Latest / European Society for Vascular Surgery / ESVS 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases - Part 3

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ESVS 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases - Part 3 · European Society for Vascular Surgery

• 0:08
  Hello and welcome back to the ESVS podcast. This
• 0:10
  is Suzanne Stokmans and you are listening to
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  part three of the Q &A series on the ESVS 2026
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  clinical practice guidelines on the management
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  of descending thoracic and thoraco -abdominal
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  aortic diseases. In this episode, we'll focus
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  on the final sections of the guideline, which
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  deal with rupture, trauma and post -operative
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  complications. These are scenarios where decisions
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  are often made under time pressure. Evidence
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  is limited and outcomes can be profoundly affected
• 0:33
  by organization of care, experience and judgment.
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  I'm very pleased to once again be joined by Professor
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  Wanhainen, Dr. Fernandez-Prendes and Professor
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  Katsargyris. Let's start with ruptured descending
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  thoracic and thoracopneumonoaortic disease. These
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  are among the most challenging situations we
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  face with high mortality and very limited randomised
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  evidence. Across this section, the guideline
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  consistently favours an endovascular first approach
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  whenever feasible, largely based on observational
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  data and expert consensus. From the committee's
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  perspective, what are the key factors that should
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  drive decision making in the acute setting when
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  managing rupture? and where do you think outcomes
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  can still be most improved in daily practice?
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  Decision -making and ruptured descending and
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  tracheo -abdominal aortic is a time -critical
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  and multifactorial risk -benefit assessment rather
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  than a purely anatomical or technical issue.
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  Outcome depends as much on the organisation and
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  patient physiology as on the repair technique
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  itself. So hemodynamic status is a primary factor
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  to consider. states whether there is time for
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  transfer and planning or whether immediate intervention
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  is required. And when feasible, rapid transfer
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  under permissive hypotension to a high -volume
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  aortic centre for definitive management is the
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  preferred strategy. Endovascular first approach
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  requires rapid CTA to assess anatomical suitability
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  and guide planning, including defining the extent
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  and complexity of the repair. And in highly complex
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  anatomies, damage... control or stay strategy
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  may be appropriate. These scenarios place a substantial
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  demand on the receiving aortic centre, requiring
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  immediate access to the full spectrum of surgical
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  and endovascular technique, experienced teams
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  available 24 -7, and a multidisciplinary support.
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  Finally, patient -specific factors, including
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  age, frailty, and comorbidity, are critical in
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  determining whether intervention is appropriate
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  or not and selecting the optimal treatment strategy.
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  So in summary, successful management is fundamentally
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  determined by two key factors, appropriate patient
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  selection and treatment at centres with sufficient
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  experience and resources. Like you just said,
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  patient selection is very important. Even with
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  an endovascular first approach, not all patients
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  with rupture will benefit from intervention.
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  In daily practice, which clinical or anatomical
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  factors should prompt caution or even a decision
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  not to intervene? And how does the guideline
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  address the concept of fertility in this setting?
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  The guideline clearly states that intervention
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  is not universally appropriate in all patients
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  with rupture. So decision -making must incorporate
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  and assess the potential benefit versus futility,
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  recognizing that some patients are unlikely to
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  survive or gain meaningful benefit despite a
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  technical successful repair. So clinical factors
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  that should prompt caution include profound hemodynamic
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  instability, for example, shock, cardiac arrest,
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  or need for CPR, severe metabolic derangement,
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  for example, acidosis or elevated lactate, advanced
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  frailty with limited physiological reserve, and
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  established or evolving multi -organ failure.
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  Anatomical and technical factors may also limit
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  benefits, particularly when repair becomes disproportionately
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  complex and the time and physiological burden
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  required to achieve technical success exceeds
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  what the patient can talk about. In summary,
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  an endovascular first strategy does not necessarily
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  mean to treat all. The central question is not
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  if this can be repaired, but will this patient
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  benefit from repair? And accordingly, not all
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  patients with rupture should undergo intervention.
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  And the decision -making should consider both
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  the likelihood of survival beyond the immediate
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  perioperative phase and the probability of a
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  meaningful recovery with an acceptable quality
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  of life. And outcomes of the rupture appear to
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  be strongly influenced by organism. From the
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  committee's perspective, where can systems of
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  care still be improved most to reduce mortality
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  in ruptured thoracic aortic disease? From the
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  writing committee's perspective, I think the
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  greatest opportunity to reduce mortality in ruptured
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  cases lies in improving systems of care rather
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  than refining technical details alone. This means
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  ensuring that the right patient the right centre
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  without delay. So the guideline places large
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  emphasis on service standard, aortic networks,
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  centre volume, and 24 -7 resources, reflecting
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  the view that outcome after rupture are often
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  determined before the procedure begins. In practice,
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  the greatest potential for improvement lies in
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  streamlining regional referral patterns, of course,
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  early diagnosis and fast imaging, and transfer
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  decentralisation to experience aortic centre
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  and guarantee around -the -clock access to both
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  endo and open expertise, including bailout options.
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  Key practical implication of the endovascular
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  first strategy is that rupture pathway must be
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  supported by predefined stock strategies and
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  procedural algorithm, ensuring that treatment
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  is not delayed. This is particularly critical
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  in complex diseases where technical success depends
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  on immediate access to a range of devices and
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  technical solutions rather than a single standard
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  option. And while rupture is often the result
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  of underlying aortic disease, the guideline also
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  addresses thoracic aortic injury in a very different
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  context, trauma. Management here is driven not
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  only by the aortic lesion itself, but also by
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  injury mechanism, associated trauma and timing.
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  Several classification systems have been proposed
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  for blunt thoracic aorta injury. A guideline
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  recommends use of ESVS classification, which
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  closely aligns with the SVS and Harborview systems
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  to improve consistency and report the latest
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  non -thoracic or tick injury classification aligns
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  also with the ESVS classification that was published
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  in the trauma guidelines in 2025. With grade
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  1 corresponding to partial wall injury with a
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  normal external wall contour. Two means complete
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  wall injury with an abnormal external wall contour
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  and or a contained bleeding. And grade three
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  denotes a complete wall injury or uncontained
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  hemorrhage. Management of blunt thoracic aortic
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  injury really comes down to two things, the grade
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  of the aortic injury and then the overall trauma
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  context. Like in all trauma, the guiding principle
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  is to treat what is most severe, so what kills
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  first. The classification system matters because
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  it directly affects the prognosis and the management.
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  With low -grade injuries having an aortic -related
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  mortality of around 1%, whereas high -grade injuries
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  can approach 15 % to 20 % or even higher. The
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  recommendation is that for grade 1 injuries,
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  they can typically be managed conservatively
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  with blood pressure control and heart rate control
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  and close imaging surveillance. For grade 2 injuries,
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  things come a little bit more nuanced. These
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  patients are going to be candidates for endovascular
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  repair, but the timing is a little bit more flexible.
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  So if the patient is stable and has other significant
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  injuries associated, it can be reasonable to
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  delay repair and prioritise other life -threatening
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  issues. On the other hand, if there are high
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  -risk features or no competing injuries, earlier
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  intervention could also be appropriate. And for
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  grade 3 injuries, those patients with uncontained
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  haemorrhage, then that's an indication for urgent.
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  repair with T -bar. The guideline emphasizes
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  injury grading and hemodynamic stability to guide
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  timing of intervention, often favouring delayed
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  repair in stable patients. How should clinicians
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  balance the risk of delayed treatment against
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  competing traumatic injuries in polytrauma patients?
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  This is a really important question and this
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  is specifically or most importantly going to
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  affect those grade 2 injuries. You know, some
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  of the reasons for delaying repair is that you
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  can stabilise the patient a little better, you
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  can address other life -threatening injuries
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  and also have a little bit more time to plan
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  the intervention. But this only works if it's
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  sort of a non-high-risk lesion. What the guideline
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  mentions as high-risk features are potential
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  hypotension, large mediastinal hematoma or a
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  left hemotorax, a large pseudoaneurysm, signs
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  of impending rupture. And if those are present,
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  particularly, as I mentioned, in grade two injury,
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  then earlier TVAR is usually safer. Whereas if
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  you don't have any of those high-risk features,
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  then a more delayed intervention may be more
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  appropriate. And beyond trauma, the guideline
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  also devotes a dedicated section to postoperative
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  complications following both open and endovascular
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  repair. Complications that often require long
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  -term surveillance and re -intervention. The
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  guideline provides detailed recommendations on
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  the management of endoleaks after TVAR, again,
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  largely based on level C evidence. In practice,
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  which endoleak type should prompt early re -intervention
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  and where is careful observation still appropriate?
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  Thank you for the question. and actually direct
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  type 1 and 3 endoleaks after thoracic or thoracobdominal
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  endovascular repair should be considered for
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  intervention mainly. Now, indirect type 2 endolics
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  can be observed, especially if we have a good
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  proximal and distal ceiling zone. However, upon
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  large aneurysm progression, more than 1 cm, we
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  may consider to intervene also for this type
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  2 endolics, especially if we fear that the further
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  progression of the aneurysm may compromise our
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  proximal and distal sealing zones. Having said
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  that, I would like to highlight also a new recommendation,
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  which actually suggests that if we have a compromised
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  or inadequate loading zone, even without a visible
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  endolic, we may consider to do an intervention
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  to improve sealing in these cases. And this is
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  something we need to keep in mind, I think. Another
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  post -operative complication that receives specific
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  attention in the guideline is distal standcraft
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  -induced new entry, or D -CINE. Recommendation
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  102, a new class 2a level C recommendation, states
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  that DCNA should be considered for re -intervention
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  with distal endograft extension. Given that reported
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  incident rates vary widely and that most evidence
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  comes from retrospective series, how should clinicians
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  recognise DCNA early and which patient do you
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  consider to be at highest risk in daily practice?
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  Indeed, the DCNA is a new, so to say, entity
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  that points a lot of attention lately. Well,
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  I would say that patients after DVAR or or frozen
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  elephant trunk procedures, landing in a descending
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  thoracic aorta should certainly have a close
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  follow -up to exclude the existence of distal
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  sine. Patients with excessive distal or resizing
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  seem to be at a higher risk for this complication,
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  and also patients with genetic autopathies may
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  be at the same time at a higher risk due to increased
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  aortic role and fragility. Another important
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  factor to consider is the choice in the anatomy
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  of the distal landing zone, meaning that we should
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  avoid landing in a curved or an angulated part
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  of the descending thoracic aorta since the rigid
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  end of the stent graft pressing against the outer
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  curve of the angulated aorta may cause significant
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  biomechanical stress at the aorta and cause a
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  new DCN. Now patients with all these characteristics
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  as described above may be at a higher risk of
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  DCN and should be closely followed. Now which
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  patients do they really need treatment I would
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  say that this scene should be considered for
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  intervention, especially in cases of a false
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  luminary perfusion with new onset of symptoms,
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  in cases of sac expansion, malperfusion, or a
• 12:28
  contained rupture, obviously. Across multiple
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  chapters, the guideline consistently recommends
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  long -term, often lifelong, clinical and imaging
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  follow -up of the thoracic and thoracic abdominal
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  aortic repair. Given the burden this places on
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  both patients and healthcare systems, how should
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  clinicians individualise follow-up strategies
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  while maintaining patient safety? Well as discussed
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  before also follow -up of all these patients
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  is mandatory given that mid -term and long -term
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  complications may appear due to progression of
• 12:56
  disease but also due to other causes as well.
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  So clearly we need to try to individualise the
• 13:02
  follow -up of our patients depending on the pathology
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  initially treated, the genetic background, the
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  type of treatment and the life expectancy obviously
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  of all these patients. There is a certainly no
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  gold rule here, but obviously we can be more
• 13:17
  relaxed, so to say, for a patient that received
• 13:21
  a short TVAR for a blunt aortic trauma and the
• 13:24
  aorta is now completely healed some years after
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  the procedure. But if we have a case that has
• 13:30
  a genetic autopathy, there we need to be strict
• 13:33
  and have a closer follow -up. Now, it's also
• 13:36
  important to consider MRA as an alternative imaging
• 13:40
  modality whenever possible in order to reduce
• 13:43
  the burden of radiation. And also something that
• 13:45
  I really find very useful in my clinical practice
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  is to try to have also low -dose protocol of
• 13:52
  CTA. This can be done in close collaboration
• 13:54
  with the radiologists and the radiology technicians
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  and they can help us have a nice image quality
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  with not so much contrast use. And to conclude,
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  the guideline also addresses a number of rarer
• 14:06
  and more complex conditions, including genetic
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  aortopathies, inflammatory and infectious aortic
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  disease. For this rare conditions, recommendations
• 14:13
  are almost exclusively based on expert consensus.
• 14:17
  How should clinicians approach decision -making
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  in these patients and what role do multidisciplinary
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  teams and referral to specialised centres play
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  according to the guideline? Well, a central recommendation
• 14:26
  is that these patients should be managed within
• 14:29
  a multidisciplinary framework involving vascular
• 14:32
  surgeons, cardiologists, radiologists, geneticists,
• 14:36
  infection disease specialists, and other relevant
• 14:38
  disciplines as appropriate. This approach, we
• 14:41
  believe, is essential to address the complexity
• 14:44
  of the underlying disease, procedural risk, and
• 14:47
  long -term management. Furthermore, the guidelines
• 14:49
  strongly support referral to specialised high
• 14:52
  -volume centres with specific expertise in these
• 14:55
  rare conditions. So, concentration of care is
• 14:58
  considered critical to optimise outcome, ensure
• 15:01
  access to advanced diagnostic and treatment options,
• 15:05
  and also facilitate participation in registries
• 15:08
  and in collaborative research efforts. So in
• 15:11
  summary, for rare and complex disease, the combination
• 15:14
  of multidisciplinary evaluation, centralisation
• 15:17
  to expert centres, and careful individualised
• 15:20
  decision -making forms the cornerstone of high
• 15:23
  -quality care in the absence of robust evidence.
• 15:26
  And looking across this final part of the guideline,
• 15:28
  many recommendations still rely on level C evidence.
• 15:31
  If you personally had to prioritise one unanswered
• 15:33
  question for the next guideline update, what
• 15:35
  would it be? Overall, I believe the most urgent
• 15:38
  unresolved issue is to indicate for repair. Several
• 15:41
  high quality studies on the role of T -bar in
• 15:45
  uncomplicated tapida section are ongoing and
• 15:48
  I really look forward to the results, but also
• 15:51
  the optimal size threshold for intervention in
• 15:53
  descending and thoracoabdominal aortic aneurysm
• 15:56
  and how maybe additional factors can be integrated
• 15:59
  into a more patient -centered decision -making
• 16:02
  framework. I definitely agree, Anders. I think
• 16:05
  those are incredibly relevant and important things.
• 16:09
  that we hopefully will have more information
• 16:12
  on in the next edition of the guidelines. And
• 16:15
  then another thing that I've sort of been working
• 16:17
  on is specific differences that may play a role
• 16:21
  in between men and women, including, as Anders
• 16:25
  said, indications and size thresholds, rupture
• 16:28
  risk, mortality risk, and so on. So I hope that
• 16:31
  we will also have some more information in that
• 16:33
  regard in the next coming update. Yeah, and I
• 16:36
  couldn't also agree more with Anders particularly.
• 16:38
  for the acute dissection patients, we really
• 16:41
  have a very low level of evidence. And hopefully
• 16:44
  we will be able to have some more evidence in
• 16:47
  the next guidelines. But I think overall, my
• 16:50
  feeling is maybe with the exception of female
• 16:53
  patients, but overall, I suspect that we over
• 16:56
  -treat patients, mostly because of the minimal
• 16:59
  invasive endovascular options. then we can treat
• 17:02
  basically anyone. But the question is, do they
• 17:05
  need treatment? That is my biggest thing that
• 17:08
  I'm looking forward to in the future, to better
• 17:10
  sort of define or find the correct patient for
• 17:14
  treatment. That brings us to the end of this
• 17:16
  third episode, where we discussed rupture trauma,
• 17:18
  post -operative complications, and rare aortic
• 17:20
  conditions. Before we close, I would like to
• 17:23
  take a moment to reflect on the guideline as
• 17:24
  a whole. This is an exceptionally comprehensive
• 17:26
  document covering the full spectrum of descending
• 17:29
  thoracic and thoracope abdominal aortic disease
• 17:31
  in great depth. It brings together a vast body
• 17:34
  of literature, expert consensus, and practical
• 17:36
  experience. It's clear that doing justice to
• 17:38
  the entire guideline in a podcast format is simply
• 17:41
  not possible. Throughout the series, we've therefore
• 17:43
  deliberately selected a number of key themes,
• 17:46
  new recommendations, and clinically challenging
• 17:48
  areas to discuss in more detail with the aim
• 17:51
  of providing context, highlighting areas of uncertainty,
• 17:54
  and supporting decision -making in daily practice.
• 17:56
  I would strongly encourage all listeners to read
• 17:59
  the guideline in full as many important nuances,
• 18:01
  technical details and recommendations could not
• 18:04
  be covered here. I would like to sincerely thank
• 18:06
  my guests for their time, openness and thoughtful
• 18:08
  insights throughout the series. Developing such
• 18:12
  a comprehensive guideline is a tremendous effort,
• 18:14
  and we are very grateful for your work and for
• 18:16
  sharing your perspectives with us. Thank you
• 18:19
  to our listeners for joining us throughout this
• 18:21
  series. We hope these conversations will help
• 18:23
  support thoughtful, evidence -informed, and patient
• 18:25
  -centered care for this complex group of patients.
• 18:28
  For all our listeners, we will be back soon with
• 18:30
  more ESVS podcasts. Remember, you can listen
• 18:32
  to them on all channels and in the ESVS eLibrary.
• 18:35
  Please follow the ESVS LinkedIn page so you don't
• 18:38
  miss any new podcast episodes. Have a nice day.
• 18:40
  to you soon bye for now bye thank you bye and
• 18:43
  thank you so much bye thank you