4/16/2015 Chronic Aortic Dissection Treatment of Chronic Aortic Dissection Is Evolving � 40% of repairs of the descending thoracic aorta have chronic dissection Chronic Aortic Dissection � Previous Ascending Repairs performed in 41% New Strategy or Tried Treatment � Endovascular treatment of chronic Type B dissections with aneurysmal degeneration is gaining traction Wayne Causey, MD • Mid Term Results are promising with over 90% aortic 2 nd Year Vascular Surgery Fellow specific survival at 60 months • Endovascular repair is known to decrease aneurysms sac/false lumen pressure 2 55M presented with 6 hour history of severe The New Battle: Open vs. Endovascular Repair tearing back pain Open and Endovascular Repair has demonstrated success � Comparative analyses have demonstrated success with � 15 years prior to presentation he had a Type A both techniques dissection that extended to the right common iliac � 30 day outcomes are similar and currently appear to be • Aortic root replacement independent of surgical technique • Aortic valve replacement • Mortality 4%, stroke 2%, paraplegia 3% � Asymptomatic since that presentation and had • Predictors of adverse survival are concomitant treatment poor recent follow up with his cardiac surgeon of the visceral segment and large aortic diameter � Studies suggest that TEVAR may need careful patient � CTA 6 months prior for similar symptoms selection demonstrated type B dissection with thoracic aortic degeneration to 5cm 3 4 1
4/16/2015 CT Angiogram Presentation Chest/Abdomen/Pelvis � His pain was different and now localized to the chest, back, and upper abdomen • PMHx: HTN, HLD, Renal cell carcinoma (treated 20 years prior, no recurrence) • PSHx: Left nephrectomy, Aortic valve and root replacement • Remote 10 pack year smoking history � No abdominal tenderness � Exam with palpable pulses (including radial Type B Aortic Dissection Begins just and pedal pulses) distal to the left subclavian artery; � Cr 0.8; H/H 14/40 normal proximal aorta measures 33mm 5 Abdominal Aorta Thoracic Aorta Dissection extends throughout the entire thoracic aorta with maximal Aorta measures diameter 5.8 cm 2.8cm at maximal diameter and all visceral vessels fed off the true lumen, except the right renal which has a large fenestration 2
4/16/2015 After 72 hours, his pain persisted but HR How would you manage this and BP were well controlled. patient? How would you manage this patient? 48% A. Continued anti-impulse control and repeat 38% A. Anti-impulse therapy and pain CTA in 1 week 35% control B. TEVAR with coverage of the left subclavian 30% and carotid/subclavian bypass B. Stent-graft placement in the 14% descending thoracic aorta C. TEVAR with coverage of the left subclavian 18% 15% C. Open thoracic aortic repair D. Open thoracic aortic aneurysm repair 0% E. Continue anti-impulse therapy and repeat D. Thoracoabdominal aortic repair 3% r CTA in 1 month . . . . a i . . . . . n p t i n i e r a o t r y n a c p e i l t a . . a m r . . . . . . n . t t . . r e o . n . h e a i e f f c m s o o a t h e t a c u l e e c i o g g i s e p l c p t l d a a r u s a b m r r o p t e e l f r a i a m u a o - v v p o t i o o c i r h n i - m g t c c c c i a a a t - h h n i t n r d r a - n o t t o i e e w i w i t e p h u h e n t u t O T n R R A S n n t i A A i n e t V V p n o E E O o C T T C 9 10 Open thoracotomy through 4 th and 9 th Patient returns in 1 month with continued pain, requesting repair as he cannot function interspaces What would be your operative approach (3cm landing zone if left 34mm Dacron Tube graft from left subclavian to diaphragmatic subclavian covered, right vertebral dominant) aorta Size based on normal proximal aorta and covering left subclavian � Left heart bypass A. Cover the entry tear only 38% � Proximal clamp between left CCA and subclavian, dissection to that B. Cover the throacic aorta to the level of 35% level but not involving the left subclavian the celiac, subclavian revascularization if symptomatic C. Cover the thoracic aorta to the level of the celiac; carotid-subclavian bypass 11% 11% D. Coil embolize the false lumen, cover the 5% thoracic aorta to the level of the celiac, carotid-subclavian bypass Cover the entry tear only Cover the throacic aorta .. Cover the thoracic aorta .. Open thoracic aortic an... Coil embolize the false l... E. Open thoracic aortic aneurysm repair Proximal Descending Thoracic Aorta 11 12 3
4/16/2015 Distal Recovery � Pain resolved after repair and subsequent recovery � False lumen in abdominal segment unchanged and false lumen not Descending thrombosed Thoracic Aorta at Diaphragm � Abdominal aortic aneurysmal changes may be treated with multibranch graft repair 13 Presentation Title and/or Sub Brand Name Here 4/16/2015 14 Conclusion � Endovascular repair of chronic dissections is evolving • Extent of coverage • Adjunctive procedures are emerging • Young patients and those with poor follow up compliance may be best served with open surgical repair 15 4
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