Managing the Asymptomatic Type A and Type B Dissection

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Presentation transcript:

Managing the Asymptomatic Type A and Type B Dissection Robert M. Bersin, MD, MPH, FACC, FSCAI Medical Director, Endovascular Services Seattle Cardiology and Swedish Medical Center Seattle, Washington

Managing the Asymptomatic Type A and Type B Dissection Robert M. Bersin, MD, MPH, FACC, FSCAI Medical Director, Endovascular Services Seattle Cardiology and Swedish Medical Center

Disclosure Information Managing the Asymptomatic Type A and Type B Dissection Robert M. Bersin MD, MPH, FACC, FSCAI The following relationships exist related to this presentation: Name of Company: Cook Inc. C, P Name of Company: Cordis Endovascular AB,C, EI, P, SB Name of Company: Medtronic Vascular P Name of Company: W.L. Gore C, P Off label use of products will be discussed in this presentation: Use of endografts for aortic dissection, ascending and arch aneurysms AB: Advisory Board C: Consulting Relationship EI: Equity Interest GS: Grant Support P: Proctor or Training Course Sponsorships SB: Speakers Bureau SE: Spouse Employee SO: Stock Options or Positions

Aortic Dissection Classifications

Type A Aortic Dissection Asymptomatic Type A dissection is a misnomer! It is a surgical emergency! 1-2% mortality/hour Death is from rupture, acute AI, tamponade or organ ischemia Survival linked to number of pulse deficits (malperfusion syndromes)

Type A Dissection-Class I Indications for Surgery For patients with ascending thoracic aortic dissection, all aneurysmal aorta and the proximal extent of the dissection should be resected. If a DeBakey Type II dissection is present, the entire dissected aorta should be replaced. (Level of Evidence: C) Separate valve and ascending aortic replacement are recommended in patients without significant aortic root dilatation, in elderly patients or in young patients with minimal dilatation in whom a biological valve is being implanted. (Level of Evidence: C) Patients with Marfan, Loeys-Dietz, and Ehlers-Danlos syndromes and other patients with dilatation of the aortic root and sinuses of Valsalva should undergo root replacement with a valve graft conduit or excision of the sinuses in combination with a valve sparing procedure if technically feasible (Level of Evidence: B) In recent years, we have witnessed a tremendous progress in the management of AAA using endovascular technique and it has become a widely accepted treatment of choice in many patients. Studies have documented excellent mid-term clinical efficacy of this treatment modality in AAA. DTAA, while less prevalent than the abdominal counterparts, are estimated to affect 1 of every 10,000 elderly adults. 30 – 40% of these aneurysm occur exclusively in the descending thoracic aorta.

Surgical Approach to Type A Dissection Retrograde Subclavian Perfusion Femoral perfusion can accentuate retrograde perfusion of the false lumen and worsen the dissection

Surgical Approach to Type A Dissection Preservation of the Arch Pedicle

30 Day Mortality with Acute Aortic Dissection A medical B medical All patients A surgical From IRAD study, based on 464 patients B surgical Eagle Circulation 2003;

Long-term Mortality After Surgical Repair of Type A Dissection Based on Crawford’s series from Baylor University Based on crawford’s sereies from UT. Top is actuarial survival for population. Type a dissection surgically repaired. Kirklin, Textbook of Cardiac Surgery

Late Complications of Surgical Repair of Type A Dissection Expansion of the false lumen Aortic insufficiency New dissection Cerebral or visceral malperfusion Aortic root expansion Complications of the original repair (e.g., false aneurysm)

False Lumen Patency and Late Aneurysmal Degeneration Fig 1. False lumen (FL) patency was recorded at five levels in each patient: the mid portion of the arch, bifurcation of the pulmonary artery, lower cardiac border, celiac trunk, and lower border of the left kidney. (A) Thoracic aortic false lumen was recorded as patent if all or upper two levels had patent false lumen, and abdominal aortic false lumen was recorded as patent if one of two levels had patent false lumen. (B) Partially thrombosed false lumen was recorded as patent. (C) Separately in thoracic and abdominal segments, widths of true and false lumens were measured at the level where the aortic diameter is largest. (T = true lumen width; F = false lumen width; T + F = diameter of the aorta.) Park K-H et al; Ann Thorac Surg 2009; 87: 103-108

Late Degeneration of the Descending Aorta According to the Patency of the False Lumen Fig 4. Later change of the descending aortic lesion according to early postoperative profile of the false lumen. (AAA = abdominal aortic aneurysm; TAAA = thoracoabdominal aortic aneurysm.) Park K-H et al; Ann Thorac Surg 2009; 87: 103-108

Thoracic Stent Grafts WL Gore TAG endoprosthesis Cook TX2 thoracic device Medtronic Talent device

Treatment Strategies for Acute Type B Dissections Uncomplicated: medical management Antihypertensives Beta-blockers Complicated: surgical management Symptomatic Impending rupture End-organ ischemia Complicated: endograft? Elefteriades JA. Management of descending aortic dissection. Ann Thorac Surg 1999;67:2002-5 Kouchokos NT. Surgery of the thoracic aorta. NEJM 336(26):1876-1888

Gore TAG Endoprosthesis for Acute Type B Dissection

Meta-Analysis of TEVAR for Type B Thoracic Aortic Dissection 39 Published Series Eggebrecht H et al Euro Heart J 2006; 27: 489–498

Expert Consensus Document on TEVAR for Type B Thoracic Dissection “Stent-grafting as a therapeutic option for high surgical risk patients with subacute or chronic aortic dissection may be considered for those who have a patent false lumen and an identifiable, proximal entry tear that can be covered by stent-graft implantation in association with: A maximal thoracic aorta diameter greater than 5.5 cm, or Documented increase of aortic diameter of more than 1.0 cm within 1 year, or Resistant hypertension despite antihypertensive combination therapy associated with a small true lumen or renal malperfusion, or Recurrent episodes of chest/back pain that cannot be attributed to other causes.” Svensson L et al Ann Thorac Surg 2008; 85: S1–41

The IRAAD Registry Complicated Dissections Treated with Endografts do as well as Uncomplicated Dissections Managed Medically Fattori R et al J Am Coll Cardiol Intv 2008; 1: 395– 402

TEVAR for Uncomplicated Dissection: INSTEAD Randomized Trial Nienaber CA et al Circulation 2009; 120: 2519-2528

TEVAR for Uncomplicated Dissection: ADSORB Randomized Trial Brunkwall J Veith Mtg 2009

TEVAR for Uncomplicated Dissection: ADSORB Randomized Trial Brunkwall J Veith Mtg 2009

TEVAR for Acute Catastrophes of the Descending Thoracic Aorta Kaplan-Meier analysis of time to first major device related adverse event. Cambria R et al J Vasc Surg 2009; 50: 1255-1264

PETTICOAT Technique for Malignant DTA Dissection Kaplan-Meier analysis of time to first major device related adverse event. STABLE Trial: Cook Zenith TX2 and TXD Nienaber CA Veith Mtg 2009

Intramural Hematomas IMH is presumed to occur as a result of rupture of the vaso vasorum in the medial layer of the aortic wall It is a variant of aortic dissection and can lead to dissection IMH is associated with a high mortality in the ascending aorta All IMH of the ascending aorta and symptomatic IMH of the descending aorta should be repaired

Guidelines on TEVAR for Descending Thoracic Aortic Diseases ACC/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM 2010 Guidelines For The Diagnosis And Management Of Patients With Thoracic Aortic Disease

Management of Asymptomatic Type A/B Dissections: Conclusions Type A dissections and ascending IMH are surgical emergencies. There is presently no role for medical therapy or endografting. Complicated Type B dissection is likely to be best managed with TEVAR when feasible, however… The need for repeat procedures and/or surgical conversion to treat late false lumen patency and/or aneurysmal degeneration is 36% There is presently no role for surgical or endovascular repair of asymptomatic/uncomplicated Type B dissection. Asymptomatic IMH should be managed medically (Class III). Symptomatic descending IMH should be treated. TEVAR is an ideal therapy for this condition.