santi trimarchi, md, phd - promedica international cme · presentation outline • irad and...
TRANSCRIPT
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
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.
6000
7000
8000
6100 (83.2%)
7333
4000
5000
6000
3000
40003168 (57.3%)
1000
2000
0
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
IRAD InterVentional Cohort - IVC
Cases Enrolled to Date
22512251
2251
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
IRAD InterVentional Cohort - IVC
• 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
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
Retrograde Extension of Type B Dissection in Arch
Retrograde Extension of Type B Dissection in Arch
XXXX
Incidence 16.5%
Retrograde Extension of Type B Dissection in Arch
G 1: 337 pts G 2: 67 pts
Retrograde Extension of Type B Dissection in Arch
No difference in management
Retrograde Extension of Type B Dissection in Arch
No difference in mortality
Retrograde Extension of Type B Dissection in Arch
No difference in 5-year survival
Retrograde Extension of Type B Dissection in Arch
No difference in 5-year survival
Retrograde Extension of Type B Dissection in Arch
No difference in 5-year survival
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
Retrograde Extension of Type B Dissection in Ascending Aorta
Sem Thor Cardiovasc Surg, in pressSem Thor Cardiovasc Surg, in press
Retrograde Extension of Type B Dissection in Ascending Aorta
Retrograde Extension of Type B Dissection in 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.
Retrograde Extension of Type B Dissection in 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).
Retrograde Extension of Type B Dissection in Ascending Aorta
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
18.6%
Retrograde Extension of Type B Dissection in Ascending Aorta
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).
Retrograde Extension of Type B Dissection in Ascending Aorta
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).
• 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%
Retrograde Extension of Type B Dissection in Ascending Aorta
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).
• 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%
Retrograde Extension of Type B Dissection in Ascending Aorta
RetrogradeType A
Type AAD
P
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
Retrograde Extension of Type B Dissection in Ascending Aorta
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)
Retrograde Extension of Type B Dissection in Ascending Aorta
Tear in Descending Aorta
Retrograde Extension of Type B Dissection in Ascending Aorta
Thrombosed FLin Ascending Aorta
Tear and patent FLin Descending Aorta
2 month F-Up:Thrombosed FLin Descending Aorta Thrombosed FL
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
Uncomplicated Type B Dissection: In-H mortality/compl.
IRAD, unpublished
Uncomplicated Type B Dissection: In-H mortality/compl.
Uncomplicated Type B Dissection: In-H mortality/compl.
• Results• Results
• Patients in group I showed a trend for higher BMI
Uncomplicated Type B Dissection: In-H mortality/compl.
• Results• Results
• 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
Uncomplicated Type B Dissection: In-H mortality/compl.
• Results• Results
• 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
Uncomplicated Type B Dissection: In-H mortality/compl.
The in-hospital mortality rate in Group I was 17.4%• Results The in-hospital mortality rate in Group I was 17.4%• Results
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 InterVentional Cohort - IVC
• 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
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
d
IRAD IVC – Trends
Results Aortic Valve managementResults Aortic Valve management
d
IRAD IVC – Trends
Results Aortic Root managementResults Aortic Root management
dd
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
Results Aortic Arch managementResults Aortic Arch management
IRAD IVC – Trends
Results Aortic Arch managementResults Aortic Arch management
Update on IRAD – Conclusions
Update on IRAD – Conclusions
XX
• Retrograde extension of type B dissection into the Archmight be treated similarly to those with no retrogradeextension
XXX
Update on IRAD – Conclusions
XX
• Retrograde extension of type B dissection into the Archmight be treated similarly to those with no retrogradeextension
XXX
• There is a subset of patients with acute retrograde type AAD who can be managed non-operatively with acceptableshort and long-term results.
Update on IRAD – Conclusions
XX
• Retrograde extension of type B dissection into the Archmight be treated similarly to those with no retrogradeextension
XXX
• 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.
Update on IRAD – Conclusions
• 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.