aortic surgery symposium 2010 new york, ny april, 2010 department of cardiothoracic and vascular...

Aortic Surgery Symposium 2010

New York, NYApril, 2010

Department of Cardiothoracic and Vascular Surgery

The University of Texas Medical School at HoustonMemorial Hermann Heart & Vascular Institute

Anthony Estrera, MD, C.D. Nugent, BA, Jennifer Goodrick, RN, Charles Miller, III, PhD, Hazim Safi, MD

Acute Type B Aortic Dissection: Results of a Standardized Management Protocol

PurposePurpose

• Analyze our experience with Acute Type B Aortic dissection using a standardized medical management protocol

• Analyze our experience with Acute Type B Aortic dissection using a standardized medical management protocol

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MethodsMethods

January 2001 – May 2009January 2001 – May 2009

308 Acute Type B Dissection308 Acute Type B Dissection

35%35%65%65%

Median age was 62 years (16-94)Median age was 62 years (16-94)

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• Rupture• Mal-perfusion• Stroke/Coma• Paraplegia• Visceral-Bowel,

Hepatic• Renal failure• Peripheral vascular

• Rupture• Mal-perfusion• Stroke/Coma• Paraplegia• Visceral-Bowel,

Hepatic• Renal failure• Peripheral vascular

Complicated DissectionComplicated Dissection

ProtocolProtocolAdmit CVICUAdmit CVICU

C-line, arterial line, UOPC-line, arterial line, UOP

Anti-impulse TherapyAnti-impulse TherapySBP<120, MAP<80SBP<120, MAP<80

Control painControl pain

B-B-BlockerBlockerCaCa+2+2 Blocker BlockerNitroglycerinNitroglycerinNitroprussideNitroprusside

RespiratoryRespiratoryDVT preventDVT prevent

NutritionNutritionMobilizationMobilization

ReassessmentReassessmentBlood pressureBlood pressure

Pain Pain

ProtocolProtocol

Surgical InterventionSurgical InterventionPercutaneous InterventionPercutaneous Intervention

Rupture/LeakRupture/LeakMal-perfusion (visceral, peripheral)Mal-perfusion (visceral, peripheral)

Acute ExpansionAcute ExpansionRefractory SymptomsRefractory Symptoms

IV MedicationsIV Medications

• 98% required one IV medication

• 80% required multiple IV medications

• Median time SBP < 140 mmHG 48 hr (0-720 hr)

• Median time control pain 48 hr (0-264 hr)

• 98% required one IV medication

• 80% required multiple IV medications

• Median time SBP < 140 mmHG 48 hr (0-720 hr)

• Median time control pain 48 hr (0-264 hr)

ResultsResults

• ICU LOS 8 days (1-58 days)

• LOS 15 days (1-88 days)

• ICU LOS 8 days (1-58 days)

• LOS 15 days (1-88 days)

ResultsResults

Hospital mortality Hospital mortality 7.8% (24/308)7.8% (24/308)

Surgical mortality Surgical mortality 15% (8/54) 15% (8/54)

Non-surgical mortalityNon-surgical mortality 6.3% (16/254) 6.3% (16/254)

Hospital mortality Hospital mortality 7.8% (24/308)7.8% (24/308)

Surgical mortality Surgical mortality 15% (8/54) 15% (8/54)

Non-surgical mortalityNon-surgical mortality 6.3% (16/254) 6.3% (16/254)

ResultsResults

Complicated Complicated 41% 41% 18%18%

Uncomplicated Uncomplicated 59% 59% 0.5%0.5%

(p<0.0003)

Complicated Complicated 41% 41% 18%18%

Uncomplicated Uncomplicated 59% 59% 0.5%0.5%

(p<0.0003)

(N=308)

Incidence Mortality

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SummarySummary

• Mortality 7.8%• Complicated (41%) 18%

• Uncomplicated (59%) 0.5%

• Morbidity remains significant

• Early Intervention 15%

• Mortality 7.8%• Complicated (41%) 18%

• Uncomplicated (59%) 0.5%

• Morbidity remains significant

• Early Intervention 15%

ConclusionsConclusions

• Medical management for acute type B aortic dissection (uncomplicated) is associated with acceptable outcomes.

• Outcomes of complicated acute type B aortic dissection may warrant use of endovascular approaches.

• Medical management for acute type B aortic dissection (uncomplicated) is associated with acceptable outcomes.

• Outcomes of complicated acute type B aortic dissection may warrant use of endovascular approaches.