Latest / European Society for Vascular Surgery / ESVS 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases - Part 1

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ESVS 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases - Part 1 · European Society for Vascular Surgery

• 0:10
  Hello and welcome to the ESVS podcast. This is
• 0:13
  Suzanne Stokmans and you're listening to part
• 0:15
  one of the Q&A series on the ESVS 2026 clinical
• 0:19
  practice guidelines on the management of descending
• 0:21
  thoracic and thoracoabdominal aortic diseases.
• 0:24
  In this podcast series, we will focus on the
• 0:26
  new, complex and sometimes controversial recommendations
• 0:29
  in the guideline. Not just what is recommended,
• 0:31
  but why these choices were made and how they
• 0:34
  translate into daily clinical practice. In today's
• 0:36
  episode, the first of this three -part series,
• 0:39
  we will discuss the opening section of the guideline,
• 0:41
  service standards and general considerations.
• 0:44
  Before moving to specific disease entities or
• 0:47
  operative strategies, the guideline deliberately
• 0:49
  starts with the fundamentals. How care should
• 0:51
  be organized, how patients should be assessed,
• 0:54
  and which general principles should guide our
• 0:56
  decision -making. In the upcoming episodes, we
• 0:58
  will move on to disease -specific management,
• 1:01
  including acute thoracic aortic syndromes, chronic
• 1:03
  type B dissection, degenerative aneurysmal disease,
• 1:06
  rupture and trauma, post -operative complications,
• 1:09
  and finally, some of the rarer and more complex
• 1:11
  conditions, such as genetic aortopathies and
• 1:14
  inflammatory diseases. I'm very pleased to welcome
• 1:17
  the chair of the Guideline Writing Committee,
• 1:18
  Professor Juan Heinen, together with two members
• 1:21
  of the Guideline Writing Committee. Dr. Fernandez
• 1:23
  -Prendes and Professor Katsargyris. Professor
• 1:26
  Wanhainen is professor and chair of vascular
• 1:28
  surgery at the Uppsala University Hospital in
• 1:30
  Sweden. Dr. Fernandez-Prendes is a consultant
• 1:33
  vascular surgeon also at the Uppsala University
• 1:35
  Hospital. Professor Katsargyris is a professor
• 1:39
  of vascular surgery at the University of Athens
• 1:41
  and consultant vascular surgeon in Paracelsus
• 1:44
  Medical University of Nuremberg in Germany. Congratulations
• 1:47
  on the publication of the new guideline and thank
• 1:49
  you all for taking time to join us to discuss
• 1:51
  it today. Nice to be here. Thank you for the
• 1:54
  invitation to participate in this podcast. My
• 1:56
  pleasure. This guideline is a major update of
• 1:59
  the 2017 version. The 2026 guideline includes
• 2:03
  129 recommendations, 83 of them entirely new
• 2:07
  and 33 significantly regraded or rephrased. only
• 2:11
  13 recommendations remain unchanged this reflects
• 2:14
  both the rapid evolution of the field and the
• 2:17
  broader scope of the document in total 458 new
• 2:21
  references published between 2018 and 2025 were
• 2:25
  included at the same time the overall strength
• 2:27
  of the evidence remains limited only three recommendations
• 2:30
  are supported by level a evidence five by level
• 2:33
  b while the vast majority about 94 percent are
• 2:36
  still based on level c evidence or expert consensus
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  this clearly highlights the ongoing need for
• 2:41
  robust prospective studies in descending thoracic
• 2:44
  and thoracoabdominal aortic disease. So let's
• 2:47
  start dissecting the guideline. It opens with
• 2:49
  a full chapter on service standards, which is
• 2:51
  new compared with 2017. The first four recommendations
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  clearly advocate for centralization of care,
• 2:58
  defined referral networks, prompt transfer of
• 3:01
  acute cases to specialized neurotic centers,
• 3:03
  a minimum annual case volume of 20, descending
• 3:06
  thoracic repairs, and fast track pathway for
• 3:08
  patients who meet elective size criteria. In
• 3:11
  other words, before discussing how we treat the
• 3:13
  disease, the guideline makes a very clear statement
• 3:16
  about where and by whom these patients should
• 3:18
  be treated. All four recommendations strongly
• 3:20
  promote centralization, yet they are all based
• 3:22
  on expert consensus rather than robust outcome
• 3:25
  data. Why did the committee feel confident placing
• 3:28
  such strong organizational recommendations right
• 3:30
  at the start of the document, and how should
• 3:32
  clinicians interpret and implement them in healthcare
• 3:35
  systems where this level of centralization is
• 3:37
  not yet a reality? The structure and organization
• 3:39
  of care have a direct impact on clinical outcome
• 3:43
  and are therefore I think critical elements that
• 3:46
  should be addressed in a clinical practice guideline.
• 3:49
  There is strong evidence supporting a volume
• 3:52
  outcome relationship across multiple surgical
• 3:55
  disciplines, including aortic surgery. This relationship
• 3:59
  is most evident in open aortic procedures where
• 4:02
  outcomes are closely linked to the operative
• 4:04
  performance itself, captured by early endpoints
• 4:07
  such as 30 -day mortality. In contrast, endovascular
• 4:11
  procedures are associated with lower immediate
• 4:14
  procedural risk due to the minimally invasive
• 4:17
  nature. Instead, long -term outcomes such as
• 4:20
  durability and late failures are of more importance,
• 4:24
  but they are more challenging to assess. Furthermore,
• 4:27
  many of the conditions and interventions addressed
• 4:30
  in these thoracic guidelines are highly complex
• 4:34
  and relatively uncommon. attachment within a
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  multidisciplinary framework and access to highly
• 4:40
  specialized expert teams and infrastructures.
• 4:43
  So while the fundamental principles of centralization
• 4:47
  are well supported by evidence, data defining
• 4:51
  specific thresholds for thoracic and thoracoabdominal
• 4:54
  aortic disease remain limited. Nevertheless,
• 4:57
  to provide clear and pragmatic guidance, The
• 5:01
  inclusion of definitive thresholds was considered
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  justified. That's the reason why these recommendations
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  are classified as consensus -based. And finally,
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  as with all guidelines recommendations, they
• 5:12
  should be applied whenever they are expected
• 5:15
  to benefit the individual patient. However, where
• 5:18
  deviation is considered... needed, the rationale
• 5:21
  should be clearly documented. The at least 20
• 5:24
  cases per year threshold is quite explicit. Is
• 5:27
  this meant as a strict minimum standard or more
• 5:29
  as a signal to healthcare system about the level
• 5:32
  of expertise and infrastructure required? Good
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  question. So the caseload threshold is likely
• 5:37
  to be higher than 20 in optimal settings. However,
• 5:41
  given that these guidelines are intended for
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  a pan -European context with variation in healthcare
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  systems, epidemiology and geography, we felt
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  a pragmatic and moderate threshold was considered
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  more appropriate at this stage. Accordingly,
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  these numbers should be regarded as a minimum
• 6:02
  standard to be met. The guideline then moves
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  on to recommendation 5, a class 1 level C recommendation,
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  stating that aortic centers performing descending
• 6:11
  thoracic aortic repair should enroll cases in
• 6:13
  validated prospective quality registries. This
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  again reflects a strong emphasis on transparency
• 6:19
  and continuous quality improvement. Could you
• 6:22
  explain why the committee felt it was important
• 6:24
  to explicitly recommend registry participation
• 6:26
  as part of standard care and how you see registries
• 6:29
  contributing to better decision making and patient
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  outcomes in daily practice? As you mentioned
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  in your introduction, Susanne, a fundamental
• 6:37
  challenge in the management of descending thoracic
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  and thoracic abdominal orchid disease is the
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  lack of high -quality evidence. It's a rare heterogeneous
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  disease and requires highly complex management.
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  And this limits the feasibility of large, robust
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  studies. And therefore, much of the available
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  evidence comes from single -center retrospective
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  series with a great risk of selection. and reporting
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  bias. So as you mentioned, the vast majority,
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  94 % of all recommendations are just level C
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  evidence or expert consensus. So this underscores
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  the need for prospective studies to strengthen
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  the evidence based in this field. And in this
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  context, prospective national and international
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  registries play a very important role in expanding
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  the collective knowledge and informing future
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  guideline development. The 458 new references
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  that you mentioned that was included in this
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  updated DTA guideline, 75 of those references
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  are based on vascular registries or quality improvement
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  initiative. And this highlights the growing importance
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  of registry -based data. And beyond the contribution
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  to research and new knowledge, I think registries
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  also serves as essential tools for quality assurance,
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  enabling benchmarking of performance and outcome
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  for the individual clinic. And for centres that
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  are not yet participating in registries, what
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  would you see as the first practical step? Centres
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  are strongly encouraged to join established registries,
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  regional, national or international, whatever
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  possible. Where such registries are not available,
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  the development of a structured local registry
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  should be considered as a minimum standard. And
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  I think resources such as Vasconet provide a
• 8:25
  very valuable resource for guidance and benchmarking
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  opportunities. All right, let's move on to the
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  next chapter on general consideration, starting
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  with imaging. CTA with 1 mm or smaller slices
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  is recommended as first -line imaging, extending
• 8:39
  from the supraaortic vessels to the common femoral
• 8:42
  arteries. When supraaortic vessels are involved,
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  the guideline explicitly recommends including
• 8:47
  the circle of Willis to assess stroke risk and
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  guide potential revascularization strategies.
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  In carotid surgery, however, the completeness
• 8:55
  of the circle of Willis had not proven to be
• 8:57
  a reliable predictor of stroke risk. and rarely
• 8:59
  changes management. In descending thoracic aortic
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  repair, how should we practically use this information?
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  Is it mainly supportive and anatomical information
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  or should it actively influence decisions on
• 9:10
  left subclavian artery coverage and revascularization?
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  So this was a class one recommendation, but based
• 9:16
  on consensus rather than high level evidence.
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  And I think importantly, we're treating something
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  different than carotid disease. I would say that
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  it's more about anticipating risk in specific
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  procedural scenarios where we might... need to
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  alter the cerebral inflow. So I think in thoracic
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  aortic repair, this is particularly relevant
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  when we're talking about the left subclavian
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  artery. And there are many cases where this may
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  need to be intentionally covered. Or for example,
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  if there are anatomical variants, such as an
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  independent takeoff of the left vertebral artery.
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  Also, some of these patients are going to require
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  extensive either thoracic repairs, so a full
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  endoarch or even cervical debranching. So I think
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  it's important to understand exactly what we're
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  doing and how, if we're clamping multiple supraortic
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  vessels, how this is going to affect our circulation.
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  And there are cases where it's effectively going
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  to change the surgical planning. another important
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  theme throughout this chapter is frailty the
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  guideline repeatedly emphasizes the need to consider
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  functional capacity and frailty when making treatment
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  decisions recommendation 15 a class 2a level
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  c recommendation states that multidisciplinary
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  frailty assessment should be considered for candidates
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  for elective descending thoracic aortic repair
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  the recommendation does not specify how frailty
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  should be measured nor does it endorse a specific
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  tool given the right range of available frailty
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  scores and the limited evidence How did the committee
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  approach this issue and what would you consider
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  a pragmatic and reproducible way to access frailty
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  in daily practice? Frailty was one of the key
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  themes in this section, but the challenge is
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  exactly what you mentioned, that there is no
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  validated tool specifically endorsed for a lot
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  of our vascular pathologies and even more so
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  for thoracic aortic disease. So rather than selecting
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  one, the guideline has taken a pragmatic approach,
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  emphasizing the need for multidimensional assessment.
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  including functional capacity and then some other
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  objective markers like lab works, nutritional
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  status, albumin, BMI, all of those things. And
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  the combination of this sort of multimodal approach
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  is probably going to be a much better tool than
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  just selecting one specific scale. In your opinion,
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  should frailty primarily guide how we treat patients
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  or can it also become a threshold factor for
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  deciding whether to intervene at all? I think
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  the answer is both. Frailty is going to, in some
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  way, inform how we treat a patient, whether we
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  stage a procedure or maybe choose a less invasive
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  option, or even think about optimizing the patient
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  beforehand with nutritional support and things
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  like that. But it can also become a decisive
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  factor to perhaps hold off on an intervention
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  or even take a conservative approach. Now let's
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  move on from general consideration to a very
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  practical and surgical topic, left subclavian
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  artery revascularization. Recommendation 21,
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  class 2A, level B, states that LSA revascularization
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  should be considered in patients undergoing elective
• 12:27
  TVAR with intentional left subclavian artery
• 12:29
  coverage, taking into account the risk of end
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  -organ ischemia and urgency of the procedure.
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  Given the lack of randomized data and the conflicting
• 12:37
  observational evidence, how did the committee
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  balance routine... versus selective revascularization
• 12:43
  in formulating this recommendation? Obviously,
• 12:45
  LSA coverage without revascularization during
• 12:49
  TIVA may compromise perfusion to the brain, the
• 12:52
  spinal cord, the left arm, or the myocardium,
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  especially in patients with left internal mammary
• 12:58
  artery bypass. Increasing, therefore, the risk
• 13:01
  for stroke, spinal cord ischemia, limb ischemia,
• 13:04
  and also myocardial infarction. So preemptive
• 13:07
  LSA revascularization can mitigate this risk
• 13:10
  but carries at the same time some procedural
• 13:13
  risks such as stroke, nerve injury, and infection.
• 13:16
  Up to now, there are no randomized controlled
• 13:19
  trials comparing routine versus selective versus
• 13:22
  no LSA revascularization at all. And meta -analysis
• 13:27
  of some observational studies suggest actually
• 13:30
  that revascularization reduces rates of stroke
• 13:33
  and spinal cord ischemia, but not paraplegia
• 13:37
  or death. So given the lack of strong evidence,
• 13:40
  and also this somewhat conflicting data, we decided
• 13:43
  in the committee to suggest revascularization
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  primarily in high -risk scenarios. As for example,
• 13:49
  in cases of a dominant left vertebral artery,
• 13:53
  a compromised right vertebral artery, incomplete
• 13:56
  circle of willis, lima bypass graft, left upper
• 14:00
  limb dialysis axis, and also in cases of extensive
• 14:03
  aortic coverage. So the choice between routine
• 14:07
  and selective revascularization should be individualized
• 14:10
  based on patient anatomy, urgency, and overall
• 14:14
  risk profile, I would say. And you just mentioned
• 14:17
  several high -risk scenarios, such as the dominant
• 14:19
  left vertebral artery, Lima grafts, or incomplete
• 14:22
  circle of villus. In your experience, which of
• 14:25
  these factors most strongly influences your own
• 14:27
  decision on revascularization? And are there
• 14:30
  any that you feel are sometimes overemphasized
• 14:32
  in daily practice? Well, certainly in cases of
• 14:35
  incomplete circle of willis, extensive aortic
• 14:39
  coverage that is already planned, or in the case
• 14:41
  of a lima bypass graft, I would go for LSA revascularization,
• 14:45
  especially in the elective set of elective patients.
• 14:49
  Now, for patients requiring maybe only a short
• 14:52
  TIVA, for example, that have a patent contralateral
• 14:56
  vertebral artery. And we have signs that we have
• 14:59
  a complete circle of willis. I might be more
• 15:01
  liberal to accept an LSA coverage without revascularization,
• 15:05
  especially in cases that the LSA revascularization
• 15:08
  might be associated with some increased risks
• 15:11
  for whatever reason. And now let's talk about
• 15:14
  how we should revascularize. Recommendation 22,
• 15:17
  class 2A, level C states that the choice between
• 15:19
  open and endovascular LSA revascularization during
• 15:22
  TVAR should be considered on a case -by -case
• 15:24
  basis. taking into account urgency, patient physiology,
• 15:28
  anatomy, underlying pathology, and patient preferences.
• 15:32
  In elective cases, do you see open surgical bypass
• 15:34
  still as the golden standard in terms of durability,
• 15:37
  or are branched and fenestrated endovascular
• 15:39
  solutions now your preferred option when anatomy
• 15:41
  allows? With suitable anatomy for endovascular,
• 15:44
  I would now go for an endovascular approach,
• 15:47
  with this meaning either a fenestrated or branched
• 15:50
  device, depending obviously on the anatomy and
• 15:52
  the setting. Having said that, I would not go
• 15:55
  for a parallel graft solution, certainly not
• 15:57
  in an elective situation. And this should be
• 16:00
  highlighted to my opinion. I still consider open
• 16:04
  surgical bypass as an option, but obviously nowadays,
• 16:07
  mainly in anatomies that are not really suitable
• 16:10
  or less suitable for an endovascular repair.
• 16:13
  Now let's move on to another challenging topic,
• 16:15
  spinal cord ischemia or SCI, one of the most
• 16:18
  feared complications after open and endovascular
• 16:21
  thoracobdominal aortic repair. Despite declining
• 16:24
  rates, SCI still occurs in around 2 % to 20 %
• 16:27
  of cases, particularly in the setting of extensive
• 16:29
  aortic coverage, cross -clamping, prolonged procedures,
• 16:32
  blood loss, and hypotension. Recommendation 23,
• 16:35
  class 1, level C, states that protocolized strategies
• 16:39
  for the prevention, early detection, and management
• 16:41
  of spinal cord ischemia are recommended for patients
• 16:44
  undergoing descending thoracic and thoracobdominal
• 16:46
  aortic repair. From the committee's perspective,
• 16:49
  what are the most critical elements of such a
• 16:51
  protocol, and where do you... you think centers
• 16:53
  still tend to underestimate the risk of spinal
• 16:55
  cord ischemia in daily practice? So in the context
• 16:58
  of endovascular repair, I think stage treatment
• 17:01
  is the most important strategy. It enables stepwise
• 17:05
  coverage of the spinal circulation and maybe
• 17:07
  even more important, reduces the complexity of
• 17:11
  the procedure and thereby the risk of prolonged
• 17:13
  hypotensive episodes by distributing the intervention
• 17:16
  across multiple smaller procedures. So this is
• 17:18
  critical as perioperative hypotension appears.
• 17:21
  to be one of the strongest risk factors for spinal
• 17:24
  cord ischemia, and it should therefore be rigorously
• 17:27
  prevented, and it would be occurs promptly corrected.
• 17:30
  So the final stage should be undertaken only
• 17:33
  when the patient is optimized and hemodynamically
• 17:36
  stable, and where feasible, perform the procedure
• 17:39
  under local anesthesia to allow optimal neurological
• 17:42
  monitoring. And one specific element of these
• 17:45
  protocols that has clearly evolved over time
• 17:47
  is cerebrospinal fluid drainage. While prophylactic
• 17:51
  CSF drainage remains strongly recommended for
• 17:53
  open thoracic and thoracobdominal repair, the
• 17:56
  guideline now favors a more selective rescue
• 17:58
  -based approach in extensive endovascular repair,
• 18:01
  largely because of drain -related complications
• 18:03
  and equipoison outcomes. Could you explain what
• 18:06
  drove this shift in strategy? and what you would
• 18:09
  consider a safe and pragmatic approach to CSF
• 18:11
  drainage in contemporary endovascular practice.
• 18:14
  Recent publications have highlighted the risks
• 18:17
  associated with cerebrospinal fluid drainage.
• 18:21
  with the overall risk -benefit balance increasingly
• 18:24
  arguing against its routine use. In parallel,
• 18:28
  large cohort studies have demonstrated that a
• 18:30
  restrictive selective drainage strategy has resulted
• 18:34
  in favorable outcomes, in some cases superior
• 18:37
  to those previously reported with routine prophylactic
• 18:40
  use. Taken together, this evidence led the writing
• 18:43
  committee to recommend a selective or reactive
• 18:46
  approach to cerebrospinal fluid drainage. And
• 18:49
  as you mentioned, stage repair is now strongly
• 18:52
  promoted for extensive endovascular torco -abdominal
• 18:55
  repair with convincing reductions in paraplegia
• 18:58
  and mortality. At the same time, staging delays
• 19:01
  full exclusion and may increase rupture risk.
• 19:03
  How do you personally balance these competing
• 19:05
  risks and are there specific patients in whom
• 19:08
  you would still favor a single stage approach?
• 19:10
  We have pushed the staging strategy very far
• 19:13
  and try to stage a procedure whenever feasible,
• 19:16
  typically in a three -step approach in the an
• 19:19
  initial T -bar, followed by fenestrated and branched
• 19:22
  T -bar, and finally completion with an iliac
• 19:25
  extension or a single branch. Staging is pursued
• 19:28
  even in the acute settings where clinically conditioned
• 19:31
  allows. And today, I think only in cases of frank
• 19:35
  rupture or hemodynamic instability is a single
• 19:39
  stage procedure currently performed in my center.
• 19:42
  Obviously, the interval between stages should
• 19:44
  be kept short, typically in the order of a couple
• 19:46
  or a few weeks. Great. Thank you so much for
• 19:48
  all your clear answers to these questions, because
• 19:51
  that brings us to the end of the first episode
• 19:53
  already, where we focused on the foundations
• 19:55
  of the guidelines, how care is organized and
• 19:57
  how key general principles shape decision making.
• 20:00
  In the next episode, we will move on to acute
• 20:02
  thoracic aortic syndromes and discuss how these
• 20:05
  recommendations play out in real -time clinical
• 20:07
  practice. Thank you to my guests and my listeners
• 20:10
  for being here today. Until next week. Bye. Bye.
• 20:13
  Bye. Bye.