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

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

4/4/2019 3 Repair ? Observation: Repair: Risk of Rupture Risk of Morbidity, Mortality, Risk of death from rupture Secondary procedures 4 2

4/4/2019 5.5 CENTIMETERS 1998 5 Penetrating Ulcer IMH Saccular Aneurysm 6 3

4/4/2019 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. 7 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 8 4

4/4/2019 Penetrating Ulcer • 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%) Harris et al. JVS, 1994. Coady et al. JVS, 1998. 9 Penetrating Ulcer-Treatment • Conservative • TEVAR • Open 10 5

4/4/2019 Penetrating Ulcer-Presentation • Pain (≈75%) • Incidental finding (≈ 25%) Cho et al. J Thorac Cardiovasc Surg, 2004. 11 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 Harris et al. JVS, 1994. Cho et al. J Thorac Cardiovasc Surg, 2004. Hussain et al. JVS, 1989. 12 6

4/4/2019 Penetrating Ulcer-Treatment • Indications – Serial enlargement on interval scans – Persistent symptoms? • Risk/Benefit – Length of coverage required – Side branch involvement – Relationship to arch 13 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 14 7

4/4/2019 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 15 Zones of the Aortic Arch 16 8

4/4/2019 Potential Solutions 1. Hybrid repair 2. Total endovascular 3. Open 17 Hybrid Repair-Zone 1 18 9

4/4/2019 19 Hybrid Repair-Zone 0 20 10

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4/4/2019 HEAD Innominate Artery Aorta to Innominate bypass graft Endovascular access “Chimney” FEET 23 Single independent predictor of n=104 mortality: landing in Zone 0 Heterogeneous group (Zone 0, 1, 2) Mean follow-up — 29 months Total Debranching (n=16) Technical success — 97% 30 day mortality — (6) 5.8% Odds Ratio 30 day mortality 30 day stroke — (4) 3.8% Retrograde Type A dissection — (4) 3.8% Odds ratio, 11.1, 95% CI, 1.86-15.45) Freedom from endoleak at 5 years — 88% 24 12

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4/4/2019 Inominate Branch: 12 mm Left Carotid Branch: 8 mm 27 28 14

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4/4/2019 1 Month 2 Year 31 Intramural Hematoma • Intramural hematoma: A collection of blood confined to the aortic media 32 16

4/4/2019 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 33 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 34 17

4/4/2019 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 35 Index Admission 36 18

4/4/2019 Post TEVAR 37 2 years later 38 19

4/4/2019 4 years later (6 years total) 39 SMA Celiac R Renal L Renal 40 20

4/4/2019 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? 41 42 21

4/4/2019 43 Penetrating Ulcers, IMH, Saccular Aneurysms: When to Treat Observation: Repair: Risk of Rupture Risk of Morbidity, Mortality, Risk of death from rupture Secondary procedures 44 22

4/4/2019 Thank You. 45 23