Classification and management strategy of spontaneous carotid artery dissection.

OBJECTIVE: Spontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance. METHODS: This is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs. RESULTS: A total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P > .05). Favorable outcome was achieved in 168 patients (93.9%). CONCLUSIONS: This study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research.

Disección Aórtica Tipo A como diagnóstico diferencial potencialmente letal de dolor torácico: revisión de casos / Type A Aortic Dissection as a potentially lethal differential diagnosis of chest pain: case Review

Chest pain (CP) is a frequent reason for consultation in emergency departments (ED). It responds to a broad spectrum of pathologies, ranging from banal causes to severe conditions with high mortality. The clinician must be able to distinguish prompt when CP is due to severe pathology and thus make a timely intervention for the patient's benefit. Acute Aortic Syndrome (AAS) is one of the potentially fatal causes of CP. Within this syndrome, we find aortic dissection (AD), intramural hematoma and atherosclerotic penetrating ulcer. AD is the most frequent presentation of AAS. Although it is not a common condition, its high lethality and low suspicion make it of particular interest as a differential diagnosis of CP. The following are two clinical cases of AD of the ascending aortic treated at the Hospital Regional de Talca (HRT) to analyse the clinical characteristics that help to differentiate this condition, the main electrocardiographic and imaging findings, as well as some of its complications and management.

Application of the Type, Entry Site, and Malperfusion Classification in Treatment of Aortic Dissection.

BACKGROUND: Our goal is to investigate a new practical dissection classification system, including type of dissection, location of the tear of the primary entry, and malperfusion. METHODS: The outcome of 151 patients with aortic dissection between January 2019 and May 2020 retrospectively were analyzed. All cases were classified with the Stanford dissection classification (A and B) by adding type non-A non-B. They were then further classified by the new classification system, including location of the primary Entry (E) and Malperfusion (M). All cases were followed up for six months. RESULTS: The distribution of 151 patients was 53.0%, 27.8%, and 19.2%, respectively, in type A, B, and non-A non-B. The in-hospital mortality rate was 8.8%, 2.4%, and 3.4% in type A, B, and non-A non-B (P < 0.05) and postoperative neurological complications occurred in 33.8%, 7.1%, and 13.8% in type A, B, and non-A non-B (P < 0.05). Total arch replacement was performed in 53.8%, 4.8%, and 13.8% in type A, B, and non-A non-B. The in-hospital mortality rate was 12.0%, 10.4%, and 8.5% in type E1, E2 and E3, while it was 20.0%, 10.4%, and 8.5% in type M1, M2 and M3 (P < 0.05). CONCLUSIONS: The new practical dissection classification system is useful as a supplement to the Stanford dissection classification by regarding the extent of the disease process, aiding in decision-making about the operative indication and plan, and helping in anticipating prognosis.

Hybrid repair versus conventional open repair for aortic arch dissection.

BACKGROUND: A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known as the true lumen), but also through a second channel between the intima and media (known as the false lumen). Aortic dissection is a life-threatening condition which can be rapidly fatal. There is debate on the optimal surgical approach for aortic arch dissection. People with ascending aortic dissection have poor rates of survival. Currently open surgical repair is regarded as the standard treatment for aortic arch dissection. We intend to review the role of hybrid and open repair in aortic arch dissection. OBJECTIVES: To assess the effectiveness and safety of a hybrid technique of treatment over conventional open repair in the management of aortic arch dissection. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 8 February 2021. We also undertook reference checking for additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and clinical controlled trials (CCTs), which compared the effects of hybrid repair techniques versus open surgical repair of aortic arch dissection. Outcomes of interest were dissection-related mortality and all-cause mortality, neurological deficit, cardiac injury, respiratory compromise, renal ischaemia, false lumen thrombosis (defined by partial or complete thrombosis) and mesenteric ischaemia. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all records identified by the literature searches to identify those that met our inclusion criteria. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of the evidence using GRADE. MAIN RESULTS: We identified one ongoing study and two unpublished studies that met the inclusion criteria for the review. Due to a lack of study data, we could not compare the outcomes of hybrid repair to conventional open repair for aortic arch dissection. AUTHORS' CONCLUSIONS: This review revealed one ongoing RCT and two unpublished RCTs evaluating hybrid versus conventional open repair for aortic arch surgery. Observational data suggest that hybrid repair for aortic arch dissection could potentially be favourable, but conclusions can not be drawn from these studies, which are highly selective, and are based on the clinical status of the patient, the presence of comorbidities and the skills of the operators. However, a conclusion about its definitive benefit over conventional open surgical repair cannot be made from this review without published RCTs or CCTs. Future RCTs or CCTs need to have adequate sample sizes and follow-up, and assess clinically-relevant outcomes, in order to determine the optimal treatment for people with aortic arch dissection. It must be noted that this may not be feasible, due to the reasons mentioned.

Elephant Trunk Stent Fenestration for Acute Type A Aortic Dissection.

BACKGROUND: This study investigated the clinical outcomes of elephant trunk stent fenestration in patients with acute type A aortic dissection (ATAAD). METHODS: From January 2009 to December 2019, 271 ATAAD patients were treated in the Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University. Patients underwent deep hypothermia circulatory arrest with bilateral antegrade cerebral perfusion with total arch replacement and elephant trunk stent fenestration. Patient characteristics, perioperative findings, and follow-up results were analyzed retrospectively. RESULTS: The average in-hospital mortality rate was 4.1%, the cardiopulmonary bypass time was 160.8 ± 60.4 minutes, the cross-clamp time was 91.1 ± 24.5 minutes, and the circulatory arrest time was 22.8 ± 5.5 minutes. The rate of reoperation for bleeding was 1.5%, and the pericardial mediastinal drainage volume was 312.0 ± 159.2 mL 24 hours after surgery. Follow-up data were available for 95.4% of patients. Endoleaks developed in 2 patients 3 years after surgery. The postoperative survival rate was 93.0% at 1 year, 89.3% at 5 years, and 81.7% at 10 years. CONCLUSIONS: Elephant trunk stent fenestration can simplify reconstruction of the left subclavian artery in ATAAD patients and reduce surgical difficulty. Because the early postoperative outcomes and long-term results were satisfactory in our sample, this technique should be promoted for some patients with ATAAD.

When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review.

BACKGROUND: Acute type A aortic dissection (ATAAD) is a surgical emergency with an operative mortality of up to 30%, a rate that has not changed meaningfully in more than 2 decades. A growing body of research has highlighted several comorbidities and presenting factors in which delay or permanent deferral of surgery may be considered; however, modern comprehensive summative reviews are lacking. The urgency and timing of this review are underscored by significant challenges in resource use posed by the coronavirus disease 2019 (COVID-19) pandemic. This review provides an update on the current understanding of risk assessment, surgical candidacy, and operative timing in patients with ATAAD. METHODS: A literature search was conducted through PubMed and Embase databases to identify relevant studies relating to risk assessment in ATAAD. Articles were selected by group consensus on the basis of quality and relevance. RESULTS: Several patient factors have been identified that increase risk in ATAAD repair. In particular, frailty, advanced age, previous cardiac surgery, and use of novel anticoagulant medications have been studied. The understanding of malperfusion syndromes has also expanded significantly, including recommendations for surgical delay. Finally, approaches to triage have been significantly influenced by resource limitations related to the ongoing COVID-19 pandemic. Although medical management remains a reasonable option in carefully selected patients at prohibitive risk for open surgery, endovascular therapies for treatment of ATAAD are rapidly evolving. CONCLUSIONS: Early surgical repair remains the preferred treatment for most patients with ATAAD. However, improvements in risk stratification should guide appropriate delay or permanent deferral of surgery in select individuals.

Remodeling, Reintervention, and Survival After Endovascular Repair of Chronic Type B Dissection.

BACKGROUND: The efficacy of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection (cTBAD) is controversial. Only limited evidence describes temporal anatomic changes after TEVAR for cTBAD and their relationship to outcomes. We sought to investigate early aortic remodeling events after TEVAR for cTBAD with thoracic aneurysm and determine the association with reintervention and survival. METHODS: Records from 95 cTBAD patients undergoing TEVAR from 2005 to 2017 were reviewed. Using 3-dimensional centerline analysis, anatomic phenotyping of the thoracoabdominal aorta was performed. Reverse aortic remodeling (RAR) was defined by a ≥5-mm reduction in maximal thoracic aortic diameter. Kaplan-Meier analysis estimated freedom from reintervention and survival. RESULTS: Visceral segment dissection involvement was present in 89% of patients (n = 85), and the mean preoperative thoracic diameter was 63 mm (SD, 10). Complete thoracic false lumen thrombosis occurred in 71% of patients (n = 67), whereas abdominal false lumen thrombosis was documented in 60% (n = 57) by 6 months. RAR occurred in 41%. Aortic reintervention rate was 39% (n = 37). The 1- and 3-year freedom from reintervention was significantly higher in subjects experiencing early RAR (log-rank P = .02), but reintervention did not impact overall survival (log-rank P = .9). Similarly, overall survival was similar between patients with or without RAR (log-rank P = .4). CONCLUSIONS: Early RAR is associated with decreased rates of reintervention; however, overall survival is not impacted by these changes. TEVAR for cTBAD results in a high rate of reintervention, which mandates vigilant surveillance protocols.

Repair of Massive Stanford Type A Aortic Dissection in a Jehovah's Witness Using Bloodless Surgery.

Refusal of blood product transfusion presents a unique challenge in patients requiring major cardiac surgery. We present a case of a 45-year-old African American female Jehovah's Witness with a history of aortic dissection who presented to the emergency department with worsening back pain. Imaging revealed aneurysmal dilatation of her known Stanford type A dissection measuring 10.9 cm. A staged carotid-subclavian bypass followed by aortic valve, ascending aorta, and aortic arch replacement with debranching was performed using a bloodless strategy.

Managing Malperfusion Syndrome in Acute Type A Aortic Dissection With Previous Cardiac Surgery.

BACKGROUND: Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. METHODS: From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. RESULTS: Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality. CONCLUSIONS: Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.

Acute Type A Aortic Dissection With Cardiopulmonary Arrest at Presentation.

BACKGROUND: Management of acute type A aortic dissection (AADA) presenting with cardiopulmonary arrest (CPA) may require aggressive cardiopulmonary resuscitation (CPR), including extracorporeal CPR followed by aortic repair. This study evaluated the early and long-term outcomes of patients with preoperative CPA related to AADA. METHODS: Between September 2003 and August 2019, 474 patients with AADA were brought to our hospital, 157 (33.1%) presenting with CPA. Their mean age was 74.3 ± 11.3 years and prevalence of out-of-hospital CPA 90%, and causes of CPA were cardiac tamponade in 75%, hemothorax in 10%, and coronary malperfusion in 10% of cases. In the same time periods 2974 patients with CPA were transported, and AADA was 4.8% of all cause of CPA. RESULTS: Return of spontaneous circulation was achieved in 26 patients (17%) and extracorporeal CPR was required in 31 (20%); 131 CPA patients (83%) died before surgery, 24 (15%) underwent aortic repair, and 2 (1%) received nonsurgical care. Hospital mortality was 90%, and none survived without aortic repair. Of patients achieving return of spontaneous circulation 17 underwent aortic repair, 13 survived, and 5 fully recovered. All patients with extracorporeal CPR died: 24 before surgery and 7 postoperatively. There were significant differences in hospital mortality between patients who did and did not undergo aortic repair (P < .01). Aortic repair was the only significant predictor of long-term survival (P < .01). CONCLUSIONS: AADA with CPA is associated with significantly high mortality; however aortic repair can be performed with a 30% likelihood of functional recovery, if return of spontaneous circulation is achieved. Preoperative extracorporeal membrane oxygenation is not recommended in this patient cohort.

[Follow-up after surgical treatment of type A acute aortic dissection: current evidence and controversies]. / Follow-up dei pazienti sottoposti ad intervento per dissezione aortica acuta di tipo A: evidenze e controversie.

Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.

Fluoroquinolone-Associated Type A Aortic Dissection in Alpha-1 Anti-Trypsin Deficiency.

Fluroquinolone antibiotics have come under increased scrutiny given their recent association with aortic events. Although judicious use has been urged in select patient populations, such as those with Marfan and Ehlers-Danlos syndromes, that have a known predisposition for aortopathy, other at-risk patient populations may remain. We describe the atypical delayed-presentation of a type A aortic dissection in a patient with alpha-1 anti-trypsin (A1AT) deficiency and longstanding FQ exposure. This case suggests that caution in prescribing fluroquinolone antibiotics should be extended to include those with A1AT deficiency.

Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis.

BACKGROUND: The optimal cerebral perfusion strategy during hypothermic circulatory arrest for acute type A aortic dissection repair is controversial. This study used a national clinical registry to evaluate cerebral protection strategies. METHODS: Using the Society of Thoracic Surgeons Adult Cardiac Surgical Database, study investigators identified 6387 patients with aortic dissection (mean age, 60.4 years, SD 13.5 years) who underwent total arch (n = 872; 13.7%) or ascending or hemiarch (n = 5515; 86.3%) replacement with circulatory arrest between 2014 and 2016 in the United States. Multivariable analysis adjusted for potential confounders, including demographics and comorbidity. Outcomes were compared according to the following: use of retrograde, antegrade, or no cerebral perfusion; nadir temperature; and duration of circulatory arrest. The primary end point was a composite of 30-day and in-hospital mortality or stroke. RESULTS: The rate of death or stroke was 25.5% (n = 1627). Antegrade cerebral perfusion was used in 46.2% (n = 2950) patients, retrograde cerebral perfusion was used in 22.6% (n = 1445), and no cerebral perfusion was used in 31.2% (n = 1992). In multivariable analysis, death or stroke risk increased with longer circulatory arrest duration (adds ratio [OR], 1.11 per 10-minute increment; 95% confidence interval [CI], 1.08 to 1.14). Multivariate analysis stratified by temperature showed improved outcomes with cerebral perfusion (antegrade or retrograde) and deep (OR, 0.86; 95% CI, 0.74 to 0.98), or moderate (OR, 0.78; 95% CI, 0.65 to 0.95) hypothermic circulatory arrest vs circulatory arrest without cerebral perfusion. There was a slight correlation between nadir temperature and the primary outcome. CONCLUSIONS: Cerebral perfusion should be used during arch repair for aortic dissection because antegrade and retrograde cerebral perfusion strategies are associated with reduced death and stroke risk compared with hypothermic circulatory arrest without cerebral perfusion.

Neomedia Aortic Root Repair for Type A Aortic Dissection Despite Anomalous Right Coronary Artery.

An anomalous right coronary artery arising from the left coronary sinus is a rare anatomic variant. Here we report a patient who presented with an acute type A dissection and underwent successful aortic root reconstruction with resuspension of the aortic valve and neomedia creation in the presence of an anomalous right coronary artery with a good clinical outcome.

Distal Stent Graft-Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC.

BACKGROUND: The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. METHODS: In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. RESULTS: The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. CONCLUSIONS: dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.

Fate of the Preserved Sinuses of Valsalva After Emergency Repair for Acute Type A Aortic Dissection.

BACKGROUND: Patients with acute type A aortic dissection (ATAAD) present with heterogeneous involvement of the aortic root complex. Despite this variation, the aortic root can usually be preserved the majority of the time by Teflon (WL Gore, Newark, DE) inlay patch reconstruction of the dissected sinuses of Valsalva (SOV). In this study, we report the long term anatomic, functional, and clinical outcomes associated with the preserved SOV after surgery for ATAAD. METHODS: From 2002-2017, of 776 emergency ATAAD operations at a single institution, 558 (71.9%) underwent valve resuspension with SOV preservation. Echocardiography reports were reviewed to obtain postoperative SOV dimensions. Cumulative incidence of SOV dilation ≥ 4 5mm was calculated using the Fine-Gray method with death as a competing risk. Repeated-measures linear mixed effects model was used to determine risk factors for SOV growth over time. RESULTS: During the follow-up period, 62 of 558 (11.1%) patients developed SOV diameter ≥ 45 mm. Cumulative incidence of SOV dilation ≥ 45 mm at 1, 5, and 10 years was 5.5%, 12.4%, and 18.9% respectively. In a multivariable Cox regression model, preoperative SOV diameter ≥ 45 mm was associated with a hazard ratio of 14.11 (95% confidence interval 7.03-31.62) for postoperative SOV dilation ≥ 45 mm. In a repeated-measures linear mixed effects model, preoperative and discharge SOV diameter were significant predictors of SOV dilation. Postoperative time course was also identified as significant indicating growth over time. CONCLUSIONS: The preserved sinuses of Valsalva after surgery for ATAAD may be prone to progressive dilatation over time. Closer echocardiographic surveillance may be warranted in these patients.

Top 10 candidate aortic disease trials.

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.