Acute P AU & IMH in Proximal Descending Aorta CUS P 2016 - - PowerPoint PPT Presentation

Acute P AU & IMH in Proximal Descending Aorta

CUS P 2016 Toronto

I Always Treat Aggressively

“ … .if t here is an anat omically favorable endovascular solut ion”

RS McClure MD  University of Calgary

Penetrating Atherosclerotic Ulcers (P AU) & Intramural Hematomas (IMH)

• Entities within the spectrum of Acute Aortic S

yndrome continuum

• IMH – bleed within the media of the aortic wall in the absence of a

clearly defined primary intimal tear site

• P

AU –An ulcerated atherosclerotic lesion that penetrates the internal elastic lamina into the media

• Main obj ective of IMH & P

AU treatment is to prevent progression to classic aortic dissection and/ or aortic rupture

Acute P AU or IMH S

• What Are We Really Talking About?
• P

AU or IMH present with symptoms and impending rupture or rupture

• This is acute process & patient unstable = Aggressively Treat!
• P

AU or IMH found incidentally in asymptomatic patient

• This is chronic process & patient stable = Conservatively manage!
• P

AU or IMH presents with symptoms but clinically settles = ? ? ? ? ?

S

• What Do We Really Know?
• Pat ient s are older wit h more co-morbidit ies

At herosclerot ic burden / HTN / S mokers / Male

• Nat ural hist ory for IMH & P

AU not fully underst ood or properly defined Dat a quit e limit ed

• Case report s / S

mall series / Ret rospect ive

• Varied lesion locat ions combined int o conj oined analyses
• Varied pat ient present at ions combined int o conj oined analyses
• Conflict ing experiences → Asia (indolent ) vs. t he West
• Neit her pat hology is st at ic

Each rat her unpredict able → unsuspect ing progression brings serious consequences

• TEV

AR is a low impact and high yield in t he right anat omy

AGGRES S IVELY TREAT ALL ACUTE P AU AND IMH IN THE PROXIMAL DES CENDING AORTA?

YES !!

Rationale

• S

ingle Center Retrospective Case S eries S panning 19 years (1995 – 2014)

• 10/ 55 (18%

) patients with IMH had rupture state on admission

• 17/ 53 (32%

) patients with P AU had rupture state on admssion

 May speak to the instability of these lesions in the acute phase?

Both > type A (8% ) or B dissection (4% ) (p<.001)

• For IMH with follow-up imaging (mean follow up 9.4 months)
• 8/ 14 (57%

) worsened

• 6/ 14 (43%

) underwent surgery

• For P

AU with follow-up imaging (mean follow up 34.3 months)

• 6/ 20 (30%

) worsened and underwent surgery

• 11/ 20 (55%

) showed no change

• No operative deaths occurred for patients with non rupture state.

Tick Tick… ..Boom!

• IMH & P

AU Descending Aorta, 38/ 86 = 44% immediate surgery 48/ 86 = 56% initial medical management 6/ 48 = 13% cross over to surgery thereafter

• Total Operative Group

44/ 86 = 51%

• Rigorous Literature Review = 30 publication
• 925 patients suffered type B IMH
• 731 conservative management (79%

)

• 108 surgical management (12%

)

• 86 TEVAR (9%

)

• Weighted 30-day mortality 3.9%

, overall late mortality 14.3% (mean 36 months)

• Late mortality in type B IMH was due to aortic complications in at least 50%
• f cases

Mortality & Treatment S trategies

Medical Treatment = mean mortality rate in acute phase was 3.4% = 3 year aortic related mortality was 5.4% S urgical Treatment = mean mortality rate in acute phase was 16% = 3 year aortic related mortality was 23.2% KEY POINT  Used for failed med mgmt and/ or progression to dissection/ aneurysm/ rupture Endovascular Treatment = Data was limited (only 9 articles) = mean mortality rate in acute phase was 4.6% = 3 year aortic related mortality 7.1% KEY POINT  Indications not well established but generally was utilized in patients who showed signs of aortic rupture or aortic enlargement

Endovascular Treatment 1st Line?

• Potential Advantages
• P

AU – Focal entity, segmental

• Theoretically ideal for TEVAR coverage and exclusion
• IMH – Coverage of discreet ulceration/ disruption sites
• Pathophysiogic evidence to support theory

Endovascular Treatment 1st Line?

• Concerns
• P

AU – Heavy atherosclerotic burden

• Vascular complications, Embolic complications
• Endoleaks
• IMH – Heavy atherosclerotic burden though less than P

AU

• S

econdary endoleaks from intimal rupture in friable tissues

• Pseudoanerysm formation

• Rigorous Literature Review – 20 year period (1994 – 2014)
• 31 S

tudies included in final qualitative analysis with 310 total patients treated by TEVAR for P AU

• 9%
• f patients were asymptomatic (chronic?

)

• IMH as a component of P

AU identified in 45%

• f cohort

Endovascular Results - P AU

• Technical success 98.3%
• Data on landing zone available in 253 cases
• Zone 0

6 patients

• Zone 1 to 2

39 patients

• Zone 3 to 4

207 patients

• 1 Device 80%
• f cases

Endovascular Results - P AU

• 30 – day mortality 4.8%

(15/ 310)

• 6 multi-organ failure
• 2 acute respiratory distress
• 3 aortic rupture (2 thoracic, 1 abdominal)
• 1 retroperitoneal bleed
• 1 aortoesophageal fistula
• 1 mesenteric ischemia
• Early morbidity 36.4%
• Vascular access problems 16.1%
• Endoleaks 8%

(type 1 9 cases, type 2 in 10, type 3 or 4 in 6 cases)

• S

troke 2.4%

• Permanent paraplegia 1 patient

Concluding Comments

• Data is sparse – natural history is truly unknown
• Type B IMH/ P

AU is not a benign entity

• High morbidity and mortality
• TEVAR is good option in appropriately selected patients
• Technology will only continue to get better