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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
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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
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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
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ProtocolProtocol
Surgical InterventionSurgical InterventionPercutaneous InterventionPercutaneous Intervention
Rupture/LeakRupture/LeakMal-perfusion (visceral, peripheral)Mal-perfusion (visceral, peripheral)
Acute ExpansionAcute ExpansionRefractory SymptomsRefractory Symptoms
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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)
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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)
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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)
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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%
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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.