Authors
Francesco Squizzato, University of Padua
Mario D'Oria, University Hospital of Cattinara, Trieste, Italy
Michele Antonello, University of Padua
Santi Trimarchi, Università degli Studi di Milano
Kevin Mani, Uppsala University
Andrew Holden, Auckland City Hospital
Tilo Kölbel, University Hospital Hamburg-Eppendorf
Stephan Haulon, Hôpital Marie Lannelongue
Eric Verhoeven, General Hospital and Paracelsus Medical University
Dittmar Böckler, University Hospital Heidelberg
Tim Resch, Copenhagen University Hospital
Ali Azizzadeh, Cedars-Sinai Medical Center
Joseph Lombardi, AtlantiCare Health System
Michele Piazza, University of Padua
Aaron Thomas Fargion, University of Ferrara
Alexander Zimmerman, University of Zurich
Ali Azizzadeh, Cedars-Sinai Medical Center
Anders Wanhainen, Uppsala University
Andrew Holden, Northern Region Interventional Radiology Service
Antonio Freyrie, University of Parma
Adam W. Beck, University of Alabama
Adi Bachar, Meir Medical Center
Barend M. E. Mees, Maastricht University Medical Centre
Blandine Maurel, Nantes University Hospital
Cristoph A. Nienaber, Royal Brompton and Harefield Hospital NHS Foundation Trust
Christos Karkos, Aristotle University of Thessaloniki
Daniela Branzan, TUM University Hospital
Darren Schneider, University of Pennsylvania
Randall DeMartino, Mayo Clinic
Dittmar Boeckler, University Hospital Heidelberg
Domenico Angiletta, University of Bari School of Medicine "Aldo Moro"
Emanuel J. R. Tenorio, University of Texas Health Science Center at Houston
Enrico Gallitto, University of Bologna
Eric Verhoeven, General Hospital and Paracelsus Medical University
Fabio Verzini, University of Turin
Felice Pecoraro, University of Palermo
Filippo Benedetto, Policlinico "G. Martino" University of Messina School of Medicine
Firas F. Mussa, McGovern Medical School at UTHealth
Francesco Squizzato, University of Padua
Franco Grego, University of Padua
Gabriele Piffaretti, University of Insubria School of Medicine
Emanuele Gatta, Ospedali Riuniti di Ancona, Ancona, Italy
Giovanni Pratesi, University of Genoa
Giovanni Tinelli, Fondazione Policlinico Universitario A. Gemelli-IRCCS
Giuseppe Asciutto, Uppsala University
Glenn Wei Leong Tan, Tan Tock Seng Hospital
Hence Verhagen, Erasmus MC, Rotterdam, the Netherlands
Giacomo Isernia, Santa Maria della Misericordia Hospital
Jean-Paul P. M. de Vries, University of Groningen
Jacob Budtz-Lilly, Aarhus University Hospital
Jorge Fernández-Noya, A Coruña University Hospital Complex, A Coruña, Spain
Jonathan Sobocinski, Centre de l'Aorte
Joseph Hockley, Sir Charles Gairdner Hospital, Perth, WA, Australia
Kak Khee Yeung, University of Amsterdam
Andrea Kahlberg, Vita-Salute San Raffaele University
Kevin Mani, Uppsala University
Joseph V. Lombardi, AtlantiCare Health System, Egg Harbor, NJ
Luca Bertoglio, University of Brescia
Luca Mezzetto, Integrated University Hospital of Verona
Ludovic Canaud, Arnaud de Villeneuve Hospital, Montpellier, France
Manar Khashram, Waikato Hospital
Marcelo Ferreira, Casa de Saúde São José, Rio de Janeiro, Brazil
Marco Virgilio Usai, St Franziskus Hospital
Mark G. Davies, University of Texas Health San Antonio
Mark Farber, University of North Carolina
Martin Czerny, University Clinic Freiburg, Freiburg, Germany
Matthew R. Smeds, St Louis University, St Louis
Mauro Gargiulo, University of Bologna, Bologna, Italy
Germano Melissano, "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
Michel Bosiers, University of Bern, Bern, Switzerland
Michele Antonello, University of Padua, Padua, Italy
Michele Piazza, University of Padua, Padua, Italy
Miranda Witheford, Toronto General Hospital, University Health Network
Michel M.P.J. Reijnen, Rijnstate Hospital, Arnhem, the Netherlands
Marc Schermerhorn, Harvard Medical School
Nikolaos Tsilimparis, Ludwig-Maximillian University Hospital
Nun Dias, Lund University
Jean Panneton, Macon & Joan Brock Virginia Health Sciences at Old Dominion UniversityFollow
Kosmas Paraskevas, Red Cross Hospital, Athens Greece
Gianbattista Parlani, Santa Maria della Misericordia Hospital
Patrick W.H.E. Vriens, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
Rafael Malgor, Colorado University
Raffaele Pulli, University of Florence
Ross Milner, The University of Chicago Medicine
Salvatore T. Scali, University of Florida Health, Gainesville, FL
Sani J. Laukontaus, University of Helsinki and Helsinki University Hospital
Santi Trimarchi, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico
Sandro Lepidi, University of Trieste
Konstantinos Spanos, University Hospital of Larissa
Stefano Fazzini, University of Rome Tor Vergata
Theodosios Bisdas, Athens Medical Center, Athens, Greece
Thomas Maldonado, NYU School of Medicine
Tilo Koelbel, University Hospital Hamburg-Eppendorf
Tim Resch, Copenhagen University Hospital
Tomasz Jakimowicz, Medical University of Warsaw, Warsaw, Poland
Nicola Troisi, University of Pisa
Isabelle Van Herzeele, Ghent University Hospital
Vicente Riambau, University of Barcelona
Wassim Mansour, "Sapienza" University of Rome
Wouter Van Den Eynde, Imelda Hospital, Bonheiden, Belgium
Yamume Tshomba, Università Cattolica del Sacro Cuore
DOI
10.1016/j.ejvs.2025.09.045
Publication Title
European Journal of Vascular and Endovascular Surgery
Abstract
Objective
The aim of this study was to achieve an international expert consensus on managing acute type B penetrating aortic ulcers (PAUs) and intramural haematomas (IMHs).
Methods
A modified Delphi consensus process was employed to develop recommendations for the management of acute type B PAU and IMH. Surveys were sent to international experts practicing in high volume aortic centres worldwide. Statements were voted on using a four point Likert scale in a three round Delphi process. Statements achieving grade A (full agreement 75%) or B (overall agreement 80%, full disagreement < 5%) were included as expert recommendations. Consistency of responses was measured using Cohen's κ and the intraclass correlation coefficient.
Results
Eighty three experts were included in the final analysis: 25 statements achieved a consensus, 18 (72%) receiving a grade B strength and seven (28%) a grade A strength. Most statements (97%) had a high consistency classified as grade I or II. The expert panel agreed on the indication for thoracic endovascular aortic repair (TEVAR) for complicated IMH/PAU, defined by rupture or refractory pain/hypertension. Uncomplicated IMH/PAU should be managed conservatively and followed up with serial computed tomography imaging during the acute phase. High risk uncomplicated IMHs are identified by increased haematoma thickness, new onset or increased size of ulcer like projections, or transition to aortic dissection; high risk uncomplicated PAUs are defined by new associated haematoma, PAU width/depth increase, or total aortic diameter increase. Uncomplicated high risk IMH/PAUs may be considered for TEVAR. In performing TEVAR, a proximal sealing length > 20 mm in a site free from haematoma should be achieved, eventually extending in zone 2, with a 0 - 10% oversize. Patency of the left subclavian artery should be maintained.
Conclusion
An agreement among international experts was achieved on assessment, management, and follow up of acute type B IMHs and PAUs, addressing areas of inconsistencies or knowledge gaps in existing guidelines.
Original Publication Citation
Squizzato, F., D'Oria, M., Antonello, M., Trimarchi, S., Mani, K., Holden, A., Kölbel, T., Haulon, S., Verhoeven, E., Böckler, D., Resch, T., Azizzadeh, A., Lombardi, J., Piazza, M., Fargion, A., Zimmermann, A., Wanhainen, A., Holden, A., Freyrie, A.,…Tshomba, Y. (2026). Editor's choice - International expert consensus on the management of acute aortic type B intramural haematoma and penetrating ulcer. European Journal of Vascular & Endovascular Surgery, 71(3), 402-412. https://doi.org/10.1016/j.ejvs.2025.09.045
Repository Citation
Squizzato, F., D'Oria, M., Antonello, M., Trimarchi, S., Mani, K., Holden, A., Kölbel, T., Haulon, S., Verhoeven, E., Böckler, D., Resch, T., Azizzadeh, A., Lombardi, J., Piazza, M., Fargion, A., Zimmermann, A., Wanhainen, A., Holden, A., Freyrie, A.,…Tshomba, Y. (2026). Editor's choice - International expert consensus on the management of acute aortic type B intramural haematoma and penetrating ulcer. European Journal of Vascular & Endovascular Surgery, 71(3), 402-412. https://doi.org/10.1016/j.ejvs.2025.09.045
