santi trimarchi, md, phd - promedica international cme · presentation outline • irad and...

Thoracic AorticResearch Center

University of Milan

Update on IRADUpdate on IRAD

Santi Trimarchi, MD, PhDSanti Trimarchi, MD, PhD

Associate Professor of Vascular Surgery, University of MilanHead, Unit of Vascular Surgery II°Head, Unit of Vascular Surgery II°

Director, Thoracic Aortic Research CenterIRCCS Policlinico San Donato

IRAD Disclosures

• W.L. Gore & Associates, Inc.

• Active Sites

• Medtronic

• Varbedian Aortic Research Fund

• The Hewlett Foundation• The Hewlett Foundation

• The Mardigian Foundation

• UM Faculty Group Practice

• Terumo• Terumo

• Ann and Bob Aikens

Presentation Outline

• IRAD and IRAD-IVC actual data

• Retrograde Extension of Type B Dissection in Arch• Retrograde Extension of Type B Dissection in Arch

• Retrograde Extension of Type B Dissection in Ascending Aorta• Retrograde Extension of Type B Dissection in Ascending Aorta

• Uncomplicated Type B Dissection: In-H mortality/complications

• Trend in Surgical Treatment of Type A-AD

IRAD: 1996 - 2016

Active IRAD Sites [49]Active IRAD Sites [49]

IRAD – Total Patients

Type A

Type BType B

IRAD – Total Follow-Up

80007333

Follow-up defined as a patient having at least one completed follow-up form.

6100 (83.2%)

40003168 (57.3%)

Total Survived Followed Up

IRAD InterVentional Cohort – IVC: 2010 - 2016

Active IRAD IVC Sites [26]Active IRAD IVC Sites [26]

IRAD InterVentional Cohort - IVC

Aim: to better address surgical variablesAim: to better address surgical variables

131 variables131 variables

Cases Enrolled to Date

22512251

15441544

17591759

22512251

cases enrolled816816

970970

13481348

14921492 15051505 15441544

284284

462462

616616 668668

816816

AHA2010

ACC2011

AHA2011

ACC2012

AHA2012

ACC2013

AHA2013

ACC2014

AHA2014

ACC2015

AHA2015

ACC2016

• 1836 Type A cases• 1751 surgical• 39 endovascular

18,43%18,43%

• 39 endovascular• 45 hybrid• 1 surgical + endo

• 415 Type B cases81,56%81,56% • 415 Type B cases• 104 surgical• 280 endovascular• 29 hybrid

81,56%81,56%

Type A Type B

Retrograde Extension of Type B Dissection in Arch

Incidence 16.5%

G 1: 337 pts G 2: 67 pts

No difference in management

No difference in mortality

No difference in 5-year survival

Retrograde Extension of Type B Dissection in Ascending Aorta

Sem Thor Cardiovasc Surg, in pressSem Thor Cardiovasc Surg, in press

Methods and Results:

• between 1996 and 2014 were analyzed

• 99 patients (67 men; 63.2±14.0 years) with an entry tear in the DTA and retrogradeextension into the arch or ascending aorta.

Methods and Results:

• between 1996 and 2014 were analyzed

• 99 patients (67 men; 63.2±14.0 years) with an entry tear in the DTA and retrogradeextension into the arch or ascending aorta.

Independent predictors of retrograde type A AD were:

• increasing age (OR 1.0; 95% CI, 1.0 to 1.0; P=0.004)• increasing age (OR 1.0; 95% CI, 1.0 to 1.0; P=0.004)

• history of cocaine abuse (OR 4.9; 95% CI, 1.7 to 13.6; P=0.003)

• back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002)• back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002)

• non-white race (OR 0.4; 95% CI, 0.2 to 0.6; P<0.001).

Results:

MED SURG ENDO P

Initial management 44 33 22Initial management 44 33 22

Early mortality (30-day or in-hospital) 9.1% 18.2% 13.6% P=0.51

5-year survival (mean follow-up, 3.3 years) 86.7% 80.0% 90.9% P=0.67

• A trend of favorable early mortality wasobserved in patients with retrogradeextension till zone 1 (8.6%) versus intoextension till zone 1 (8.6%) versus intozone 0 (18.6%, P=0.14).

Earlymortalitymortality

Results:

• Patients in the SURG group presented with larger ascending aortic diameters thanMED and ENDO patients (P=0.04).MED and ENDO patients (P=0.04).

Results:

• The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extensionconfined to zone 1 (proximal arch, P<0.001)

MED 72.7%MED 72.7%ENDO 86.4%

Results:

• The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extensionconfined to zone 1 (proximal arch, P<0.001)

• Most of the SURG patients (71.8%) presented with AD extension into zone 0 (proximalto the innominate artery, P<0.001).

SURG71.8%

RetrogradeType A

Type AAD

Results:

Type A AD

Early mortality (30-day or in-hospital) 12.9% 20.0% P=0.001

5-year survival (mean follow-up, 3.3 years) 86.8% 89.5% P=0.965-year survival (mean follow-up, 3.3 years) 86.8% 89.5% P=0.96

Details of endovascular treatment

Variable ENDO

Dissection flap fenestration (%) 7 (31.8)

Descending thoracic aortic stent graft (%) 6 (27.3)

SMA stent (%) 2 (9.1)

Renal artery stent (%) 3 (13.6)Renal artery stent (%) 3 (13.6)

Iliac artery stent (%) 3 (22.7)

Tear in Descending Aorta

Thrombosed FLin Ascending Aorta

Tear and patent FLin Descending Aorta

2 month F-Up:Thrombosed FLin Descending Aorta Thrombosed FL

Uncomplicated Type B Dissection: In-H mortality/compl.

IRAD, unpublished

• Results• Results

• Patients in group I showed a trend for higher BMI

• The maximum aortic diameter at any level on initial imaging studieswas significantly larger in group I compared to group IIwas significantly larger in group I compared to group II

• patients in group I were more likely to have multiple intimal tears

The in-hospital mortality rate in Group I was 17.4%• Results The in-hospital mortality rate in Group I was 17.4%• Results

• 1836 Type A cases• 1751 surgical• 39 endovascular

18,43%18,43%

• 39 endovascular• 45 hybrid• 1 surgical + endo

• 415 Type B cases81,56%81,56% • 415 Type B cases• 104 surgical• 280 endovascular• 29 hybrid

81,56%81,56%

Type A Type B

IRAD IVC – Trends

MethodsMethods

• From patients enrolled in IRAD-IVC, only TAAD surgically repaired were included.

• Type B aortic dissection and those with endovascular/hybrid management were• Type B aortic dissection and those with endovascular/hybrid management wereexcluded.

• Patients were split into three equal groups based on time of intervention• Patients were split into three equal groups based on time of intervention(T1: 1996-2003; T2: 2004-2009; T3: 2010-2016).

IRAD IVC – Trends

ResultsResults

IRAD IVC – Trends

Results In-hospital mortalityResults In-hospital mortality

IRAD IVC – Trends

Results Cerebral perfusion managementResults Cerebral perfusion management

Ov erall T im e 1 T im e 2 T im e 3 p -v alu e

T rend p -v alu e

Cereb ralp erfu s ion

1256(84.2)

141 (67.1) 528 (89.5) 587(84.8) <.001 <.001

Antegrade 461(61.9)

76 (55.9) 303 (58.8) 369 (66.1) .015 .005(61.9)

Retrograde 461(38.9)

60 (44.1) 212 (41.2) 189 (33.9) .015 .005

IRAD IVC – Trends

Results Cerebral perfusion managementResults Cerebral perfusion management

Ov erall T im e 1 T im e 2 T im e 3 p - T rend p -Ov erall T im e 1 T im e 2 T im e 3 p -v alu e

T rend p -v alu e

H y p otherm icCircArres t

1257(85.5)

173 (80.1) 483 (85.9) 601 (86.8) .045 .030

IRAD IVC – Trends

Results Arterial Cannulation managementResults Arterial Cannulation management

p - T rend p -Ov erall T im e 1 T im e 2 T im e 3

p -v alu e

T rend p -v alu e

R Ax illary arterycannu lation

527(40.4) 39 (18.0) 175 (33.2) 313 (55.7) <.001 <.001

Fem oralcannu lation

615 (47.1) 165 (76.0) 281 (53.3) 169 (30.1) <.001 <.001

IRAD IVC – Trends

Results Aortic Valve managementResults Aortic Valve management

IRAD IVC – Trends

Results Aortic Valve managementResults Aortic Valve management

IRAD IVC – Trends

Results Aortic Root managementResults Aortic Root management

IRAD IVC – Trends

Results Ascending managementResults Ascending management

Ov erall T im e 1 T im e 2 T im e 3 p -v alu e

T rend p -v alu ev alu e v alu e

Op enp rocedu re

1455 (92.4) 205 (94.9) 565 (89.8) 685 (938) .007 .486

Sim p le as c.rep lacem ent

1172 (77.6) 165 (76.4) 392 (72.5) 615 (81.7) <.001 .004

IRAD IVC – Trends

Results Aortic Arch managementResults Aortic Arch management

IRAD IVC – Trends

Update on IRAD – Conclusions

• Retrograde extension of type B dissection into the Archmight be treated similarly to those with no retrogradeextension

• There is a subset of patients with acute retrograde type AAD who can be managed non-operatively with acceptableshort and long-term results.

• This implies that a selective approach may be reasonable,particularly among those with proximal extension limitedto the arch distal to the innominate artery.

• Initially uncomplicated type B dissection may in hospitalcomplicate in up to 10% patients

Update on IRAD IVC – Conclusions

• Utilization of adjunctive are associatedwith improved outcome in acute type A dissection

Update on IRAD IVC – Conclusions

• IRAD IVC can be useful for addressing surgical andendovascular issues in the management of acutedissection.

santi trimarchi, md, phd - promedica international cme · presentation outline • irad and...

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