1. Vascular Peter Lin, MD Southern Association for Vascular Surgery 2007 Postgraduate Course San Juan, Puerto Rico Penetrating Ulcer and Aortic Dissection Peter H. Lin, MD Baylor College of Medicine Houston, TX

2. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Presentation Outline Thoracic Aortic Pathology Aortic Dissection Classification Treatment Strategy Medical Stent-grafting Fenestration

3. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Acute Aortic Syndrome Aortic dissection Limited intimal tear with eccentric bulge Intramural hematoma Pre-dissection ? Associated with penetrating ulcer Penetrating ulcer Traumatic transection

4. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Hayter RG, Radiology 2006; 238:841-852

5. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Suspected Acute Aortic Syndrome MDCT in 373 Emergency Evaluation N=365 patients; men: 56%; women: 44% Mean age: 61 years (range 21 to 96); men: 61; women: 69 67 cases (18%) positive for acute aortic disorders (n=112) 23 (34%) acute aortic dissections; A=13 (19%), B=10 (15%) 14 (21%) acute aortic IMH; A=1 (2%), B=13 (19%) 20 (30%) acute penetrating ulcer; A=3 (5%), B=17 (25%) 44 (67%) new or enlarging aortic aneurysms 11 (17%) acute aortic ruptures Overall hospital mortality: 6% (4/67); A=2; B=2; 3/4 ruptured Hayter RG, Radiology 2006; 238:841-852

6. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Diagnosis of Chest Pain in the ER. von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.

7. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Presentation Outline Thoracic Aortic Pathology Aortic Dissection Classification Treatment Strategy Medical Stent-grafting Fenestration

8. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Acute Aortic Dissection Most common aortic emergency Incidence double that of ruptured abdominal aortic aneurysms Without treatment, 36-72% of patients will die within 48 hours (one week mortality of up to 91% )

9. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Aortic Dissection Classic presentation includes acute-onset, severe chest/back pain described as “tearing” or “ripping” Atypical presentations are common 15% of patients report NO pain Supportive findings include pulse deficit, new aortic regurgitation, tamponade, and focal neurological deficits Majority of patients have no specific physical findings

10. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Aortic Dissection: CXR Findings Klompas M. JAMA. 2002;287:2262-72.

11. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Abnormal CXR finding – a 1-cm separation between the intimal calcification and the adventitial outline of the descending aorta (the “calcium sign”), consistent with aortic dissection.

12. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Transesophageal Echocardiography of Aortic Dissection

13. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Presentation Outline Thoracic Aortic Pathology Aortic Dissection Classification Treatment Strategy Medical Stent-grafting Fenestration

14. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD

15. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Stanford Type A / DeBakey Type II Classification

16. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Stanford Type B / DeBakey III Classification

17. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Classification of Aortic Dissection 1.Classic with true and false lumens separated by intimal flap 2.Medial disruption with intramural hematoma or hemorrhage 3.Discrete/subtle aortic dissection bulge at tear site with no hematoma 4.Plaque rupture/penetrating aortic ulcer 5.Iatrogenic and traumatic dissection Task force on aortic dissection, European Society of Cardiology, Eur Heart J 2001;22: 1642-81

18. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Class 1: Classic dissection

19. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Aortic Dissection

20. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Class 2: Intramural hematoma

21. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Intramural Hematoma In contrast to typical aortic dissection, in which there is an intimal tear, IMH is caused by a spontaneous hemorrhage of the vasa vasorum of the medial layer, which weakens the media without an intimal tear. Clinical manifestations and the risk factors in IMH are similar to those in typical aortic dissection. IMH accounts for approximately 13% of the prevalence of acute aortic dissection.

22. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Intramural Hematoma

23. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Class 3: Discrete/subtle dissection

24. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Class 4: Penetrating ulcer

25. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Class 4: Penetrating ulcer

26. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Penetrating Ulcer

27. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Class 5: Iatrogenic/traumatic

28. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Presentation Outline Thoracic Aortic Pathology Aortic Dissection Classification Treatment Strategy Medical Stent-grafting Fenestration

29. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Initial Treatment of Type B Dissection Initial treatment: hypotensive medication Reserve intervention for 30-40% with: Rupture End-organ ischemia / malperfusion Localized false aneurysm Refractory hypertension Continuing pain

30. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Initial Medical Therapy Pain control: opiates Heart Rate control: Labetalol (bolus & maintenance) Heart Rate < 70 BP control: Nipride (Target SBP< 110, DBP<70) Monitor hemodynamics, UOP, swan ganz catheter placement, pulses

31. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Initial Treatment of Type B Dissection Initial treatment: hypotensive medication Reserve intervention for 30-40% with: Rupture End-organ ischemia / malperfusion Localized false aneurysm Refractory hypertension Continuing pain

32. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Mechanisms Involved in Aortic Dissection Type B Primary tear: usually close to the aortic isthmus End-organ ischemia: Static obstruction from extension of dissection into side branches Dynamic obstruction from the intimal flap bowing into the true lumen Combination of static and dynamic obstruction

33. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD MALPERFUSION MICHIGAN CLASSIFICATION

34. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD TREATING MALPERFUSION DYNAMIC OBSTRUCTION ENDOGRAFT ACROSS INTIMAL TEARS FENESTRATION STATIC OBSTRUCTION STENTS FOR UNCOMPLICATED STENOSIS WITH MECHANICAL THROMBECTOMY FOR STENOSIS COMPLICATED BY POST-OBSTRUCTIVE THROMBOSIS OF TRUE LUMEN OR EMBOLISM TO TRUE LUMEN

35. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD TX – Endografing vs. Fenetration

36. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Tx – Stenting for uncomplicated stenosis

37. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Endovascular Treatment Decreases pressure in false lumen by obliterating flow Causes thrombosis of the false lumen which is associated with good long term outcome Should treat dynamic obstruction of branches Can help with static obstruction of branches Induction of aortic remodeling Primary tear: cover with stent graft

38. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Thoracic Stent-Grafting for Dissection

39. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Thoracic Stent-Grafting for Dissection

40. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Thoracic Stent-Grafting for PU

41. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Thoracic Stent Grafts TAG, WL Gore & Associates Nitinol stent with polytetrafluoroethylene Talent, Valiant, Medtronic AVE Nitinol stent with polyester TX-2, Cook Inc. Stainless steel with polyester Endofit, Endomed Inc. Nitinol stent with polytetrafluoroethylene

42. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Thoracic Stent-Graft

43. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Zenith Thoracic Stent-Graft

44. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Fenestrated Thoracic Endograft

45. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD

46. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Endovascular Treatment (Non-endograft option) Static obstruction: u ncovered stents in origin of branches Dynamic obstruction: percutaneous fenestration of the intimal flap

47. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD WHAT FENESTRATION DOES CREATES HOLE IN THE FLAP SEPARATING FALSE AND TRUE LUMEN RAISES PRESSURE IN THE TRUE LUMEN PROMOTES FLOW IN THE FALSE LUMEN

48. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD WHAT FENESTRATION DOES NOT DO DOES NOT REDUCE PRESSURE IN THE FALSE LUMEN DOES NOT “DECOMPRESS” THE FALSE LUMEN DOES NOT MODIFY THE RISK OF ACUTE AORTIC RUPTURE IN TYPE A DISSECTIONS DOES NOT REDUCE LONG-TERM ANEURYSMAL DEGENERATION OF THE FALSE LUMEN

49. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Fenestration & stents = Rx for malperfusion Static obstruction (S) Aortic obstruction due to thrombosing false lumen (F/S) Dissection presenting with paraplegia Dynamic obstruction when entry tear is unsuitable for endografts (F/S) tear in ascending aorta or arch dissections with entry

50. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD FENESTRATION CONTRAINDICATIONS Sever aortic insufficiency Leaking false lumen Coronary artery dissection with MI or right heart failure

51. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Eggebrecht et al, Heart 2003: 89: 973

52. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD A 61 y/o male with acute type B thoracic dissection. Despite of maximal medical therapy, he developed right leg arterial occlusion. Endovascular fenestration was performed Eggebrecht et al, Heart 2003: 89: 973

53. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Endovascular fenestration was performed. Right groin access and intimal flap was punctured at the aortic bifurcation using a Brockenborough needle into the false lumen. PTA was performed to enlarge the intimal fenestrated site Eggebrecht et al, Heart 2003: 89: 973

54. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Although balloon PTA has reestablished the flow to the right leg, the flow remained impaired. A 14 stent was placed from the aorta into the right common iliac artery. His right leg perfusion was restored. Eggebrecht et al, Heart 2003: 89: 973

55. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Uncomplicated type B aortic dissection should be treated with medical therapy Symptomatic type B aortic dissection refractory to medical intervention should undergo repair Open surgical repair – physiologically suitable patients Aortic stent-graft – to cover entry site Stent – to treat static obstruction Fenestration – to treat dynamic obstruction CONCLUSIONS

56. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Endovascular Treatment Principles yes no fenestration prolonged malperfusion? A B surgical medical Suitable entry tear? endograft yes no dissection type? residual malperfusion? no yes Goals: Treatment of malperfusion and thrombosis of false lumen

57. VASCULAR Vascular “Penetrating Ulcer and Aortic Dissection” Peter Lin, MD Be Prepared and Know Your Tools