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“Non‐Traumatic Aortic Emergencies”

Gregory D. Rushing, MDAssistant Professor, Division of Cardiac Surgery

September 15, 2017

Objectives

Thoracic Aortic Anatomy

Acute Aortic Syndrome Dissection PAU IMH

Surgical/Medical Intervention Historical Current Future

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Remember, Surgery is Cool…..

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Anatomy

Anatomy

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70% 15% 10%

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Anatomy

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Eat more chicken

Pathology

Dissection

Intramural hematoma

Penetrating atherosclerotic ulcer

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Dissection Diagnosis

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ACC/AHA Guidelines:

Aortic Dissection

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60% 10-15% 25-30%

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Type A Dissection

Still a true surgical emergency!

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Priorities of surgical repair:

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1. Operative survival2. Stable aortic root3. Competent valve4. Normal coronary perfusion5. Resection of intimal tear6. Normal size arch7. Obliteration descending false lumen

Type A Aortic Dissection (Basic Minimum Strategy)

• Axillary cannulation

• Reconstruct dissected layers

• Re-suspend aortic valve

• Supracoronary graft

• Open hemi-arch

• Resect intimal tear in ascending +/- arch

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Mortality 7+/- 5% for ascending.

(overall operative mortality was 23%)

- Miller, (Shumway) Circulation 1984

Survival after:

30d 10 yr 20 yr

Ascending repair 97% 61% 39%

Arch repair 84% 48% 31%

- Crawford 1992, JTCVS

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43% had patent false

lumen on post-op CT

Hospital Mortality Rate 14%

10 year survival 66% vs 77% of

matched controls.

Growth rates (mm/yr): Arch 0.8 Descending 1 Abdominal 0.8

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Type B Dissection

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Blood Pressure Control: 140/90 mmHg or 130/80 mmHg (DM)

Use Beta blockers, ACE inhibitors, and ARB’s when tolerated

Statin to reduce LDL less than 70mg/dl

Smoking cessation

Medical Treatment

Type B Dissection

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Malperfusion SyndromeInability to control blood pressure with oral agentsContinued pain

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Type B Dissection –TEVAR approved

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Operative Mortality : 3% versus 11%

Spinal cord Ischemia: 3% versus 14%

Renal failure: 1% versus 13%.

JTCVS 2007, 133(2):369-367.

STABLE Trial for Type B DissectionCook Zenith Dissection Endovascular System

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From the Society for Vascular Surgery

Aortic remodeling after endovascular treatment ofcomplicated type B aortic dissection with the use ofa composite device designJoseph V. Lombardi, MD,a Richard P. Cambria, MD,b Christoph A. Nienaber, MD,cRoberto Chiesa, MD,d Peter Mossop, MD,e Stéphan Haulon, MD,f Qing Zhou, PhD,g and Feiyi Jia, PhD,gon behalf of the STABLE investigators, Camden, NJ; Boston, Mass; Rostock, Germany; Milan, Italy; Melbourne,Victoria, Australia; Lille, France; and West Lafayette, Ind

JOURNAL OF VASCULAR SURGERYVolume 59, Number 6

30 Day Mortality Rate 4.7%Freedom from all cause mortality 1 year: 88.3%

2 year: 84.7%

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TEVAR for Type B DissectionINSTEAD trial - Medtronic Talent System

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DOI: 10.1161/CIRCULATIONAHA.109.886408

Randomized Comparison of Strategies for Type B Aortic Dissection

The INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) Trial

Christoph A. Nienaber, MD, PhD; Hervé Rousseau, MD, PhD; Holger Eggebrecht, MD;Stephan Kische, MD; Rossella Fattori, MD, PhD; Tim C. Rehders, MD; Gunther

Kundt, PhD; Dierk Scheinert, MD, PhD; Martin Czerny, MD, PhD; Tilo Kleinfeldt, MD; Burkhart Zipfel, MD; Louis Labrousse, MD, PhD; Hüseyin Ince, MD, PhD;for the

INSTEAD Trial

Failed to improve survival and SAE rates at 2 years despite favorable aortic remodeling.

Freedom from all cause Mortality 2 year: 88.9% (95%)

DOI: 10.1161/CIRCINTERVENTIONS.113.000463

Endovascular Repair of Type B Aortic DissectionLong-term Results of the Randomized Investigation of Stent Grafts in

Aortic Dissection TrialChristoph A. Nienaber, MD, PhD; Stephan Kische, MD; Hervé Rousseau, MD, PhD; Holger

Eggebrecht, MD; Tim C. Rehders, MD; Guenther Kundt, MD, PhD; Aenne Glass, MA;Dierk Scheinert, MD, PhD; Martin Czerny, MD, PhD; Tilo Kleinfeldt, MD;

Burkhart Zipfel, MD; Louis Labrousse, MD; Rossella Fattori, MD, PhD; Hüseyin Ince, MD, PhD; for the INSTEAD-XL trial

Instead XLCirc Cardiovasc Int 2013

RCT -140 pts OMT vs. OMT + TEVAR

Improved aortic remodelling & aorta specific survival in TEVAR group at 5 years

ADSORBEuropean J Vasc Endovasc Surg 2014

RCT 61 pts OMT vs. OMT + TEVAR

Improved aortic remodeling at 1 year

IRADAnn Cardiothorac Surg2014

Retrospective review of registry patients

Improved aorta related survival at 5years

Uncomplicated Type BMedical Management Alone vs. TEVAR & Medical management

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Intramural Hematoma versus Penetrating Ulcer

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Endovascular stent grafting for ascending aorta repair in high-risk patients

Eric E. Roselli, MD, Jahanzaib Idrees, MD, Roy K. Greenberg, MD, Douglas R. Johnston, MD, and Bruce W. Lytle, MD

JTCVS 2015;149:144-152

• N= 22 patients (mean age 72 years)

• Mortality 27%

• Re-intervention rate of 36%

• Best results in pseudoaneurysm and PAU

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Thank You !