false-negative rate of 1.7% (1/84). 3
43. Adachi H, Omoto R, Kyo S, et al. Emergency surgical intervention of acute aortic dissection with the rapid diagnosis by transesophageal echocardiography. Circulation. 1991;84(5 Suppl):III14-19. Observational-Dx 45 patients Evaluate rapid diagnosis and emergency surgical intervention of AAD by biplanar TEE. Sufficient information for surgery obtained with bedside TEE (uniplane and biplane) with 98% of patients diagnosed accurately without aortography. 3
44. Keren A, Kim CB, Hu BS, et al. Accuracy of biplane and multiplane transesophageal echocardiography in diagnosis of typical acute aortic dissection and intramural hematoma. J Am Coll Cardiol 1996; 28(3):627-636. Observational-Dx 112 consecutive patients To evaluate the diagnostic accuracy of biplane and multiplane TEE in patients with suspected aortic dissection, including IMH. Biplane and multiplane TEE are highly accurate for prospective identification of the presence and site of aortic dissection, its ancillary findings and major complications in a large series of patients with varied aortic pathology. IMH carries a high complication rate and should be treated identically with aortic dissection. 3
45. Omoto R, Kyo S, Matsumura M, et al. Evaluation of biplane color Doppler transesophageal echocardiography in 200 consecutive patients. Circulation. 1992;85(4):1237-1247. Observational-Dx 200 consecutive patients To evaluate the clinical applicability and advantages of biplane images of the heart using a biplane TEE probe. Both transverse and longitudinal scans allowed correct identification of true and false lumina in all 30 AD examinations but longitudinal scans were superior in detecting types I and III entry sites. Longitudinal images increased acoustic window of the heart. 3
46. Willens HJ, Kessler KM. Transesophageal echocardiography in the diagnosis of diseases of the thoracic aorta: part 1. Aortic dissection, aortic intramural hematoma, and penetrating atherosclerotic ulcer of the aorta. Chest. 1999;116(6):1772-1779. Review/Other-Dx 1 patient Cased-based review to focus on the use of TEE in the acute aortic syndrome (AD, aortic IMH and penetrating atherosclerotic ulcer) of the aorta. Discusses the strengths and weaknesses of monoplane and biplane TEE in particular the problems with both in the assessment of the ascending aorta. Suggests use of TEE-derived M-mode echocardiography may help to distinguish reverberation artifacts originating from posterior wall of the aorta or right pulmonary artery and to differentiate these artifacts from dissection. 4
47. Agricola E, Slavich M, Bertoglio L, et al. The role of contrast enhanced transesophageal echocardiography in the diagnosis and in the morphological and functional characterization of acute aortic syndromes. The International Journal of Cardiovascular Imaging. 30(1):31-8, 2014 Jan.Int J Cardiovasc Imaging. 30(1):31-8, 2014 Jan. Observational-Dx 66 non-consecutive patients. To evaluate the role of contrast transesophageal echocardiography (cTEE) in the diagnostic characterization of acute aortic syndromes (AAS) [aortic dissection, intramural hematoma, penetrating ulcer] Standard TEE correctly diagnosed aortic dissection in 20/22 (91%) and cTEE in 22/22 (100 %) (P = 0.5) cases. cTEE was superior than standard TEE in the visualization of false lumen entry tear (22/22 vs. 16/22, P = 0.03). Standard TEE correctly diagnosed intramural hematoma in 11/15 and cTEE 15/15 (P = 0.12) cases. Microtears were identified in 3 patients by cTEE an in 1 patient by standard TEE (P = 0.4). The presence of focal contrast enhancement was identified in 4 and 0 patients by cTEE and standard TEE respectively (P = 0.06). Both standard and cTEE correctly diagnosed penetrating aortic ulcer in 11/11 (100%) (P = 1.0) cases. cTEE provides additional value over standard TEE in the diagnosis and in the anatomic and functional characterization of AAS. 3
48. Erbel R, Engberding R, Daniel W, Roelandt J, Visser C, Rennollet H. Echocardiography in diagnosis of aortic dissection. Lancet. 1989;1(8636):457-461. Observational-Dx 164 consecutive patients Multicenter study to measure sensitivity, specificity and predictive value of echocardiography including TEE in diagnosis AD. Echocardiography had sensitivity of 99% and specificity of 98% with PPV of 98% and NPV of 99%. CT had sensitivity of 83% and specificity of 100%, with PPV of 100% and NPV of 86%. Aortography had sensitivity of 88% and specificity of 94% with PPV of 96% and NPV of 84%. 3
49. Evangelista A, Avegliano G, Aguilar R, et al. Impact of contrast-enhanced echocardiography on the diagnostic algorithm of acute aortic dissection. Eur Heart J. 2010;31(4):472-479. Observational-Dx 128 consecutive patients To determine the usefulness of contrast echocardiography in the diagnosis of AD and in the assessment of findings necessary for adequate patient management. Sensitivity and specificity of conventional TTE increased after contrast enhancement from 73.7% to 86.8% (P<0.005) and 71.2% to 90.4% (P<0.05), respectively. Sensitivity and specificity of enhanced TTE was similar to conventional TEE in ascending aorta (93.3% vs 95.6% and 97.6% vs 96.4%, respectively) and in the arch (88.4% vs 93.0% and 95.3% vs 98.82%, respectively). Contrast-enhanced TEE permitted the location of nonvisualized entry tear in 7 cases (10.6%), helped to correctly identify the true lumen in 6 (9.1%), and diagnosed retrograde dissection in 9 (13.6%). Contrast enhancement substantially improves TTE in the diagnosis of AD and should be considered as the initial imaging modality in the emergency setting. Contrast enhancement also has significant value for obtaining critical morphological and haemokinetic information by TEE useful for adequate patient management. 2
50. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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