Changing Paradigms in Aortic Dissection

Ali Azizzadeh, MD, FACS

Director, Vascular Surgery

Vice Chair, Department of SurgeryAssociate Director, Heart Institute

Cedars-Sinai Medical CenterLos Angeles, CA

Controversies & Advances inthe Treatment ofCardiovascular Disease

11/16/18

Classifications of Dissection:Stanford and DeBakey

Epidemiology

10-15 cases/100,000adults/year

2/3 type A

1/3 type B

Acute Type B Acute Type B

30% Cx

70% UnCx

Male: Female 2-5:1

Paradigm Shift

Management of Type B Aortic Dissection

OR / TEV AROR / TEV ARCX

TYPE BTYPE B

OMTOMTUNCX

TYPE BTYPE B

+ TEV AR+ TEV AR

TYPE B Aortic Dissection

R ecom m endationsforT EVA R Class L evel

A cuteT ypeB Dissection

Ischem ia I A

S T S ExpertConsensusDocum ent2008T reatm entofDescendingT horacicA orticDisease

10585286 DOC

S venssonL G,etal.Ann Thorac Surg, 2008;85:S 1-41

Ischem ia I A

N oIschem ia IIb C

ClassIIb:usefulness/efficacy islessw ellestablished by evidence

TYPE B Aortic Dissection

R ecom m endations Class L evel

Inuncom plicated T ypeB AD,m edicaltherapy shouldalw aysberecom m ended.

I C

ES C Guidelines2014R ecom m endedT reatm entofA orticDissection

10585286 DOC

Inuncom plicatedT ypeB A D,T EVAR shouldbeconsidered. IIa B

Incom plicatedT ypeB A D,T EVAR isrecom m ended. I C

Incom plicatedT ypeB AD,surgery m ay beconsidered. IIb C

ClassIIa:w eightofevidenceisinfavorofusefulness/efficacy

ErbelR ,etal.Eur Heart J.2014 N ov1;35(41):2873-926.

Treatment of ATBAD

3° Referral Center

Multi-specialtyteam: CT, Vasc Surg

Critical care

Consultants

Advanced imaging: Advanced imaging: CT, MR, IVUS, TEE

Hybrid OR’s

Monitoring MEP,SSEP

Full spectrum ofopen/endovascularprocedures

Admit CVICUCVC, arterial line, UOP

Admit CVICUCVC, arterial line, UOP

Anti-impulse TherapySBP<120, HR<60

Anti-impulse TherapySBP<120, HR<60

B-Blocker

Ca+2 Blocker

B-Blocker

Ca+2 BlockerRespiratory

DVT prevent

Respiratory

DVT prevent

Protocol

SBP<120, HR<60Control pain

SBP<120, HR<60Control pain

Ca+2 Blocker

Nitroglycerin

Nitroprusside

Ca+2 Blocker

Nitroglycerin

Nitroprusside

DVT prevent

Nutrition

Mobilization

DVT prevent

Nutrition

Mobilization

Reassessment

Blood pressure

Pain

Reassessment

Blood pressure

Pain

Percutaneous InterventionSurgical Intervention

Percutaneous InterventionSurgical Intervention

Protocol

Rupture/ LeakMalperfusion (renal, visceral, peripheral)

Acute ExpansionRefractory Symptoms

Rupture/ LeakMalperfusion (renal, visceral, peripheral)

Acute ExpansionRefractory Symptoms

UT Houston Series

2000 to 2014

1079 pts AD

532 ATBAD

60% Male

Mean age 60.6 ± 13.6 yrs

Median age = 60.5 yrs

Range 16 –98 yrs

Average Follow up: 3.7 yrs

Aortic Dissection

1079 DISSECTIONS

Aortic Dissection

535 532

1079 DISSECTIONS

535TYPE A

532TYPE B

Aortic Dissection

535

294UNCOMPLICATED

1079 DISSECTIONS

535TYPE A

238COMPLICATED

Complicated ATBAD

Rupture

Malperfusion: Neurologic

Spinal Cord Spinal Cord

Visceral (Celiac, SMA)

Renal

Lower Limb

Refractory Pain & HTN

• In-hospitalm ortality significantlyhigherw ithm edicalm anagem ent

• 2/3rd m edicalrx deathsduetorupture

• R efractory pain/HT N independent

refractory pain/HTN

Refractory Pain and HTN

• R efractory pain/HT N independentpredictorofin-hospitalm ortality

• Interventionassociatedw ithim provedoutcom esoverm edicalm anagem entforrefractorypain/HT N

Medical Management: In-hospital mortality

No pain/HTN

Circulation2010;122:1283-9

Types of Malperfusion

DynamicObstruction:• Prolapsed septum

into ostium duringcardiac cyclecardiac cycle

Static Obstruction: Dissection extends

into branch vessel

Dynamic Obstruction

Static Obstruction

Selective angiogram

Measure pull backpressures

Adjunctive stenting

Extend stent into TL

Williams DM, Patel HJ. Endovascular Therapy for Malperfusion in Acute Type B AorticDissection. Operative Techniques in Thoracic and Cardiovascular Surgery. p 2-11. 2009

Extend stent into TL

Static Obstruction: SMADissection

Static Obstruction: Left RenalArtery Dissection

Goals of TEVAR for cATBAD

Seal off proximal entry tear

Alleviate malperfusion

Expand compressed truelumenlumen

Induce false lumenthrombosis

Prevent/treat rupture

TEVAR DON’TS

Oversize >10%

Balloon Angioplasty

Place distal device first

IVUS Adjunct to CTA,

angiogram andTEE

Wire placementin true lumen

Assesses Assessesadequacy oftreatment

Guide additionaltherapy

Diagnosecomplications

True Lumen Compression

IVUS after TEVAR

Aortic Remodeling

Mortality by Management Strategy

Total = 444Uncomplicated

N=271

C o m p l i c a t e d ( N = 1 7 3 )OR,

p-valueMedN=69

OpenN=52

TEVARN=37

Other CVN=15

Mortality5

1.9%13

18.8%6

11.5%5

13.5%3

20%* 8.8, 0.0001

* Uncomplicated compared to complicated type b aortic dissection

Survival at 5 yrs foruATBAD was 76.6%

Overall Survival: Max Aortic Diameter

uATBAD High Risk Criteria

Aortic diam e te r>44m m is a predictorof mortality after adjustment forsignificant risk factors.

Decreased intervention-free survivalin those with FL>22m m and/or m axin those with FL>22m m and/or m axaortic diam e te r>44m m onadmission.

Age >60 y e arsis a risk factor formortality.

Incidence of Risk Factors in AUTBAD

Risk Factors

TAD >44mm / FLD >22 / Age >60

1 Risk Factor 44%

2 Risk Factors 19%

3 Risk Factors 6%

Total 69%

The Fate of the 31%:uTBAD & no high-risk criteria

OMT 5% mortality / year

10% intervention / year

OMT + TEV AR 5-10% procedural morbidity and

mortality

Aortic stabilization

INSTEAD XL: 5 Year Analysis

INSTEAD XL: 5 Year Extended Follow-up

Clin

icalEvide

nce

O M T +T EVAR :N om id-orlate-term Aortic

O M T O nly:S ignificantm id-andlate-term term Aortic

m ortalityandlate-termm ortality

Complicated ATBAD

75 yo female with chestand back pain

CTA: ATBAD with aortoiliacthrombosis

On exam, mottled from the On exam, mottled from theumbilicus down

No motor or sensation inthe lower extremities

CTA

3D reconstruction

OR

Open right femoralaccess (no pulse)

Diagnostic angiogram

Glide catheter/ glidewire access toascending aortaascending aorta

IVUS confirmedplacement of the wirein the true lumen fromRCFA to ascendingaorta

Planned LSCA coverage

Abdominal Aortogram

Management RLE ischemia

Remove sheath

Open repair of RCFAarteriotomy

RLE angiogram?

Explore abdomen? Explore abdomen?

RLE fasciotomy?

Completion angiogram after open repair RCFA/SFA

HPI

P M H: Ascendingaorticaneurysm com plicatedby acutetypeA aorticdissection,P araparesis,N eurogenicbladder,Intracranialhem orrhage,T IA w ithsym ptom sofaphasia,Chronicleftfrontallobeinfarct,Chronicm icrovascularchanges,Hypertension,Hyperlipidem ia.

P S H: AscendingAortaR eplacem ent,Appendectom y,T onsillectom y.

• 72 y/om alereferredforsurgicalevaluationof6.8cm DT AA.

M edications: Glycolax,Florinef,Zetia,Ecotrin,Bystolic,P epcid,L asix,M ulti-vitam ins,M icro-K,Vitam inC,N eurontin,N orco,Caltrate,P lavix.

Allergies: N KA

FH: Father:history ofCAD,M aternalgrandfather:diedat43

S H: S m okingstatus:never,Alcohol:rarely

Consult: 07/05/2018

Surgical evaluation: enlarging 6.8cm DTAA

Vitals

P hysicalExam

General: Aw ake,Alert,O riented

HEEN T : N orm ocephalic,atraum atic,scleraeareanictericBP : 123/70

P ulse: 75

R R : 18

T em p: 97.4

HEEN T : N orm ocephalic,atraum atic,scleraeareanicteric

N eck: S upple,nom asses

L ungs: Cleartoauscultation

Cardiac: R R R ,norub,m urm urorgallop

Abdom en: S oft,nondistended,nontender,bow elsoundspresent

Incisions: W ell-healedm ediansternotom y andrightinfraclavicularincision.S ternum stable.

CTA

Problem list

Ascending aortic pseudoaneurysm

Residual arch and type B dissection

6.8 cm DTAA

CAD

Cerebrovascular disease Cerebrovascular disease

Solution?

Procedure 7/30/18

Repair of ascending aorta pseudoaneurysm and hemiarchreplacement

Ascending aorta to innominate artery bypass

CABG

DHCA with RCP DHCA with RCP

CTA

CTA

Video

CTA

Video

CTA

Video

CTA

Video

CTA

Video

CTA

Video

Residual 7 cm DTAA: Solution?

Arch Debranching

RCCA to LCCA to LSCAbypass

LSCA dissection with flow tofalse lumenfalse lumen

TEVAR: Zone 0

RAO

Markers for origin of aorto-innominate bypass

Procedure: TEVAR

Device #1: covered theorigin of the innominate, leftcarotid and left subclavianarteries (zone 0).

Device #2: overlap tocover zones 2 and 3.

Device #3: deployedabove the celiac artery.

Completion Angiogram

Successful exclusion of theextensive aortic aneurysmwith coverage of the nativewith coverage of the nativeinnominate, left commoncarotid and left subclavianarteries.

Type 2 endoleak: LSCA origin with dissection

Management?

Amplatzer plug 14mm

14mm Amplatzer Plug

Hospital course

Patient tolerated the procedure well.

Oriented, sensory and motor function intact, noneurological issues.neurological issues.

Lumbar drain removed: 09/23/2018

Discharge from hospital: 9/26/18

Conclusion

Paradigm shift in therapy for TBAD

All CTBAD should undergo TEVAR as first linetherapy

UTBAD patients with high risk criteria (2/3 of thecohort): TAD >44, FLD>22, Age >60 arecohort): TAD >44, FLD>22, Age >60 arecandidates for OMT+TEVAR

UTBAD patients with no high risk criteria (1/3 ofthe cohort): should be counseled about therisk/benefits of OMT vs. OMT+TEVAR

Thank You