Type B Dissection Sub-Categories Acute Complicated Rupture - - PowerPoint PPT Presentation

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Type B Dissection Sub-Categories Acute Complicated Rupture - - PowerPoint PPT Presentation

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Disclosure Nothing to disclose Type B Dissection On Whom to Operate on and When to do it Charles Eichler Professor, Department of Surgery Division of Vascular and Endovascular Surgery University of California San Francisco 4/14/2016 2 TBAD

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 1

Type B Dissection On Whom to Operate on and When to do it

4/14/2016

Charles Eichler Professor, Department of Surgery Division of Vascular and Endovascular Surgery University of California San Francisco

Disclosure

Nothing to disclose

4/14/2016 TBAD 2

Title Garamond – 38pt font Subtitle Garamond Italic – 38pt font

4/14/2016

Presenter’s Name Office or Department Name

Uncomplicated Type B dissections

Type B Dissection Sub-Categories

  • Acute Complicated
  • Rupture
  • Malperfusion
  • Chronic
  • Potential reasons for intervention
  • Aneurysm degeneration
  • Up to 30% become aneurysmal1
  • Rupture
  • Dissection extension
  • Malperfusion or ischemic events

1Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with

type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC: Cardiovascular Interventions 2013;6(8):876-882.

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 2

Type B Dissection Sub-Categories

  • Uncomplicated
  • Potential reasons for intervention
  • “High Risk” patients

Can we Identify high risk patients that could benefit from early TEVAR than Best Medical Therapy alone? What are the risks of treatment?

Benefits and Risks of Endovascular vs BMT

Risk Benefit

Long-term

  • utcomes

Patient management Aortic Remodeling Stroke Paraplegia Procedural Complications

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 3

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

184 patients (108 type A) with acute dissection Followed for 6.4 years 49 patients died during follow up, 31 suddenly 81% survived for 5 years Entry tear size ≥ 10 mm and entry tear in a proximal location was associated with increased dissection-related adverse events and mortality

4/14/2016 TBAD 10

Conclusion: Type B aortic dissections that are not symptomatic but have entry tears ≥ 10 mm in a proximal location should be considered for TEVAR given that 63% of deaths during follow up were sudden with no precedent symptoms

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

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False Lumen Measurement

Initial Presentation

Measurement at Upper Thoracic (UT) or Distal to Arch

Song J-M, Kim S-D, Kim J-H, et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection J Am Coll Cardiol 2007;50:799-804.

False lumen diameter > 22 has more discriminatory ability to predict late aneurysmal change than does total aorta diameter. Pts with FL > 22 should have increased surveillance or consideration for TEVAR

4/14/2016

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

Partial False Lumen Thrombosis

1 year follow-up

Tsai TT, Evangelista A, Nienaber CA, Myrmel T, Meinhardt G, Cooper JV et al. Partial thrombosis of the false lumen in patients with acute type B aortic

  • dissection. N Engl J Med 2007;26;357:349-59
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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/14/2016 5

Literature-Based “High Risk” Predictors used in Retrospective Imaging Evaluation

Initial Presentation: Primary entry tear diameter ≥ 10 mm Primary entry tear location Total aortic diameter ≥ 4 cm False lumen diameter ≥ 22 mm Partial false lumen thrombosis Fusiform index ≥ .64

Fusiform Index

Initial Presentation

Marui A, Mochizuki T, Koyama T, Mitsui N. Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events. Journal of Thoracic & Cardiovascular Surgery 2007;134(5):1163-1170.

FI > .64 is associated with increased adverse events

4/14/2016

Summary

Literature-based “high risk” predictors may help identify uncomplicated Type B dissection patients that could benefit from early TEVAR intervention Early TEVAR intervention should be accompanied by evidenced- based medical management

  • Calcium channel blockers (decreased central aortic pressure)
  • Beta blockers (decrease heart rate)
  • HMG CoA Reductase inhibitors
  • ACE/ARBs
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Thank you for your attention

Evangelista A, Salas A, Ribera A, et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and

  • location. Circulation 2012;125(25):3133-3141.

Nienaber CA, Kische S, Rousseau H, et al; INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circulation: Cardiovascular Interventions 2013;6(4):407-416. Loewe C, Czerny M, Sodeck GH, et al. A new mechanism by which an acute type B aortic dissection is primarily complicated, becomes complicated, or remains uncomplicated. Annals of Thoracic Surgery 2012;93(4):1215-1222. Weiss G, Wolner I, Folkmann S, et al. The location of the primary entry tear in acute type B aortic dissection affects early outcome. European Journal of Cardiothoracic Surgery 2012;42(3): 571-576. Kato M, Bai H, Sato K, et al. Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase. Circulation 1995;92(9)Supplement II: 107-112. Kudo T, Mikamo A, Kurazumi H, et al. Predictors of late aortic events after Stanford type B acute aortic dissection Journal of Thoracic & Cardiovascular Surgery 2014;148(1):98-104. Onitsuka S, Akashi H, Tayama K, et al. Long-term outcome and prognostic predictors of medically treated acute type B aortic dissections. Annals Thoracic Surgery 2004;78(4):1268-1273. Takahashi J, Wakamatsu Y, Okude J, et al. Maximum aortic diameter as a simple predictor of acute type B aortic dissection. Annals of Thoracic & Cardiovascular Surgery 2008;14(5):303-310. Song JM, Kim SD, Kim JH, et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. Journal of the American College of Cardiology 2007;50(8):799-804. Tanaka A, Sakakibara M, Ishii H, et al. Influence of the false lumen status on clinical outcomes in patients with acute type B aortic

  • dissection. Journal of Vascular Surgery 2014;59(2):321-326.

Tsai TT, Evangelista A, Nienaber CA, et al; International Registry of Acute Aortic Dissection. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. New England Journal of Medicine 2007;357(4):349-359. Marui A, Mochizuki T, Koyama T, Mitsui N. Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events. Journal of Thoracic & Cardiovascular Surgery 2007;134(5):1163-1170.