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The first guidelines of the European Society of Cardiology (ESC) on the diagnosis and treatment of aortic diseases have recently been released.1 Guidelines are particularly needed in this field characterised by a diversity of aetiologies, lesions and locations, and potentially severe complications. Over the last years, there has been growing knowledge concerning the diagnostic performance of different imaging modalities and the natural history of aortic diseases. Besides surgery, endovascular interventions have widened the range of therapeutic options. Although randomised trials are scarce in this field, indications for intervention take into account recent information on the natural history and the results of interventions. ESC guidelines cover the wide spectrum of thoracic and abdominal aortic diseases; however, we will focus here on the two most frequent presentations of thoracic aortic disease, that is, acute aortic syndromes (AAS) and thoracic aortic aneurysms (TAA), referring to corresponding recommendations from the American guidelines.2
Imaging plays a key role in the diagnosis, pre-therapeutic evaluation and follow-up of aortic diseases.3 Both ESC and American guidelines consistently highlight the need for appropriate techniques and standards for measurements and reporting. Unlike the American guidelines, the ESC guidelines recommend analysis of the entire aorta at first diagnosis using CT or MRI. The choice between techniques should be based on their performance, but also on their local availability and feasibility according to the context (eg, in emergency) and on their potential to cause harm, particularly due to radiation or renal function. Therefore, MRI is preferred over CT in young patients. The consistency between the findings of different investigations should be checked, particularly when measurements or evolutive trends have an impact on decision making for intervention.
The term AAS encompasses a variety of anatomic diseases that are characterised by tears of the intima and media. Whatever the lesion, AAS …