1. THE FUTURE PA Gaines Sheffield Vascular Institute

2. 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

3. WISH LIST

4. When to intervene? Coady,MA. J Thor Cardiovasc Surg 1997;113:476-91 DescendingAscending All Aneurysms Lower threshold for chronic type B dissection – 5.5cm

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

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

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

8. Survival following acute type B dissection Umana et al, J Thorac Cardiovasc Surg.2002;124(5):896-910 1 yr 85% 93% 5yrs 71% 91% 10yrs 38% 89% 15yrs 20% Survival Freedom From Surgery Includes IMH

9. Survival UNCOMPLICATED type B dissection following BMT Winnerkvist et al. 2006;32:349-355 INCLUDED IMH

10. 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

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

12. 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

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

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

16. 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

17. Chronic Dissection Eggebrecht Eur Ht J 2005 3 of 28 pts (11%) sustained fatal rupture of the TAA during FU median 18 months

18. Yearly risk

19. Chronic Dissection Eggebrecht Eur Ht J 2005 3 of 28 pts (11%) sustained fatal rupture of the TAA during FU median 18 months WHY?

20. Chronic Dissection ACUTE CHRONIC DIAMETER FALSE LUMEN

21. Chronic dissection

22. 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

23. PETTICOAT

24. 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

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

26. Yearly risk

27. 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

28. Chronic Dissection DIAMETER WHOLE AORTA

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