acute type b aortic dissection นพอรรถภม สศภอรรถ รพราชวถ COMPLICATIONS IN ACUTE TYPE B AORTIC DISSECTION No uniform criteria to define complicated ID: 211120
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Slide1
Management of acute type b aortic dissection
นพ.อรรถภูมิ สู่ศุภอรรถ
รพ.ราชวิถีSlide2
COMPLICATIONS IN ACUTE TYPE B AORTIC DISSECTION
No uniform criteria to define “complicated”
15-20% of cases
Impending rupture
Malperfusion
syndrome (10%)
Hemodynamic instability (15%)
Refractory hypertensionSlide3
Malperfusion syndromes
A
bout
10% of patients with type B aortic dissection
Dynamic
malperfusion caused by branch vessel occlusion of the true lumen by the pressurized false lumens Static malperfusion caused by propagation of the dissection into branch vessel ostia with distal vessel occlusionSlide4
Mesenteric ischemiaabdominal pain, nausea, and
diarrhea
associated
with an increase in laboratory markers (bilirubin, amylases, hepatic, and intestinal enzymes
).
Highly devastating and has a major impact on early mortalityLower limb ischemiaRelatively benign and surgical intervention should be performed in symptomatic patient.Spinal cord ischemiaparaparesis or paraplegiaMalperfusion syndromesSlide5
Strategy
Central Aortic Repair
Aortic Replacement
Fenestration
Endograft
Re-entry fenestrationPeripheral repairGraft BypassStentingTherapeutic AimTo restore the perfusion of the organsTo stop/limit the dissecting process to protect the organsSlide6
A 59-year-old male with history of hypertension and COPD presented with abdominal pain, painful,
pulseless
right lower extremity
TL
TLSlide7
TL
TL
Celiac a.
Rt
RA
Lt RA
FL
Rt
CIASlide8
Stent-graft placementSlide9
IVUS/ TEE
superior to angiography for identifying
Primary and distal reentry tears
Documenting
guidewire
position in the true lumenAssessing seal zonesDetecting endoleaksassessment of the ascending aorta to be mandatory at the conclusion of each TEVAR case to assess for retrograde ascending aortic dissectionCirculation. 2005;112:I260-4.Slide10
Stent placement
Uncovered stents
improve flow
inadequate relief of dynamic obstruction after surgery
static obstruction of abdominal aortic branch vessels, which is typically unaffected by proximal aortic stent-graft treatment and fenestration.Slide11Slide12
impending rupture/Rupture
P
ersistent pain despite good blood pressure control
A
ortic dissection with persistent uncontrolled hypertension
Evidence of dissection progression despite optimal medical management.An increase in perioaortic hematoma and hemorrhagic pleural effusion in 2 subsequent CT examinationsRequires sealing off the primary tear as well as the site of the leakFrequently necessitates paving the entire thoracic aorta when the site of the leak is unclear.J Am Coll Cardiol
Intv 2008;1:395– 402.
Circulation 2010;122:1283–9.Slide13
Refractory hypertensionInternational Registry of Acute Aortic Dissection (IRAD) trial data showed that in-hospital mortality after medical management was significantly increased in average-risk patients with type B aortic dissection
under medical therapy with refractory hypertension/pain
compared with those without these features (35.6% vs. 1.5%; p 0.0003)
Circulation 2010;122:1283–9.Slide14
Open surgerySlide15Slide16
Uncomplicated Acute type B aortic dissection Medical management
Anti-impulse therapy
uncomplicated dissection
lack of appropriate facilities
presence of comorbidities or morphology that made open surgery or TEVAR not feasible
IRAD: 3-yr survival = 78%Late aortic-related complications= 25-50% Slide17
Prophylactic TEVAR?
T
hrombosed
false lumen predicts lower event rates after type B dissection
Randomized comparison of strategies for type B aortic dissection: the
INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trialFound no difference in the primary end point of all-cause mortality at 2 yearsThoracic false lumen thrombosis, TEVAR> Medical Mx :91.3%VS 19.4% (P < .001)high rate of aorta-related deaths in the TEVAR group resulting from periprocedural technical complicationsCirculation.
1993;87:1604-1
5
.
Ci
r
culation.
2009;120:2519-
2
8
.Slide18
High-risk features of uncomplicated type b dissection
Initial aortic diameter
≥
4.0 cm with patent false lumen
*,€,ɸInitial false lumen diameter ≥ 22 mm in proximal DTA ∞IMH with PAU in proximal DTA *,ɸ* Eur
J
V
asc
Endovasc
Su
r
g
.2006;32:
3
49-55.
€ J
Thorac
Cardiovasc
Surg. 2007;134:1163-70.
ɸ
Circulation
. 2010;122: S74-80
.
∞J Am
Coll
Cardiol
. 2007;50:799-804
.Slide19
Long-Term Management
Specific predictors of follow-up
mortality
include
Female gender
Prior aortic aneurysmAtherosclerosis Pleural effusionIn-hospital acute renal failureHypotension or shockβ-blockade & blood pressure controlIRAD: calcium channel blockers at discharge was associated with improved long-term survival selectively in medically treated type B dissection
patients>1/3 of patients will require surgery for aortic-related
complications
within 5 years of the initial
dissection
Serial imaging
at 1, 3, 6, and 12 months after discharge, and
annuallySlide20
OUTCOME DATA FROM MEDICAL THERAPYEarly mortality rate = 6.4% (95% CI: 5.1% to 7.9%)
Stroke = 4.2% (95% CI:2.3% to 7.4%)
spinal cord ischemia =
5.3% (95% CI: 3.4% to 8.4%)
5-year survival rates ranged from 70.2% to 89%
Aortic adverse event freedom (including aortic death, rupture, new dissection, enlargement, reintervention) ranged from 75% to 88.5% at 5 years, but there were variable event definitions among studiesSlide21
OUTCOME DATA FROM TEVAR
in most of the papers, indication for TEVAR was complicated acute type B dissection
criteria for defining complicated were variable
Early mortality rate =10.2% (95%CI: 9.0% to 11.6%)
Stroke = 4.9% (95% CI: 4.0% to6.0%)
Spinal cord ischemia = 4.2.% (95% CI: 3.3% to 5.2%)5-year survival rates ranged from 56.3% to 87%Freedom from aortic events ranged from 45% to 77% at 5 years.Slide22
OUTCOME DATA FROM OPEN SURGERYEarly mortality rate = 17.5% (95% CI: 15.6% to 19.6%)
Stroke =
5.9% (95% CI: 4.8% to 7.3%)
Spinal cord ischemia = 3.3%
(95% CI: 2.4% to 4.5%)
5-year survival rates ranged from 44% to 64.8%Freedom from aortic events ranged from 58.7% to 68% at 5 years.Slide23
MEDICAL THERAPY VS TEVAR ANDOPEN SURGERY VERSUS TEVAR
invalidated by unbalanced populations (unmatched illness conditions and rates of complicated vs. uncomplicated cases of patients assigned to each treatment).
Complicated cases
Open
Sx
, TEVARuncomplicated cases Medical treatmentSlide24
Comparison of Early (30 Days/In-Hospital) Outcomes With Medical Therapy and TEVAR in Acute Type B Aortic DissectionsSlide25Slide26Slide27
Subacute type B aortic dissection
Very limited outcome data
INSTEAD (Investigation of Stent Grafts in Aortic Dissection) trial
Primary success rate = 95.7%
Early mortality = 2.8%
Stroke rate =1.4%Spinal ischemia= 2.9% Required secondary procedures = 18%Slide28
VIRTUE (VALIANT Thoracic Stent Graft Evaluation For the Treatment of Descending Thoracic Aortic Dissections- Post Marketing Surveillance Registry) Registry
24 patients with complicated
subacute
type B aortic dissections treated with TEVAR
Primary procedural success rate= 100%
Early mortality rate =1.8%Late deaths = 0%Strokes or cases of spinal cord ischemia = 0%Negative prognosis in the subacute phaseChange in aortic morphology (expanding diameter 4 mm, new onset of periaortic hematoma, and/or pleural hemorrhagic effusion)Refractory hypertension Recurrent thoracic painMalperfusionSlide29
Subacute type B aortic dissectionSlide30