changing paradigms in aortic dissection · 2019-05-24 · changing paradigms in aortic dissection...
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Changing Paradigms in Aortic Dissection
Ali Azizzadeh, MD, FACS
Director, Vascular Surgery
Vice Chair, Department of SurgeryAssociate Director, Heart Institute
Cedars-Sinai Medical CenterLos Angeles, CA
Controversies & Advances inthe Treatment ofCardiovascular Disease
11/16/18
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Classifications of Dissection:Stanford and DeBakey
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Epidemiology
10-15 cases/100,000adults/year
2/3 type A
1/3 type B
Acute Type B Acute Type B
30% Cx
70% UnCx
Male: Female 2-5:1
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Paradigm Shift
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Management of Type B Aortic Dissection
OR / TEV AROR / TEV ARCX
TYPE BTYPE B
OMTOMTUNCX
TYPE BTYPE B
+ TEV AR+ TEV AR
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TYPE B Aortic Dissection
R ecom m endationsforT EVA R Class L evel
A cuteT ypeB Dissection
Ischem ia I A
S T S ExpertConsensusDocum ent2008T reatm entofDescendingT horacicA orticDisease
10585286 DOC
S venssonL G,etal.Ann Thorac Surg, 2008;85:S 1-41
Ischem ia I A
N oIschem ia IIb C
ClassIIb:usefulness/efficacy islessw ellestablished by evidence
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TYPE B Aortic Dissection
R ecom m endations Class L evel
Inuncom plicated T ypeB AD,m edicaltherapy shouldalw aysberecom m ended.
I C
ES C Guidelines2014R ecom m endedT reatm entofA orticDissection
10585286 DOC
Inuncom plicatedT ypeB A D,T EVAR shouldbeconsidered. IIa B
Incom plicatedT ypeB A D,T EVAR isrecom m ended. I C
Incom plicatedT ypeB AD,surgery m ay beconsidered. IIb C
ClassIIa:w eightofevidenceisinfavorofusefulness/efficacy
ErbelR ,etal.Eur Heart J.2014 N ov1;35(41):2873-926.
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Treatment of ATBAD
3° Referral Center
Multi-specialtyteam: CT, Vasc Surg
Critical care
Consultants
Advanced imaging: Advanced imaging: CT, MR, IVUS, TEE
Hybrid OR’s
Monitoring MEP,SSEP
Full spectrum ofopen/endovascularprocedures
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Admit CVICUCVC, arterial line, UOP
Admit CVICUCVC, arterial line, UOP
Anti-impulse TherapySBP<120, HR<60
Anti-impulse TherapySBP<120, HR<60
B-Blocker
Ca+2 Blocker
B-Blocker
Ca+2 BlockerRespiratory
DVT prevent
Respiratory
DVT prevent
Protocol
SBP<120, HR<60Control pain
SBP<120, HR<60Control pain
Ca+2 Blocker
Nitroglycerin
Nitroprusside
Ca+2 Blocker
Nitroglycerin
Nitroprusside
DVT prevent
Nutrition
Mobilization
DVT prevent
Nutrition
Mobilization
Reassessment
Blood pressure
Pain
Reassessment
Blood pressure
Pain
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Percutaneous InterventionSurgical Intervention
Percutaneous InterventionSurgical Intervention
Protocol
Rupture/ LeakMalperfusion (renal, visceral, peripheral)
Acute ExpansionRefractory Symptoms
Rupture/ LeakMalperfusion (renal, visceral, peripheral)
Acute ExpansionRefractory Symptoms
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UT Houston Series
2000 to 2014
1079 pts AD
532 ATBAD
60% Male
Mean age 60.6 ± 13.6 yrs
Median age = 60.5 yrs
Range 16 –98 yrs
Average Follow up: 3.7 yrs
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Aortic Dissection
1079 DISSECTIONS
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Aortic Dissection
535 532
1079 DISSECTIONS
535TYPE A
532TYPE B
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Aortic Dissection
535
294UNCOMPLICATED
1079 DISSECTIONS
535TYPE A
238COMPLICATED
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Complicated ATBAD
Rupture
Malperfusion: Neurologic
Spinal Cord Spinal Cord
Visceral (Celiac, SMA)
Renal
Lower Limb
Refractory Pain & HTN
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• In-hospitalm ortality significantlyhigherw ithm edicalm anagem ent
• 2/3rd m edicalrx deathsduetorupture
• R efractory pain/HT N independent
refractory pain/HTN
Refractory Pain and HTN
• R efractory pain/HT N independentpredictorofin-hospitalm ortality
• Interventionassociatedw ithim provedoutcom esoverm edicalm anagem entforrefractorypain/HT N
Medical Management: In-hospital mortality
No pain/HTN
Circulation2010;122:1283-9
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Types of Malperfusion
DynamicObstruction:• Prolapsed septum
into ostium duringcardiac cyclecardiac cycle
Static Obstruction: Dissection extends
into branch vessel
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Dynamic Obstruction
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Static Obstruction
Selective angiogram
Measure pull backpressures
Adjunctive stenting
Extend stent into TL
Williams DM, Patel HJ. Endovascular Therapy for Malperfusion in Acute Type B AorticDissection. Operative Techniques in Thoracic and Cardiovascular Surgery. p 2-11. 2009
Extend stent into TL
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Static Obstruction: SMADissection
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Static Obstruction: Left RenalArtery Dissection
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Goals of TEVAR for cATBAD
Seal off proximal entry tear
Alleviate malperfusion
Expand compressed truelumenlumen
Induce false lumenthrombosis
Prevent/treat rupture
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TEVAR DON’TS
Oversize >10%
Balloon Angioplasty
Place distal device first
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IVUS Adjunct to CTA,
angiogram andTEE
Wire placementin true lumen
Assesses Assessesadequacy oftreatment
Guide additionaltherapy
Diagnosecomplications
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True Lumen Compression
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IVUS after TEVAR
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Aortic Remodeling
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Mortality by Management Strategy
Total = 444Uncomplicated
N=271
C o m p l i c a t e d ( N = 1 7 3 )OR,
p-valueMedN=69
OpenN=52
TEVARN=37
Other CVN=15
Mortality5
1.9%13
18.8%6
11.5%5
13.5%3
20%* 8.8, 0.0001
* Uncomplicated compared to complicated type b aortic dissection
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Survival at 5 yrs foruATBAD was 76.6%
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Overall Survival: Max Aortic Diameter
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uATBAD High Risk Criteria
Aortic diam e te r>44m m is a predictorof mortality after adjustment forsignificant risk factors.
Decreased intervention-free survivalin those with FL>22m m and/or m axin those with FL>22m m and/or m axaortic diam e te r>44m m onadmission.
Age >60 y e arsis a risk factor formortality.
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Incidence of Risk Factors in AUTBAD
Risk Factors
TAD >44mm / FLD >22 / Age >60
1 Risk Factor 44%
2 Risk Factors 19%
3 Risk Factors 6%
Total 69%
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The Fate of the 31%:uTBAD & no high-risk criteria
OMT 5% mortality / year
10% intervention / year
OMT + TEV AR 5-10% procedural morbidity and
mortality
Aortic stabilization
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INSTEAD XL: 5 Year Analysis
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INSTEAD XL: 5 Year Extended Follow-up
Clin
icalEvide
nce
O M T +T EVAR :N om id-orlate-term Aortic
O M T O nly:S ignificantm id-andlate-term term Aortic
m ortalityandlate-termm ortality
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Complicated ATBAD
75 yo female with chestand back pain
CTA: ATBAD with aortoiliacthrombosis
On exam, mottled from the On exam, mottled from theumbilicus down
No motor or sensation inthe lower extremities
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CTA
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3D reconstruction
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OR
Open right femoralaccess (no pulse)
Diagnostic angiogram
Glide catheter/ glidewire access toascending aortaascending aorta
IVUS confirmedplacement of the wirein the true lumen fromRCFA to ascendingaorta
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Planned LSCA coverage
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Abdominal Aortogram
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Management RLE ischemia
Remove sheath
Open repair of RCFAarteriotomy
RLE angiogram?
Explore abdomen? Explore abdomen?
RLE fasciotomy?
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Completion angiogram after open repair RCFA/SFA
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HPI
P M H: Ascendingaorticaneurysm com plicatedby acutetypeA aorticdissection,P araparesis,N eurogenicbladder,Intracranialhem orrhage,T IA w ithsym ptom sofaphasia,Chronicleftfrontallobeinfarct,Chronicm icrovascularchanges,Hypertension,Hyperlipidem ia.
P S H: AscendingAortaR eplacem ent,Appendectom y,T onsillectom y.
• 72 y/om alereferredforsurgicalevaluationof6.8cm DT AA.
M edications: Glycolax,Florinef,Zetia,Ecotrin,Bystolic,P epcid,L asix,M ulti-vitam ins,M icro-K,Vitam inC,N eurontin,N orco,Caltrate,P lavix.
Allergies: N KA
FH: Father:history ofCAD,M aternalgrandfather:diedat43
S H: S m okingstatus:never,Alcohol:rarely
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Consult: 07/05/2018
Surgical evaluation: enlarging 6.8cm DTAA
Vitals
P hysicalExam
General: Aw ake,Alert,O riented
HEEN T : N orm ocephalic,atraum atic,scleraeareanictericBP : 123/70
P ulse: 75
R R : 18
T em p: 97.4
HEEN T : N orm ocephalic,atraum atic,scleraeareanicteric
N eck: S upple,nom asses
L ungs: Cleartoauscultation
Cardiac: R R R ,norub,m urm urorgallop
Abdom en: S oft,nondistended,nontender,bow elsoundspresent
Incisions: W ell-healedm ediansternotom y andrightinfraclavicularincision.S ternum stable.
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CTA
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Problem list
Ascending aortic pseudoaneurysm
Residual arch and type B dissection
6.8 cm DTAA
CAD
Cerebrovascular disease Cerebrovascular disease
Solution?
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Procedure 7/30/18
Repair of ascending aorta pseudoaneurysm and hemiarchreplacement
Ascending aorta to innominate artery bypass
CABG
DHCA with RCP DHCA with RCP
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CTA
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Residual 7 cm DTAA: Solution?
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Arch Debranching
RCCA to LCCA to LSCAbypass
LSCA dissection with flow tofalse lumenfalse lumen
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TEVAR: Zone 0
RAO
Markers for origin of aorto-innominate bypass
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Procedure: TEVAR
Device #1: covered theorigin of the innominate, leftcarotid and left subclavianarteries (zone 0).
Device #2: overlap tocover zones 2 and 3.
Device #3: deployedabove the celiac artery.
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Completion Angiogram
Successful exclusion of theextensive aortic aneurysmwith coverage of the nativewith coverage of the nativeinnominate, left commoncarotid and left subclavianarteries.
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Type 2 endoleak: LSCA origin with dissection
Management?
Amplatzer plug 14mm
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14mm Amplatzer Plug
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Hospital course
Patient tolerated the procedure well.
Oriented, sensory and motor function intact, noneurological issues.neurological issues.
Lumbar drain removed: 09/23/2018
Discharge from hospital: 9/26/18
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Conclusion
Paradigm shift in therapy for TBAD
All CTBAD should undergo TEVAR as first linetherapy
UTBAD patients with high risk criteria (2/3 of thecohort): TAD >44, FLD>22, Age >60 arecohort): TAD >44, FLD>22, Age >60 arecandidates for OMT+TEVAR
UTBAD patients with no high risk criteria (1/3 ofthe cohort): should be counseled about therisk/benefits of OMT vs. OMT+TEVAR
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Thank You