Aortic-Size Paradox: Reducing the Threshold for Intervention Will Help to Save Some Lives but We Still Need Noah to Predict the Flood.

In this issue of Heart, Lung and Circulation, Papakonstantinou et al. [ [1] Papakonstantinou N.A. Rorris F.P. Antonopoulos C.N. Theodosis A. Argiriou M. Charitos C. Ascending aorta dissection before 5.5 cm diameter; "It wasn't raining when Noah built the Ark". Heart Lung Circ. 2023; 32: 379-386 Abstract Full Text Full Text PDF Scopus (1) Google Scholar ] propose a new guideline recommendation to lower the threshold for elective surgical intervention for non-syndromic, non-familial ascending aortic aneurysms (AsAA) to 5.0 cm. There is no doubt that their single-centre analysis aligns with the data from the International Registry of Aortic Dissection (IRAD)—that only about 60% of cases with acute type A aortic dissection had maximal aortic diameters >5.5 cm at presentation, a verdict which others have previously verified [ [2] Myrmel T. Larsen M. Bartnes K. The International Registry of Acute Aortic Dissections (IRAD) - experiences from the first 20 years. Scand Cardiovasc J. 2016; 50: 329-333 Crossref PubMed Scopus (9) Google Scholar , [3] Hagan P.G. Nienaber C.A. Isselbacher E.M. Bruckman D. Karavite D.J. Russman P.L. et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283: 897-903 Crossref PubMed Scopus (2746) Google Scholar ]. However, the majority of patients with aneurysms <5.5 cm who are treated medically do not endure aortic dissection or rupture. Therefore, surgery based on aortic size alone will prevent only a minority of aortic dissections because the diameter of the aneurysm alone is not specific enough to identify the dissection risk. Of note, guidelines for surgical intervention for AsAA have been founded mainly on expert consensus and retrospective observational studies, whereas the treatment guidelines for abdominal aortic aneurysms (AAA) are founded on extensive data and are widely accepted by the surgical community [ [4] Kent K.C. Zwolak R.M. Egorova N.N. Riles T.S. Manganaro A. Moskowitz A.J. et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 2010; 52: 539-548 Abstract Full Text Full Text PDF PubMed Scopus (485) Google Scholar ]. Ascending Aorta Dissection Before 5.5 cm Diameter; "It Wasn't Raining When Noah Built the Ark"Heart, Lung and CirculationVol. 32Issue 3PreviewThe aim of this study was to compare mean maximum ascending aortic diameter at the time of acute aortic dissection with the current surgical threshold for elective ascending aortic operations on non-syndromic thoracic aortic aneurysms. Full-Text PDF