Management of - PowerPoint Presentation

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.Slide11
Slide12

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 surgerySlide15
Slide16

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 DissectionsSlide25
Slide26
Slide27

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