Disclosure Nothing to disclose Type B Dissection On Whom to Operate on and When to do it Charles Eichler Professor, Department of Surgery Division of Vascular and Endovascular Surgery University of California San Francisco 4/14/2016 2 TBAD 4/14/2016 Type B Dissection Sub-Categories • Acute Complicated • Rupture • Malperfusion Title Garamond – 38pt font Subtitle Garamond Italic – 38pt font • Chronic • Potential reasons for intervention Presenter’s Name Office or Department Name • Aneurysm degeneration • Up to 30% become aneurysmal 1 4/14/2016 • Rupture • Dissection extension • Malperfusion or ischemic events Uncomplicated Type B dissections 1 Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC: Cardiovascular Interventions 2013;6(8):876-882. 1 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Benefits and Risks of Type B Dissection Sub-Categories Endovascular vs BMT • Uncomplicated Benefit Risk • Potential reasons for intervention • “High Risk” patients Aortic Procedural Complications Remodeling Can we Identify high risk patients that Patient Paraplegia could benefit from early TEVAR than management Best Medical Therapy alone? Long-term Stroke outcomes What are the risks of treatment? Literature-Based “High Risk” Predictors Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation used in Retrospective Imaging Evaluation Initial Presentation: Initial Presentation: � Primary entry tear diameter ≥ 10 mm � Primary entry tear diameter ≥ 10 mm � Primary entry tear location � Primary entry tear location � Total aortic diameter ≥ 4 cm � Total aortic diameter ≥ 4 cm � False lumen diameter ≥ 22 mm � False lumen diameter ≥ 22 mm � Partial false lumen thrombosis � Partial false lumen thrombosis � Fusiform index ≥ .64 � Fusiform index ≥ .64 2 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation 184 patients (108 type A) with acute dissection Followed for 6.4 years 49 patients died during follow up, 31 suddenly Initial Presentation: 81% survived for 5 years � Primary entry tear diameter ≥ 10 mm Entry tear size ≥ 10 mm and entry tear in a proximal location was � Primary entry tear location associated with increased dissection-related adverse events and mortality � Total aortic diameter ≥ 4 cm � False lumen diameter ≥ 22 mm Conclusion: Type B aortic dissections that are � Partial false lumen thrombosis not symptomatic but have entry tears ≥ 10 mm in a proximal location should be considered for � Fusiform index ≥ .64 TEVAR given that 63% of deaths during follow up were sudden with no precedent symptoms 10 TBAD 4/14/2016 Literature-Based “High Risk” Predictors Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation used in Retrospective Imaging Evaluation Initial Presentation: Initial Presentation: � Primary entry tear diameter ≥ 10 mm � Primary entry tear diameter ≥ 10 mm � Primary entry tear location � Primary entry tear location � Total aortic diameter ≥ 4 cm � Total aortic diameter ≥ 4 cm � False lumen diameter ≥ 22 mm � False lumen diameter ≥ 22 mm � Partial false lumen thrombosis � Partial false lumen thrombosis � Fusiform index ≥ .64 � Fusiform index ≥ .64 3 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
False Lumen Measurement Initial Presentation 4/14/2016 Measurement at Upper Thoracic (UT) or Distal to Arch False lumen diameter > 22 has more discriminatory ability to predict late aneurysmal change than does total aorta diameter. Pts with FL > 22 should have increased surveillance or consideration for TEVAR Song J-M, Kim S-D, Kim J-H, et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection J Am Coll Cardiol 2007;50:799-804. Partial False Lumen Thrombosis Literature-Based “High Risk” Predictors 1 year follow-up used in Retrospective Imaging Evaluation Initial Presentation: � Primary entry tear diameter ≥ 10 mm � Primary entry tear location � Total aortic diameter ≥ 4 cm � False lumen diameter ≥ 22 mm � Partial false lumen thrombosis � Fusiform index ≥ .64 Tsai TT, Evangelista A, Nienaber CA, Myrmel T, Meinhardt G, Cooper JV et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007;26;357:349-59 4 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Fusiform Index Literature-Based “High Risk” Predictors Initial Presentation used in Retrospective Imaging Evaluation Initial Presentation: � Primary entry tear diameter ≥ 10 mm � Primary entry tear location � Total aortic diameter ≥ 4 cm � False lumen diameter ≥ 22 mm FI > .64 is associated with � Partial false lumen thrombosis increased adverse events � Fusiform index ≥ .64 Marui A, Mochizuki T, Koyama T, Mitsui N. Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events. Journal of Thoracic & Cardiovascular Surgery 2007;134(5):1163-1170. Summary � Literature-based “high risk” predictors may help identify uncomplicated Type B dissection patients that could benefit from early TEVAR intervention � Early TEVAR intervention should be accompanied by evidenced- based medical management • Calcium channel blockers (decreased central aortic pressure) • Beta blockers (decrease heart rate) • HMG CoA Reductase inhibitors 4/14/2016 • ACE/ARBs 5 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Evangelista A, Salas A, Ribera A, et al. Long-term outcome of aortic Song JM, Kim SD, Kim JH, et al . Long-term predictors of descending dissection with patent false lumen: predictive role of entry tear size and aorta aneurysmal change in patients with aortic dissection. Journal of the location. Circulation 2012;125(25):3133-3141. American College of Cardiology 2007;50(8):799-804. Nienaber CA, Kische S, Rousseau H, et al; INSTEAD-XL trial. Tanaka A, Sakakibara M, Ishii H, et al . Influence of the false lumen Endovascular repair of type B aortic dissection: long-term results of the status on clinical outcomes in patients with acute type B aortic randomized investigation of stent grafts in aortic dissection trial. dissection. Journal of Vascular Surgery 2014;59(2):321-326. Circulation: Cardiovascular Interventions 2013;6(4):407-416. Tsai TT, Evangelista A, Nienaber CA, et al ; International Registry of Loewe C, Czerny M, Sodeck GH, et al. A new mechanism by which an Acute Aortic Dissection. Partial thrombosis of the false lumen in acute type B aortic dissection is primarily complicated, becomes patients with acute type B aortic dissection. New England Journal of complicated, or remains uncomplicated. Annals of Thoracic Surgery Medicine 2007;357(4):349-359. 2012;93(4):1215-1222. Marui A, Mochizuki T, Koyama T, Mitsui N. Degree of fusiform Weiss G, Wolner I, Folkmann S, et al. The location of the primary entry dilatation of the proximal descending aorta in type B acute aortic tear in acute type B aortic dissection affects early outcome. European dissection can predict late aortic events. Journal of Thoracic & Journal of Cardiothoracic Surgery 2012;42(3): 571-576. Cardiovascular Surgery 2007;134(5):1163-1170. Kato M, Bai H, Sato K, et al. Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase. Circulation 1995;92(9)Supplement II: 107-112. Kudo T, Mikamo A, Kurazumi H, et al. Predictors of late aortic events after Stanford type B acute aortic dissection Journal of Thoracic & Cardiovascular Surgery 2014;148(1):98-104. Onitsuka S, Akashi H, Tayama K, et al. Long-term outcome and prognostic predictors of medically treated acute type B aortic dissections. Annals Thoracic Surgery 2004;78(4):1268-1273. Takahashi J, Wakamatsu Y, Okude J, et al. Maximum aortic diameter as a simple predictor of acute type B aortic dissection. Annals of Thoracic & Thank you for your attention Cardiovascular Surgery 2008;14(5):303-310. 6 4/14/2016 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Recommend
More recommend
