THE FUTURE PA Gaines Sheffield Vascular Institute.

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Presentation transcript:

THE FUTURE PA Gaines Sheffield Vascular Institute

Outcome dissection Rx by stent-graft 1 year2 years4 years Complication free survival 34 survivors 80%75% Overall complication free survival 69%54% Freedom from re-intervention 88%66% Eggebrecht Eur Heart J 2005

WISH LIST

When to intervene? Coady,MA. J Thor Cardiovasc Surg 1997;113: DescendingAscending All Aneurysms Lower threshold for chronic type B dissection – 5.5cm

Risk Rupture Type B dissection Age COPD Elevated Blood Pressure Juvonen, J thoracic Cardiovasc Surg 1999

Medical Rx type B dissection Genoni,M. Eur J Cardioth Surg 2001;19:606-10

WISH LIST 1.Better pharmaceutical research into inhibiting sack expansion.

Survival following acute type B dissection Umana et al, J Thorac Cardiovasc Surg.2002;124(5): yr 85% 93% 5yrs 71% 91% 10yrs 38% 89% 15yrs 20% Survival Freedom From Surgery Includes IMH

Survival UNCOMPLICATED type B dissection following BMT Winnerkvist et al. 2006;32: INCLUDED IMH

INSTEAD trial Chronic dissections (2weeks – 1yr) 1 yr mortality worse in stent-graft group (10% vs 3%) 11% crossed over from medical group to stent-graft or surgery False lumen thrombosis 95% s/g vs 50% bmt

Features that predict poor outcome Patent false lumen Size > 4cm Largest diameter in the arch of aorta

WISH LIST 1.Better pharmaceutical research into inhibiting sack expansion. 2.Better data - RCT high risk uncomplicated type B - contribution to UK Thoracic Stentgraft Registry

COMPLICATIONS Stroke Paraplegia Renal failure Access site and iliac artery Retrograde propagation of dissection

BETTER DEVICES Smaller diameter Compliance better matched to the pathology Branched Better deployment

WISH LIST 1.Better pharmaceutical research into inhibiting sack expansion. 2.Better data - RCT high risk uncomplicated type B - contribution to UK Thoracic Stentgraft Registry 3. Better devices

Chronic Dissection Eggebrecht Eur Ht J of 28 pts (11%) sustained fatal rupture of the TAA during FU median 18 months

Yearly risk

Chronic Dissection Eggebrecht Eur Ht J of 28 pts (11%) sustained fatal rupture of the TAA during FU median 18 months WHY?

Chronic Dissection ACUTE CHRONIC DIAMETER FALSE LUMEN

Chronic dissection

WISH LIST 1.Better pharmaceutical research into inhibiting sack expansion. 2.Better data - RCT high risk uncomplicated type B - contribution to UK Thoracic Stentgraft Registry 3.Better devices 4.New paradigms for the endovascular management of chronic dissection

PETTICOAT

Incidence of aneurysms after type 1 and type 3 dissection Probability of aneurysm best predicted by diameter false lumen > 22 mm at presentation Song, JACC 2007

False lumen patency 6 of 51 type 1 thrombosed 3 of 47 type 3 thrombosed Song, JACC 2007

Yearly risk

Expansion Rates Normal aorta 0.09 cm/year Aneurysmal Aorta 0.1 – 0.2 cm/yr Dissected aorta 0.28 – 0.56 cm/yr Coady,MA. J Thor Cardiovasc Surg 1997;113:476-91

Chronic Dissection DIAMETER WHOLE AORTA

Chronic vs Acute Dissection type B SURVIVAL Eggebrecht Eur Ht J 2005