Aneurysms: When to Treat Andres Schanzer, MD University of - - PDF document

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4/4/2019 Penetrating Ulcers, IMH, Saccular Aneurysms: When to Treat Andres Schanzer, MD University of Massachusetts Medical School April 4 th , 2019 UCSF Vascular Symposium, CA 1 Disclosures Fenestrated Case Proctoring, Cook Medical 2 1

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Penetrating Ulcers, IMH, Saccular Aneurysms: When to Treat

Andres Schanzer, MD University of Massachusetts Medical School April 4th, 2019 UCSF Vascular Symposium, CA

Disclosures

Fenestrated Case Proctoring, Cook Medical

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Repair ?

Observation: Risk of Rupture Risk of death from rupture Repair: Risk of Morbidity, Mortality, Secondary procedures

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4/4/2019 3 5.5 CENTIMETERS

1998

Penetrating Ulcer IMH Saccular Aneurysm

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Definitions

Aortic Dissection: Intimal tear with blood

dissecting into the medial layer of the aortic wall

Penetrating Ulcer: Defect in the elastic

lamina of the aortic wall leading to localized medial disruption

Intramural Hematoma: Collection of blood

that is confined to the aortic media

Saccular Aneurysm: Non-fusiform,

asymmetric bulge, appearing on one side of the aorta.

Medical Treatment

Aimed to reduce hemodynamic forces that can exacerbate

condition

IV antihypertensives (beta blocker + vasodilator) is initiated

– Beta blocker is initiated first to avoid reflex sympathetic stimulation from direct vasodilatation – Goal HR < 80, Goal SBP < 120

Patients should be admitted to the ICU for continuous BP

monitoring, telemetry, and monitoring of UOP.

Patients can be transitioned to oral anti-HTN medications

when BP is stable and pain resolved.

Medically treated patients need to be followed with serial CT

scans

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Defect in the elastic lamina leading to localized

medial disruption and potential rupture

Affect 2-3% of population
2-8% of acute aortic syndromes
Most common location is descending aorta
Hypertension most common comorbidity (92%)

Coady et al. JVS, 1998. Harris et al. JVS, 1994.

Penetrating Ulcer Penetrating Ulcer-Treatment

Conservative
TEVAR
Open

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Penetrating Ulcer-Presentation

Pain (≈75%)
Incidental finding (≈ 25%)

Cho et al. J Thorac Cardiovasc Surg, 2004.

Penetrating Ulcer-Treatment

Conservative

– Harris et al: 1/3 progress to aneurysm – Cho et al: 1/3 progress to require treatment – Hussain et al: 80% resolution of PAU with no progression to aneurysm or rupture

Cho et al. J Thorac Cardiovasc Surg, 2004. Harris et al. JVS, 1994. Hussain et al. JVS, 1989.

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Penetrating Ulcer-Treatment

Indications

– Serial enlargement on interval scans – Persistent symptoms?

Risk/Benefit

– Length of coverage required – Side branch involvement – Relationship to arch

Penetrating Ulcer-Treatment

Indications

– Serial enlargement on interval scans – Persistent symptoms?

Risk/Benefit

– Length of coverage required-SHORT – Side branch involvement-NONE – Relationship to arch-DISTAL TO LSCA

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Penetrating Ulcer-Treatment

Indications

– Serial enlargement on interval scans – Persistent symptoms?

Risk/Benefit

– Length of coverage required-LONG – Side branch involvement-VISCERAL/ARCH – Relationship to arch-PROX TO LSCA

Zones of the Aortic Arch

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Potential Solutions

1. Hybrid repair
2. Total endovascular
3. Open

Hybrid Repair-Zone 1

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Hybrid Repair-Zone 0

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4/4/2019 12 HEAD FEET

Aorta to Innominate bypass graft Endovascular access “Chimney” Innominate Artery

n=104 Heterogeneous group (Zone 0, 1, 2) Mean follow-up—29 months Technical success—97% 30 day mortality—(6) 5.8% 30 day stroke—(4) 3.8% Retrograde Type A dissection—(4) 3.8% Freedom from endoleak at 5 years—88%

Single independent predictor of mortality: landing in Zone 0 Total Debranching (n=16) Odds Ratio 30 day mortality Odds ratio, 11.1, 95% CI, 1.86-15.45)

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Inominate Branch: 12 mm Left Carotid Branch: 8 mm

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1 Month 2 Year

Intramural Hematoma

Intramural hematoma: A collection of

blood confined to the aortic media

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Etiology and Risk Factors

Atherosclerotic plaque penetrates the

internal elastic lamina, allowing hematoma formation within the media.

Risk factors: age, hypertension, significant

atherosclerotic disease

Spontaneous rupture of vaso vasorum

within the media (less likely) vs. PAU that is unseen on imaging studies

Treatment

Natural history of asymptomatic disease is

complete resolution in 50-80% of cases

Some studies of IMH show a 16% progression to

dissection on a second imaging study

Mainstay of treatment is medical
Indications for surgical treatment:

– Aneurysmal degeneration – Rupture/impending rupture – Major progression in size despite medical therapy

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History of Present Illness

59 y/o female in usual state of health developed

acute onset of sharp, stabbing, back pain. No abdominal pain, no extremity pain.

Past Medical History

HTN, HLD

Index Admission

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Post TEVAR 2 years later

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4 years later (6 years total)

SMA Celiac

R Renal L Renal

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Questions

Was TEVAR appropriate?
Was the TEVAR treatment length

appropriate?

Was the timing of TEVAR appropriate?
What is the natural history if we had not

placed a TEVAR graft?

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Penetrating Ulcers, IMH, Saccular Aneurysms: When to Treat

Observation: Risk of Rupture Risk of death from rupture Repair: Risk of Morbidity, Mortality, Secondary procedures

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