1. Ali Khoynezhad, MD1, Carlos E. Donayre, MD2,
Current Methods and Results of Endovascular Treatment of Acute Complicated Type B Aortic Dissection in North America
Ali Khoynezhad, MD1, Carlos E. Donayre, MD2,
Rodney A. White, MD2
1Associate Professor of Surgery, Division of Cardiothoracic & Vascular Surgery, Creighton University Medical Center, Omaha, NE.
2Professor of Surgery, Division of Vascular & Endovascular Surgery, Harbor-UCLA Medical Center, Torrance, CA.
Aortic Symposium 2010

2. Overview introduction equipment, IVUS endovascular algorithm
approach for ruptured pts
approach for malperfused pts
review results in North America
reverse aortic remodeling

3. Introduction definitions! IRAD (n=82)1 hospital mortality 29.3%
new neurologic deficit 23.3%
recent study (n=76)2:
hospital mortality 22.4%
spinal cord injury 6.6%
open repair associated with significant
morbidity and mortality
clinical challenge!
1Trimarchi et al., Circulation Bozinovski et al., Ann Thorac Surg 2008

4. TEVAR-Equipment imaging system pressure injector
IVUS, TCD, pressure wire, MEP, CSF drain
nuts and bolts: needles, guide wires, dilators,
sheath, catheters, balloon, snares, coils, stents.

5. Procedural algorithm dedicated team IVUS-guided access to the TL
dx of exact location of entry tears
ruptures: coverage of entire DTA
malperfusions: coverage of
primary tear site and stagnation
of blood in false lumen
re-evaluate for branch-vessel
malperfusion

6. Endovascular technique: rupture
emergency TEVAR sets
permissive hypotension
CSF drainage and MEP if feasible
IVUS-guided access to the true lumen
coverage of entire DTA
hyperdynamic/hypertensive postop
same for patients with unrelenting
HTN/pain

7. Endovascular technique: malperfusion
more complicated!
LE < renal < mesenteric ischemia
differential-diagnosis: anatomic (static) vs. dynamic obstruction vs. both
procedural tools:
angiographic (scalloping vs.
floating viscera)
IVUS (benign vs. ischemic)
manometry
(simultaneous/pullback)
False lumen

8. Cohort: 166 Patients
six publications with accurate patient cohort using standardized definitions:
Conrad (33), Freezor (33), Khoynezhad (38),
Szeto (35), Vedantham (11), Verhoye (16).
malperfusion on 83 (50%)
average follow-up: 20 months (6-38)
primary technical success: 156 (94%)
spinal cord injury: 15 (9%)

9. Survival no intraoperative deaths hospital mortality: 20 (12%)
1y-survival 85%
treatment failure in follow-up: 41 (25%)
Aortic related mortality!

10. Reverse aortic remodeling
complete or
partial
thrombosis of
the false lumen
in 89 (79%)
survivors.
Aortic related mortality!

11. Preoperative
1-Year follow-up
SMA
Renals
Neck

12. Conclusions
TEVAR for complicated acute type B aortic dissection is a technically challenging and complex endovascular procedure.
Using a clear algorithm, it has a relatively low morbidity and mortality in experienced hands, and it compares favorably to surgical outcomes.
favorable outcome in mid-term follow-up.
standard of care and therapy of choice in experienced centers.
Aortic Symposium 2010