Eur J Vasc Endovasc Surg (2017) 54, 164e169

Aortic Elongation and Stanford B Dissection: The Tübingen Aortic

Pathoanatomy (TAIPAN) Project
M. Lescan a,*, K. Veseli a, A. Oikonomou a, T. Walker a, H. Lausberg a, G. Blumenstock b, F. Bamberg c, C. Schlensak a, T. Krüger a
a
Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
b
Institute for Clinical Epidemiology and Applied Biometry, Eberhard Karls University of Tübingen, Tübingen, Germany
c
Department of Diagnostic and Interventional Radiology, University Medical Centre Tübingen, Tübingen, Germany

WHAT THIS PAPER ADDS

Aortic elongation has not yet been considered a potential risk factor for type B dissections (TBD). Herein, a
significant elongation and dilatation in the non-dissected aortic arch of patients with TBD is demonstrated for
the first time. The question of risk stratification on the basis of these parameters is raised and the draft of a
predictive score for TBD presented.

Objective/Background: Aortic elongation has not yet been considered as a potential risk factor for Stanford type
B dissection (TBD). The role of both aortic elongation and dilatation in patients with TBD was evaluated.
Methods: The aortic morphology of a healthy control group (n ¼ 236) and patients with TBD (n ¼ 96) was
retrospectively examined using three dimensional computed tomography imaging. Curved multiplanar reformats
were used to examine aortic diameters at defined landmarks and aortic segment lengths.
Results: Diameters at all landmarks were significantly larger in the TBD group. The greatest diameter difference
(56%) was measured in dissected descending aortas (p < .001). The segment with the most considerable
difference between the study groups with regard to elongation was the non-dissected aortic arch of patients with
TBD (36%; p < .001). Elongation in the aortic arch was accompanied by a diameter increase of 21% (p < .001). In
receivereoperating curve analysis, the area under the curve was .85 for the diameter and .86 for the length of
the aortic arch.
Conclusions: In addition to dilatation, aortic arch elongation is associated with the development of TBD. The
diameter and length of the non-dissected aortic arch may be predictive for TBD and may possibly be used for risk
assessment in the future. This study provides the basis for further prospective evaluation of these parameters.
Ó 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Article history: Received 15 February 2017, Accepted 28 May 2017, Available online 27 June 2017
Keywords: Aneurysm, Aorta, Aortic dissection, Aortic elongation, Computed tomography

INTRODUCTION occurrence of the TBD.7 Thus, the identification of further

Genetic predisposition, inflammatory aortic disease, hy-
pertension, age  60 years, and male sex are well estab-
lished risk factors for Stanford type B aortic dissection
(TBD).1,2 Aortic dilatation is the only established morpho-
logical risk factor, and prophylactic intervention on the
ascending and descending aorta is recommended at a
diameter of 55 mm.3,4 However, most aortic dissections
occur at lesser diameters.5,6 Therefore, the currently pub-
lished European Society for Vascular Surgery (ESVS) guide-
lines for management of descending thoracic aorta diseases
state that the aortic diameter is not closely related to the
* Corresponding author. Department of Thoracic and Cardiovascular
Surgery, University Medical Centre Tübingen, Tübingen, Germany.
E-mail address: mario.lescan@med.uni-tuebingen.de (M. Lescan).
1078-5884/Ó 2017 European Society for Vascular Surgery. Published by
Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejvs.2017.05.017
morphological risk factors may help to better identify pa-
tients at risk for TBD.
Under physiological conditions, the aortic “Windkessel
effect” functions in both the longitudinal and circumferen-
tial directions.8,9 Aortic elongation, analogously to dilata-
tion, probably leads to a sustained loss of elastic fibres and,
consequently, to inelastic wall properties.10 Longitudinal
wall stress and failure of longitudinal wall properties result
in a circumferential laceration, as observed in dissections.
Recently, it was shown that the ascending aortas of patients
before Stanford type A aortic dissection are significantly
elongated.5,6 Hence, it was hypothesized that the incidence
of TBD is increased among patients with an elongated aortic
arch and descending aorta.
The aim of this study was to compare the three dimen-
sional (3D) morphology of TBD and healthy control aortas
and, specifically, to evaluate the role of aortic elongation in
TBD.
Aortic Elongation and Stanford B Dissection
MATERIALS AND METHODS
Study design
In this retrospective observational cross sectional study, all
patients diagnosed with an acute TBD at University Medical
Centre Tübingen between 2002 and 2016 were analysed. All
patients with known connective tissue disorders, iatrogenic
dissections, and those who had previously undergone sur-
gery on the aorta were excluded. Importantly, all TBD with
significant retrograde involvement of the aortic arch (other
than minimal wall haematoma) were excluded. Finally, 96
patients were included in the TBD group. The control group
consisted of patients who received computed tomography
angiography (CTA) for a non-vascular emergency at Uni-
versity Medical Centre Tübingen’s emergency department
between 2014 and 2015. Because the youngest patient in
the TBD group was 22 years old, only patients  22 years of
age were included in the control group (age homogenisa-
tion). Demographic data, including age, sex, body height,
and weight on admission, were collected. This study was
approved by the local ethics committee (no. 076/2015R).
Obtaining written informed consent was not necessary
because of the retrospective, observational nature of the
study.
CTA scans
CTA scans were carried out at University Medical Centre
Tübingen’s emergency department using a second genera-
tion dual source CT scanner (Somatom Definition Flash;
Siemens Healthcare, Erlangen, Germany), with a high
iodinated contrast bolus of 100 mL (400 mg/mL iodine). The
bolus was injected at a rate of 4e5 mL/s and was chased by
saline. CTA images with a maximum slice thickness of 3 mm
were accepted for further processing.
Image processing
CTA datasets were processed using OSIRIX MD (Pixmeo,
Bernex, Switzerland) software.11 Three dimensional
modeling of the aorta with the centreline tool was used to
Figure 1. Curved multiplanar reformat, aortic landmarks. Centreline of the entire aorta with short-axis view at landmarks D1eD11 used for
diameter assessment. Note. L1eL6 ¼ aortic segments for length measurement.
165
obtain reliable measurements, and curved multiplanar
reformats from the aortic valve annulus to the aortic
bifurcation were prepared.12 The aortic perimeter was
delineated using the pencil tool in the short axis view at
defined landmarks, and the optimised aortic diameter was
calculated to minimise errors due to elliptical shaped
aortas. The true lumen, false lumen, and thrombus (if pre-
sent) were included in the diameter measurement. Having
identified the defined aortic landmarks, aortic segment
lengths were measured in the curved multiplanar reformats
along the centreline.
Aortic landmarks
Guideline consistent aortic landmarks were applied (Fig. 1).4
Because it was challenging to reproduce the diaphragm as a
landmark for measurements, it was replaced by the orifice
of the coeliac trunk. The following landmarks were applied
for assessment of aortic diameters: D1 (aortic valve
annulus); D2 (sinus of Valsalva [halfway between D1 and
D3]); D3 (sinotubular junction); D4 (mid-ascending aorta
[halfway between D3 and D5]); D5 (orifice of the brachio-
cephalic trunk); D6 (mid-aortic arch [halfway between D5
and D7]); D7 (distal aortic arch [directly downstream of the
left subclavian artery]); D8 (descending aorta [at the level of
the pulmonary artery bifurcation]); D9 (thoraco-abdominal
[orifice of the coeliac trunk]); D10 (mid-abdominal [halfway
between D9 and D11]); D11 (distal abdominal [distally
bounded by the aortic bifurcation]).
The aortic segments for length measurement were
defined as follows: L1 (aortic root [D1eD3]); L2 (ascending
aorta [D3eD5]); L3 (aortic arch [D5eD7]); L4 (distal aortic
arch [D7eD8]); L5 (descending aorta [D8eD9]); L6
(abdominal aorta [D9eD11]).
Statistical analysis
Statistical analysis was performed using SPSS 23.0 software
(IBM, Armonk, NY, USA). Because criteria for normality were
not fulfilled in all cases in the ShapiroeWilk test, contin-
uous data are described as the medians with interquartile
166 M. Lescan et al.

Table 1. Baseline characteristics of patients included in the analysis.

Control (n ¼ 236) TBD (n ¼ 96) p
Male (%) 66.5 65.6 .875
Hypertension (%) 39.8 83.3 < .001
Age (y) 64.4 (51.4e77.25; 22e96) 66.00 (55.00e75.00; 22e91) .896
Height (cm) 173 (152e196; 168e180) 172 (150e199; 166e178) .270
Weight (kg) 80 (50e140; 70e90) 80 (43e130; 70e90) .627
BMI 26 (17e46; 24e29) 27 (16e45; 24e30) .132
Note. Data are median (interquartile range; min.emax.) unless otherwise indicated. BMI ¼ body mass index.

range (Q1eQ3) and the range (minimumemaximum) and
presented with box and whiskers plots. Categorical data are
reported as percentages. Differences between the study
groups were tested for significance using a closed testing
procedure: a KruskaleWallis test was run followed by a
ManneWhitneyeWilcoxon rank sum test or chi-square test.
Receivereoperating characteristic (ROC) curves were
analysed to assess the diagnostic value of the individual
aortic parameters and to identify those which can best
differentiate the two groups.13 The sensitivity and speci-
ficity of the variables and scores were calculated with
contingency tables for the dissection and control groups.
All reported p values were two sided; p < .001 was
considered significant.
RESULTS
Baseline characteristics
the coeliac trunk (D9; control: 22.1 mm [20.4e23.9; 15.5e
57.3]; TBD: 32.6 mm [29.3e36.0; 22.0e50.3]).
However, even in the non-dissected segments, aortic di-
ameters were larger in the TBD group, with the largest
difference observed for the mid-arch (D6; control: 28 mm
[25.7e30.5; 18.1e36.6]; TBD: 33.9 mm [31.3e37.5; 24.0e
45.7]).
A wide range of diameters in both study groups was
evident at the level of the abdominal aorta (D10 and D11).
The outliers result from the coincidental diagnosis of an
abdominal aortic aneurysm (AAA) in the control group and
dissection related dilatation or pre-existing AAA in the
dissection group.
Aortic segment lengths
The greatest difference in the aortic segment lengths be-
tween the two study groups (Fig. 3) was in the non-dissected

There were no significant differences in the demographic

data between the control group and the TBD group
(Table 1). The prevalence of hypertension was higher in the
TBD group.

Aortic diameters
All aortic diameters (except the annulus) in the TBD group
were significantly (p < .001) larger than those in the control
group (Fig. 2). The largest differences between the groups
were observed in the dissected segments, which were at
the level of the distal arch (D7; control: 26.4 mm [24.2e
28.3; 14.3e35.7]; TBD: 35.2 mm [31.3e38.9; 23.7e48.8]),
the descending aorta (D8; control: 25.3 mm [22.9e27.6; Figure 3. Lengths of aortic segments L1eL6 for control and type B
17.5e39.7]; TBD: 39.2 mm [33.4e42.4; 10.1e60.9]), and dissection (TBD) groups.

Figure 2. Aortic diameters at landmarks D1eD11 for the control and type B dissection (TBD) groups.
Aortic Elongation and Stanford B Dissection
Table 2. Receivereoperating area under the curve (ROCeAUC), sensitivity, and specificity for selected parameters of non-dissected aortic
segments.
Aortic variable ROCeAUC Value (diameter or length [mm])
Ascending diameter D4 .769 45
50
55
Aorta diameter at BCT (D5) .792 40
45
50
Diameter aortic arch (D6) .849 35
40
45
Length ascending Ao (L2) .588 90
95
100
Length aortic arch (L3) .863 50
55
60
Note. BCT ¼ brachiocephalic trunk; Ao ¼ aorta.
aortic arch (L3; control: 36.3 mm [32.3e40.2; 21.7e86.6];
TBD: 49.0 mm [42.0e54.2; 31.2e99.5]; p < .001). The
dissected distal arch (L4; control: 60.3 mm [49.2e74.4;
25.3e142.4]; TBD: 69.9 mm [54.0e94.3; 23.1e201.4];
p < .001) and descending aorta (L5; control: 174.6 mm
[161.1e188.2; 115.5e258.5]; TBD: 202.9 mm [173.0e229.8;
60.3e328.7]; p < .001) were also significantly elongated in
the TBD group, whereas the lengths of the aortic root,
ascending aorta and abdominal aorta showed no significant
differences between the TBD and control groups.
ROC analysis
ROC curves for the aortic dimensions were analysed to
identify parameters that best distinguished the control and
TBD groups. Table 2 shows the ROC area under the curve
(ROCeAUC) values, as well as the sensitivity and specificity
for specific parameters of the non-dissected segments. With
respect to aortic diameters, the non-dissected aortic arch
(D6) had a ROCeAUC of .849, whereas the more upstream
segments (D4 and D5) had ROCeAUCs of < .8. With respect
to the aortic length parameters, the length of the non-
dissected aortic arch (L3) had a ROCeAUC of .863,
whereas the ascending aorta length had a ROCeAUC of
.588. The dissected segments of the aorta, distal arch, and
descending aorta had high ROCeAUCs with respect to the
diameter (>.9) but not with respect to the length param-
eters (.7).
DISCUSSION
Methodological considerations
Aortic dilatation and elongation are correlated with age,14
whereas correlations with body size and weight are
weak.6 All these parameters were equally distributed in
both study groups (structural equality), such that con-
founding appears unlikely.
Three dimensional CTA modelling was used to overcome
the problems of incorrect measurement due to oblique
cross sections of the aorta. The curved planar
167
Sensitivity Specificity
.16 .98
.04 1.0
.01 1.0
.31 .97
.06 1.0
.01 1.0
.45 .97
.14 1.0
.03 1.0
.07 .97
.04 .98
.02 .99
.43 .97
.19 .99
.08 1.0
reconstruction strategy is a widely accepted method.12
However, the determination of the blood/intima margin,
the non-central placement of the centreline tool, and the
impairment of CT scan quality due to artifacts (pulsation,
implants) can still be problematic.
The control group consisted of individuals without pre-
viously known aortic pathology and represented the aortic
morphology of a clinically healthy population. However, it
included individual patients with incidental AAAs. Owing to
the cross sectional design of this study, there were no
further follow-ups of the control group. The incidence of
later TBD in that group remains unknown.
Patients with retrograde dissection of the arch were
excluded from the TBD group. This was owing to the fact
that the classification of these retrograde (proximal) dis-
sections is somewhat unclear.2 Also excluded were all pa-
tients with previously known connective tissue disorders
and with previous aortic surgery. The TBD group repre-
sented a cohort of patients who had a diagnosis of TBD
without prodromi.
Increased diameter and length parameters were found,
particularly in non-dissected aortic arches, to be associated
with TBD, but the retrospective character of this study did
not allow determination of the predictive value of aortic
elongation with regard to TBD. This study should be regar-
ded as a first insight into the topic, and larger prospective
studies are needed to confirm the findings and to judge the
predictive value of arch elongation and diameter.
Aortic diameters
The aortic diameters of the control group were comparable
with those reported in the literature.15 Significantly larger
diameters were found in the TBD aortas compared with
those of the controls at all measuring points. As expected,
the largest differences were observed in the dissected
segments. Aortic dissection leads to an acute expansion of
the diameter due to the sudden weakness of the false
lumen wall.16 This is the most likely explanation for this
finding. No reliable estimation of the distal arch and
168
descending aortic diameters shortly before the event of
acute dissection can be made on the basis of the present
data. Consequently, the prognostic values of these param-
eters remain unknown. However, with respect to the rele-
vant guidelines, it appears interesting that even in the
dissected distal arch (D7) and descending aorta (D8), a
diameter of 55 mm was reached in just one (D7) and four
(D8), respectively, out of the 96 patients with TBD. In the
control group, no patient had a diameter 55 mm in the
entire thoracic aorta. Consequently, a strictly diameter
based screening for patients at risk for TBD would be
ineffective.
However, the non-dissected segments of the thoracic
aorta in the TBD group, namely the ascending and espe-
cially the arch, showed relevant differences between the
groups: the non-dissected mid aortic arch (D6) was signifi-
cantly larger in the TBD aortas compared with controls, and
an arch diameter of 35 mm identified patients with TBD in
this retrospective analysis with a sensitivity of .45 and a
specificity of .97. Just seven of the 236 control group pa-
tients exceeded this value. Thus, dilatation in the arch of
TBD aortas was more pronounced than in all other non-
dissected segments.
Aortic elongation
Elongation is observed as a physiological result of aortic
aging. Morrison et al. described a length increase of 10e15%
in the aortic arch,17 whereas Sugawara et al. showed aortic
elongation only in the ascending aorta.14 The present au-
thors recently described a significant age related length in-
crease predominantly in the distal aortic arch (L4) and, to a
lesser extent, in the ascending aorta (L2) and arch (L3) but
not in the root or in the descending aorta.6 However, age was
controlled by the structural equality of the study groups.
Importantly, compared with control aortas, patients with
TBD were characterized by a 36% longer non-dissected
aortic arch (L3), which was by far the greatest difference
in length between the study groups. The dissected distal
arch (L4) and descending aorta (L5) were both found to be
16% longer than healthy aortas.
Rylski et al. reported geometrical changes in the
ascending aorta during the process of dissection.18 It is
plausible that similar morphological changes occur in the
descending aorta during TBD development. It remains un-
clear to what extent the length differences of the dissected
segments precede or result from TBD. The significant
elongation of the arch (L3) may be a TBD risk factor because
this segment is not dissected, even in the TBD group.
Furthermore, from a biomechanical standpoint, the
involvement of aortic arch elongation in TBD pathogenesis
appears plausible: loss of longitudinal elasticity and wall
weakening are possible factors.8,9
Prediction of Stanford B dissection
The currently published ESVS guidelines clearly state that
the aortic diameter has no close relationship to the occur-
rence of TBD. Moreover, the authors emphasize that a large
M. Lescan et al.
number TBDs do occur in aortas with normal diameters.
However, the appearance of TBD in patients with normal
aortic diameters points out the need for further morpho-
logical criteria to predict the occurrence of TBD. This work
focuses on the role of aortic elongation as a predictor for
dissections in addition to the aortic diameter in the non-
dissected mid-arch portion. Both parameters were not
addressed in the current guidelines nor in previous publi-
cations dealing with morphological risk factors of TBD.7
Recently, a risk score for Stanford A dissection based on
ascending aorta diameters and lengths was proposed.5,6
However, at that time a group of patients with CTA scans
prior to type A dissection was included in order to show that
ascending aortic elongation is not a result of dissection. In
the present study, there was no such pre-TBD group, which
is a disadvantage, but only a small minority of patients re-
ceives a CTA scan by chance before they suffer dissection.
The retrospective approach further limits the application of
the findings to prove that elongation is a new risk factor and
establish a risk score for TBD. Nevertheless, the finding of
significant morphological differences in the non-dissected
arch of TBD aortas compared with control aortas is inter-
esting. Both the arch diameter (D6, mid-arch) and the arch
length (L3; from the beginning of the brachiocephalic trunk
to the end of the left subclavian artery) differentiated be-
tween the TBD and control aortas with ROCeAUCs of .849
and .863, respectively (Table 2), and they are certainly not
affected by the dissection. Combining both parameters with
the thresholds of a 35 mm arch diameter and a 50 mm arch
length to create a score (Table 3), a score of 1 point was able
to identify TBD aortas with a sensitivity of .54 and a speci-
ficity of .93, whereas a score of 2 points had a sensitivity of
.23 and a specificity of 1.0.
Clinical relevance
Establishment of reliable predictors for TBD would enable
effective risk stratification and prophylaxis. Intensified hy-
pertension treatment could be considered in order to pre-
vent dissections. Currently, the best medical treatment for
TBD consists of beta blockers and calcium antagonists.19
The use of these substances in a prophylactic setting has
to be evaluated. Medical research aiming to directly influ-
ence pathological changes in the aorta is ambitious. Risk
prediction would further put the emphasis on this field: the
ideal, but currently unavailable, therapy would allow an-
eurysms to shrink and reverse the elongation. In patients
with thoracic aneurysms, statins seem to reduce the inci-
dence of dissections,20 and in patients with Marfan syn-
drome, sartans improve the aortic prognosis.21 The
Table 3. Proposed type B dissection risk score.
Parameter Criteria Points
D6 arch diameter (mm) <35 0
35 1
L3 arch length (mm) <50 0
50 1
Note. Calculated specificity of 1.0 and sensitivity of 0.23 for 2
points.
Aortic Elongation and Stanford B Dissection
definition of high risk populations would finally raise the
question of prophylactic surgical or interventional proced-
ures such as TEVAR and arch replacement.
CONCLUSIONS
The data support the hypothesis that, besides dilatation,
aortic arch elongation is associated with the development
of TBD. Both, the mid-arch diameter and the arch length,
defined as the distance between the beginning of the bra-
chiocephalic trunk and the end of the left subclavian artery,
were clearly enlarged in patients with TBD. Future studies
will have to assess the predictive value of both parameters
and their potential inclusion in risk scores.
CONFLICTS OF INTERESTS
None.
FUNDING
This work was supported by the Dr Karl Kuhn-Stiftung,
Tübingen.
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