Embed Size (px)
Citation preview
Azienda Ospedaliera “S. Maria” - Terni
Dipartimento Cardio Toraco Vascolare
Dr. Fiore Ferilli
Dissezione B post A e dissezione B
primaria: analogie e differenze
Dr. Paolo Ottavi
ACUTE TYPE DISSECTION
cardiac surgery vascular surgery
INCIDENCE EXCEEDING THAT OF RUPTURED ABDOMINAL AORTIC ANEURYSMS
MGH - ATKINS MD, J VASC SURG 2006:43(2 Supl.):A30-A43
ACUTE DISSECTION
intent to treat:
1.SURVIVAL
2.Prevent aortic disease
evolution
TREATMENT STRATEGY
The objective of IRAD was to assess the etiology, mode of presentation, clinical features,
management and outcomes of patients with acute aortic dissection
550 patients with TBD
250 (45.5%) complicated
300 (54.5%) uncomplicated
Dissecazione
acuta B
complicata
TEVAR-Open
Surgery d’urgenza
Dissezione acuta non complicata
Assenza di predictors
Best Medical Therapy
sorveglianza radiologica
INSTEAD XL trial
10mm
High RiskPrimary entry tear > 10 mm
Primary entry tear location (inner curve)
Total aortic diameter (> 40 mm)
False lumen diameter (> 22 mm)
Partial false lumen thrombosis
Shape (forma circolare vs ellittica VL)
Morfologia della dissezione (lineare vs spiraliforme)
PRE-EMPTIVE TEVAR
….ma le dissezioni sono una eterogeneità di manifestazioni clinico-anatomiche
The safety success of aortic
dissection
surgery depends upon
complete resection of the
primary intimal tear with
attempted obliteration of
the
false lumen
Ascending aorta and emi-arch replacement
Ascending aorta and emi-arch replacement
Ascending aorta and arch replacement
Ascending aorta replacement and aortic archdebranching
HYBRID SURGICAL APPROACHAscending aorta, arch replacement and endoposthesis (Frozen Elephant Trunk)
Ascending aorta, arch replacement and endoposthesis (Home Made Frozen Elephant Trunk)
247 pts remaining type B after type A
112 pts primary type B aortic dissection
Median follow-up 23 months
a patent primary entry tear in patients after surgery for acute
type A aortic dissection
predictor for intervention duringfollow-up
Case report 154 aa, pregressa dissezione A (EVITA)
Dolore ingravescente, anemizzazione ATBD
C-TAG 34-200 (diametro 31.5 oversizing 9%)
Estensione distale TAG GORE 37-200mm.
Rifornimento retrogrado del falso lume. Monitoraggio pressione liquorale, TEE
CONTROLLO: PERSISTENZA RIFORNIMENTO FALSO LUME
EMBOLIZZAZIONE FALSO LUME: Coils e colla (glubran)
pre-TEVAR
CT 75 mesi
24% di reinterventi (1 mese e 6 anni)
Median time: 9 mesi
DISSEZIONI B POST A
Fondamentale un follow-up ANGIO-TAC con primo esame entro 1- 3 mesi poi ogni anno
63 mm
Nel 2014 sostituzione aorta ascendente
Entry tear in arco
Evoluzione aneurismatica (42 vs 63 mm in 3 anni 6-8 mm anno)
PROGETTO:
«KICK OFF»
Richiamare tutti i pazienti sottoposti negli ultimi 5 anni ad intervento per dissezione A con programmazione di un esame angio-TC
