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.