Multidisciplinary teams at the heart of new guidelines on aortic disease management

Closer ties between cardiologists, cardiac surgeons and vascular surgeons will be a hallmark of the future treatment of diseases of the aorta, a leading figure behind new guidelines for the diagnosis and management of aortic disease tells Vascular News

Jointly published by the American College of Cardiology (ACC) and American Heart Association (AHA) in November 2022, the new guidelines are intended to support decision-making around diagnosis, screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease.

Building upon an earlier version of the document, last updated in 2010, the new guideline incorporates latest evidence to reflect advances in care. Central among the latest additions is a focus on multidisciplinary aortic team care to determine appropriate timing and optimal medical, endovascular and surgical therapies.

“The important thing for these guidelines is the multidisciplinary approach that was not evident in prior guidelines,” Ourania Preventza (cardiac surgeon at The Texas Heart Institute and professor of surgery at Baylor College of Medicine, Houston, USA), vice-chair of the guideline writing committee tells Vascular News. “There is a multidisciplinary aortic team that is determining the appropriate type of intervention and a shared decisionmaking approach between the patient and the providers.”

According to Preventza, this diversity of specialisms was embedded in the writing process from the offset, with the committee chaired by a cardiologist, Eric Isselbacher (Harvard Medical School, Massachusetts General Hospital, Boston, USA), alongside Preventza, a cardiac surgeon, and her fellow vice-chair, James Hamilton Black III (Johns Hopkins Medicine, Baltimore, USA), who is a vascular surgeon. Other spaces on the 26-strong writing committee were also taken, in addition to the cardiologists and to the cardiac and vascular surgeons, by cardiovascular anaesthesiologists, geneticists, and interventional radiologists.

“The thought process when we created this and assembled the committee was really to provide diverse perspectives. The only way to provide these diverse perspectives is when we include all these different specialties with specialist knowledge about therapy and diagnosis of patients with aortic disease,” Preventza adds.

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ESVS AAA guidelines alert recommends “enhanced surveillance” in patients treated with Nellix device

In a “focused update” to their 2019 recommendations, the European Society for Vascular Surgery (ESVS) abdominal aortic aneurysm (AAA) guidelines writing committee has published advice on the surveillance and management of patients treated with the Nellix endovascular aneurysm sealing ( EVAS) system (Endologix).

THE COMMITTEE ADVISES THAT ALL patients in whom a Nellix device has been implanted “should be identified, properly informed and enrolled in enhanced surveillance.” If device failure is detected, it states that “early elective device explant should be considered in surgically fit patients”.

The alert, authored by Jon Boyle (Cambridge University Hospitals NHS Trust and University of Cambridge, Cambridge, UK) et al, was published may sometimes be differing schools of thought, Preventza comments that the writing committee was fundamentally led by evidence available to guide best practice, and says that the proof that they got this right is in the fact that the document has been endorsed by a number of societies in different fields, including the American Association for Thoracic Surgery (AATS), the Society for Thoracic Surgery (STS), the Society for Vascular Surgery (SVS), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Cardiovascular Anesthesiologists (SCA) and the Society of Interventional Radiology (SIR).

“The guidelines are there to give the physicians something to base their practice on, guide them, and most importantly, to help patients and make sure that the medical and cardiovascular community have the same or similar approach which is safe and effective.”

Detailing what she sees as the formula for a multidisciplinary aortic team, Preventza says that there is no firm blueprint, rather the approach is guided by shared decision-making in the interest of the patient.

“It is really a collaboration between cardiology, vascular and cardiac [surgeons],” she comments. “For example, an abdominal aneurysm is very well treated by the vascular surgeons. Somebody with an abdominal aneurysm may also have a thoracic aneurysm, involving the ascending aorta, and this is something that has to be taken care of by a cardiac surgeon. Or, perhaps the annuli of the aortic valve or the ascending aorta is not at the size yet that needs intervention, so in this case the patient can be followed by cardiology.” online ahead of print in the European Journal of Vascular and Endovascular Surgery (EJVES)

Boyle and colleagues note that they performed a scoping review of risk for late serious aortic-related adverse events in patients treated with EVAS for AAA based on a literature search in PubMed up to 7 December 2022. Following synthesis of the available evidence, the writing committee agreed on recommendations graded according to the European Society of Cardiology (ESC) grading system.

“EVAS has a very high incidence of late endograft migration resulting in proximal type 1 endoleak with risk of rupture, requiring open conversion with device implant,” the authors write, detailing their key finding from the review. They add that the reported mortality for elective explantation varies between 0% and 14%, while acute conversion for rupture has a “very dismal prognosis” with 67–75% mortality.

The authors detail that ESVS guidelines are renewed every five years or so, and that ESVS focused updates are issued “to convey important new data that have emerged in between the publication of the full guidelines, that affect patient safety or impact decision-making or management of the patients”.

In their 2019 guidelines on the management of abdominal aortoiliac artery aneurysms, the writing

Patient-specific care is important, she adds, commenting that it is not a onesize-fits-all approach.

Other important takeaways from the revamped document include new thresholds for surgical intervention for sporadic aortic root and ascending aortic aneurysms, an updated definition for rapid aneurysm growth rate, and adjusted recommendations on when to intervene in patients who are smaller or taller than average. “The plan is that the guidelines are a living document, to be updated in the next three years,” adds Preventza. “Nobody has a crystal ball, but given the way that the field is evolving with regards to the treatment options I think it is important for us to re-evaluate and see where we are.” committee recommended that “conceptual new technologies, such as [EVAS], should only be used within studies approved by research ethics committees and with informed consent, until properly evaluated”.

Important areas to watch include the evolving field of genetics as it relates to aortic disease, further developments in the evidence in the area of endovascular intervention, and research looking at sex and socioeconomic disparities in aortic disease. “These are things that as we evolve we hope to improve, with more inclusive studies, and with advancements in technology; all of which will help us and help our patients and that is why it is important that these guidelines will be updated,” she concludes.

In May of last year, Endologix ended production of the Nellix EVAS system, based on reportedly higher rates of leaks around the device’s implantation, endograft migration and aneurysm sac enlargement. The guideline committee recognised, however, that there was no clear guidance on surveillance and management of patients who have already undergone AAA repair with an EVAS device. It was for this reason that the ESVS AAA guidelines writing committee initiated a literature review on the topic. “The current accumulated knowledge suggests that patients treated with EVAS for AAA may be at high risk for serious aorticrelated adverse events, which justified an updated guidance on the surveillance and management of patients already treated with EVAS,” they write in the new paper.

The committee note that they decided it was important to publish before the fully updated guidelines will be available in 2024, “to highlight the issues with EVAS failure, to promote patient safety and to encourage clinicians to identify all patients in whom a Nellix device has been implanted”.