Presentation on theme: "Management of acute type b aortic dissection"— Presentation transcript:
1Management of acute type b aortic dissection นพ.อรรถภูมิ สู่ศุภอรรถรพ.ราชวิถี
2COMPLICATIONS IN ACUTE TYPE B AORTIC DISSECTION No uniform criteria to define “complicated”15-20% of casesImpending ruptureMalperfusion syndrome (10%)Hemodynamic instability (15%)Refractory hypertensionRefractory hypertension (hypertension persisting despite 3 different classes of antihypertensive therapy at maximal recommended or maximal tolerated doses)
3Malperfusion syndromes About 10% of patients with type B aortic dissectionDynamic malperfusion caused by branch vessel occlusion of the true lumen by the pressurized false lumensStatic malperfusion caused by propagation of the dissection into branch vessel ostia with distal vessel occlusion
4Malperfusion syndromes Mesenteric ischemiaabdominal pain, nausea, and diarrheaassociated 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 paraplegia
5Strategy Central Aortic Repair Peripheral repair Aortic Replacement FenestrationEndograftRe-entry fenestrationPeripheral repairGraft BypassStentingTherapeutic AimTo restore the perfusion of the organsTo stop/limit the dissecting process to protect the organs
6A 59-year-old male with history of hypertension and COPD presented with abdominal pain, painful, pulseless right lower extremityTLTL
9IVUS/ TEE superior to angiography for identifying Primary and distal reentry tearsDocumenting 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.
10Stent placement Uncovered stents improve flow inadequate relief of dynamic obstruction after surgerystatic obstruction of abdominal aortic branch vessels, which is typically unaffected by proximal aortic stent- graft treatment and fenestration.The use of uncovered stents in the aorta and side branches may improve flow in aortic dissection (Figure 4). The most common indications include (1) inadequate relief of dynamic obstruction after surgery, stent-graft treatment, or fenestration and (2) static obstruction of abdominal aortic branch vessels, which is typically unaffected by proximal aortic stent-graft treatment and fenestration.In most cases of symptomatic static branch-vessel compromise, attempts are made to restore more normal flow dynamics by placing an uncovered stent via the aortic true lumen into the true lumen of the involved branch.
12impending rupture/Rupture Persistent pain despite good blood pressure controlAortic dissection with persistent uncontrolled hypertensionEvidence 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.
13Refractory hypertension International 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 )Circulation 2010;122:1283–9.
16Uncomplicated Acute type B aortic dissection Medical managementAnti-impulse therapyuncomplicated dissectionlack of appropriate facilitiespresence of comorbidities or morphology that made open surgery or TEVAR not feasibleIRAD: 3-yr survival = 78%Late aortic-related complications= 25-50%
17Prophylactic TEVAR?Thrombosed false lumen predicts lower event rates after type B dissectionRandomized 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:Circulation. 2009;120:
18High-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 Vasc Endovasc Surg.2006;32:€ J Thorac Cardiovasc Surg. 2007;134:ɸ Circulation. 2010;122: S74-80.∞J Am Coll Cardiol. 2007;50:
19Long-Term ManagementSpecific predictors of follow-up mortality includeFemale genderPrior aortic aneurysmAtherosclerosisPleural 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 dissectionSerial imaging at 1, 3, 6, and 12 months after discharge, and annually
20OUTCOME DATA FROM MEDICAL THERAPY Early 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 studiescombined early neurological complication event rate of 10.1% (95% CI: 7.5% to 13.5%)
21OUTCOME DATA FROM TEVAR in most of the papers, indication for TEVAR was complicated acute type B dissectioncriteria for defining complicated were variableEarly 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.
22OUTCOME DATA FROM OPEN SURGERY Early 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.
23MEDICAL THERAPY VS TEVAR AND OPEN 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 treatment
24Comparison of Early (30 Days/In-Hospital) Outcomes With Medical Therapy and TEVAR in Acute Type B Aortic Dissections
27Subacute type B aortic dissection Very limited outcome dataINSTEAD (Investigation of Stent Grafts in Aortic Dissection) trialPrimary success rate = 95.7%Early mortality = 2.8%Stroke rate =1.4%Spinal ischemia= 2.9%Required secondary procedures = 18%
28VIRTUE (VALIANT Thoracic Stent Graft Evaluation For the Treatment of Descending Thoracic Aortic Dissections- Post Marketing Surveillance Registry) Registry24 patients with complicated subacute type B aortic dissections treated with TEVARPrimary 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 hypertensionRecurrent thoracic painMalperfusion