For anyone affected by acute type A aortic dissection, time can determine whether somebody reaches an operating theatre at all. A patient first has to arrive at A&E, their symptoms must raise suspicion of an aortic emergency, appropriate imaging has to take place and the diagnosis must be confirmed. If surgery is required at another hospital, referral and transfer then have to be organised while a specialist surgical team prepares to receive the patient. Every part of that process takes time, and delays at one stage can quickly become delays throughout the whole patient journey.
This new paper published in the Annals of Cardiothoracic Surgery asks whether a much more structured approach could improve that journey. The aortic window: a temporal framework for acute type A aortic dissection, led by Dr Farhin Holia with an international group of clinicians and patient representatives, proposes a framework called RACE-RESTORE and a four hour operational window between arrival in the emergency department and the start of surgery.
The Emergency Pathway Gap
Surgery for acute type A aortic dissection has advanced considerably, and outcomes at experienced, high-volume centres can be very good. The problem is that not every person who develops a dissection reaches specialist surgery in the same circumstances or at the same speed. The paper draws attention to the striking difference in what can be achieved once somebody is in the right surgical centre.
The operating theatre is only the final part of a much longer emergency pathway. Before a surgeon can operate, somebody has to suspect the diagnosis. CT imaging has to be obtained and interpreted. The appropriate specialist service has to be contacted. For many patients, an inter-hospital transfer then needs to be arranged. At the receiving centre there must be a theatre, appropriately experienced staff and the specialist support needed for highly complex emergency aortic surgery.
Patients and families who have shared their experiences with the charity will recognise how much can happen during this period. Some describe a quick diagnosis followed by immediate action. Others have experienced hours of uncertainty because their initial symptoms pointed clinicians towards another condition, imaging was delayed or the process of reaching a specialist hospital took much longer than expected.
Acute aortic dissection can present in many different ways and crosses several different medical services. That makes the design of the system particularly important. The Aortic Window starts from the position that these delays should be identified, measured and, wherever possible, reduced.
Why Start the Clock at the Emergency Department?
One of the most important ideas in the paper is the choice of where to begin measuring time. The proposed principal measure is emergency department arrival to operation, with a target of no more than four hours.
The paper describes the proposed window as an evidence-informed target that now needs prospective testing and international consensus. If the clock only starts once aortic dissection has been diagnosed, any delay before diagnosis is excluded. A patient might spend several hours before reaching the CT scanner and then move quickly to surgery once the scan result is known. If we measured only the second part of that journey, the pathway could appear efficient while missing several hours that mattered enormously.
Measuring from arrival makes the whole system accountable for the time before surgery. If delays repeatedly occur before CT, a hospital can examine what is happening in emergency care and radiology. If the difficulty arises after diagnosis, attention can move towards referral or transfer. If patients arrive promptly at a specialist centre but still wait for theatre, another part of the system needs examination. The Aortic Window creates a way of seeing where time is actually being lost.
Following the Patient Through the Emergency
The acute part of the framework is called RACE, standing for REACH, ALERT, CONVEY and ESCALATE, following the patient from the pre-hospital phase into diagnosis, transfer and finally the operating theatre.
REACH begins before hospital and focuses on recognising acute aortic syndrome as a possible explanation for a patient’s condition. The research emphasises that this cannot depend solely on the classic description of severe chest pain. Dissection may present with neurological symptoms, collapse, limb ischaemia, hypotension or other features that initially suggest a different emergency. The aim is to create sufficient suspicion among ambulance teams and first responders that the possibility of aortic disease is carried forward urgently.
ALERT covers the hospital diagnostic phase. CT angiography remains central to confirming the diagnosis, and the framework proposes CT acquisition within 120 minutes of emergency department arrival. This is important because there is little value in describing a disease as time critical if access to the investigation needed to diagnose it does not carry similar urgency. The proposed pathway therefore treats diagnostic imaging as an integral part of emergency treatment, rather than simply another investigation in the queue.
CONVEY addresses referral and transfer. The framework proposes transfer activation within 60 minutes of diagnosis while acknowledging that actual travel times will differ considerably depending on geography. A patient presenting in central London is in a very different situation from somebody arriving at a hospital serving a large rural region. The important point is that the processes that can be controlled should be visible and measurable, while genuine geographical differences are recognised rather than ignored.
ESCALATE covers preparation for the operating theatre. By this point numerous people and services may need to be ready, including an aortic surgeon, anaesthetic team, perfusion staff, theatre nursing and blood services. If those arrangements happen one after another, time can disappear very quickly. The framework encourages hospitals to organise those activities in parallel wherever this can be done safely.
Annals of Cardiothoracic Surgery, Vol 15, No 4 Jul 2026 – Holia et al
Could ‘Code Aorta’ Change How Teams Respond?
The paper also proposes a named activation protocol called Code Aorta. The idea is familiar from other medical emergencies where a recognised alert triggers a coordinated response rather than relying on an individual clinician to contact every necessary service separately.
In an aortic emergency, that could mean that once an acute aortic syndrome is strongly suspected or confirmed, a predetermined pathway alerts the relevant teams and begins several processes at the same time. While imaging is being reviewed or a transfer is being organised, the receiving surgical centre may already be considering theatre availability and assembling the necessary team. The value comes from replacing a sequence of individual requests with a coordinated response.
In many hospitals, the required expertise, scanner, ambulance services and theatre teams already exist. What may be missing is a system that connects them quickly enough when aortic dissection occurs.
Building On Work That Has Already Started
The proposed framework builds on several years of work to improve how acute aortic dissection is recognised and managed across the NHS.
The NHS Acute Aortic Dissection Toolkit, developed with involvement from the Aortic Dissection Charitable Trust, established a set of principles for regional care. It addresses areas such as network organisation, governance, referral, multidisciplinary working, transfer and education. The Aortic Window takes this conversation further by asking whether those systems should now have more explicit time measures attached to them.
A regional network may have agreed referral arrangements, for example, but that does not automatically tell us how long it takes for a patient to be accepted, how quickly the retrieval team can leave or whether the receiving theatre begins preparing before the patient arrives. The proposed framework attempts to convert good organisational principles into measurable activity.
This matters for quality improvement because measurements allow patterns to emerge. If hospitals can reliably record emergency department to CT time, diagnosis to transfer activation and arrival to surgical incision, they can begin to see where delays occur repeatedly. Once those patterns are known, improvement can be directed towards an identifiable part of the pathway instead of relying entirely on individual case reviews after something has gone wrong.
The Pathway Doesn’t Stop at the Operation
One of the most welcome aspects of the research is that the framework does not finish at the operating theatre door. Alongside the acute RACE pathway is RESTORE, which covers postoperative recovery and lifelong aortic surveillance.
That longer view was influenced by patient and public involvement through the Aortic Dissection Charitable Trust. Patient representatives contributed to the framework’s emphasis on timely explanation of the diagnosis, support after discharge, family and cascade screening and lifelong surveillance.
Surviving an acute dissection can be the beginning of a long period of recovery. Some people experience neurological or renal complications. Others live with ongoing disease elsewhere in the aorta and require repeated imaging. There may be a hereditary cause that has implications for children, siblings or parents. The psychological impact of suddenly becoming critically ill can also be profound.
The RESTORE element acknowledges that a successful emergency pathway cannot be judged only by whether the patient survives an operation. Long-term care is part of the outcome too.
The paper includes conventional clinical measures such as mortality and stroke, but it also discusses patient and family-reported information, including the timing of diagnostic disclosure and the experiences of survivors and bereaved families. This is an important acknowledgement that good aortic care has to be viewed through more than surgical outcomes alone.
Why This Approach Has the Potential to Make a Difference
Some of the greatest improvements in healthcare have come from new medicines or surgical techniques. Others have happened because existing treatments were delivered in a better way.
Heart attack and stroke care provide familiar examples. Their pathways developed clear urgency around diagnosis, treatment and where specialist care should take place. A patient entering the system triggers a series of coordinated actions, with delays measured rather than simply accepted as unavoidable.
Acute type A aortic dissection presents different clinical and logistical challenges, so it would be inappropriate simply to copy another emergency pathway. The underlying principle, however, is highly relevant. If a condition has rapidly increasing mortality, every part of the health service involved in getting somebody to definitive treatment needs to understand that it is working against the same clock.
That is what makes the Aortic Window particularly interesting. It reframes aortic dissection from a series of separate clinical events into one continuous emergency.
A delayed CT is not just a radiology issue. A slow referral is not exclusively an administrative issue. A wait for retrieval is not separate from the surgical outcome. They are all periods during which the patient remains at risk.
The framework also gives health services a way to learn. If one network discovers that its greatest delay regularly occurs between diagnostic confirmation and transfer activation, it knows where improvement efforts should be concentrated. Another network may discover that patients reach specialist care quickly once diagnosed, but diagnosis itself commonly takes several hours. Those are very different problems and require different solutions.
Without good measurement, both simply appear as “delay”.
Research Shaped with Patients
The charity’s involvement in this work is important for another reason. It reflects a broader change in aortic research, with patients and families increasingly helping to shape the questions researchers ask and the way new approaches are designed.
The charity is also involved in work to identify future research priorities through the dedicated James Lind Alliance Priority Setting Partnership for aortic dissection. This brings patients, relatives, carers and healthcare professionals together to identify the unanswered questions that matter most to the people directly affected.
Research becomes more relevant when the experience of living through aortic dissection is part of the conversation from the beginning. In this paper, that influence can be seen most clearly in the emphasis on communication, family screening, recovery and long-term support.
What Happens Next
Publication of the Aortic Window is a starting point. There are difficult questions ahead about whether the proposed timings can be achieved safely across different NHS trusts and different parts of the country. Rural and geographically isolated populations will present different challenges from major cities. Staffing and CT availability outside normal working hours may affect what is achievable. Specialist transfer capacity varies, as does access to surgeons with extensive aortic experience.
Those questions are precisely what the framework would allow researchers and health services to investigate.
For patients and families, we already know that every hour matters. The challenge now is to establish whether an organised, measurable pathway can turn that knowledge into consistently faster care.
