Presentation is loading. Please wait.

Presentation is loading. Please wait.

Long-term Follow-up of Aortic Intramural Hematomas and Penetrating Ulcers Alan S. Chou, BA, Bulat A. Ziganshin, MD, Paris Charilaou, MD, Maryann Tranquilli,

Published byCarol Hoover Modified over 9 years ago

Similar presentations

Presentation on theme: "Long-term Follow-up of Aortic Intramural Hematomas and Penetrating Ulcers Alan S. Chou, BA, Bulat A. Ziganshin, MD, Paris Charilaou, MD, Maryann Tranquilli,"— Presentation transcript:

1 Long-term Follow-up of Aortic Intramural Hematomas and Penetrating Ulcers Alan S. Chou, BA, Bulat A. Ziganshin, MD, Paris Charilaou, MD, Maryann Tranquilli, RN, John A. Rizzo, PhD, John A. Elefteriades, MD Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine New Haven, Connecticut, USA Presented at the 95 th Annual Meeting of the American Association of Thoracic Surgery April 28 th, 2015 1

2 Disclosures Alan S. Chou, BA: – Nothing to disclose. Bulat A. Ziganshin, MD: – Nothing to disclose. Paris Charilaou, MD: – Nothing to disclose. Maryann Tranquilli, RN: – Nothing to disclose. John A. Rizzo, PhD: – Nothing to disclose. John A. Elefteriades, MD: – DSMB for Jarvik Heart, Solus Valve; Research Grant Vascutek; Medical Director for CoolSpine. 2

3 Acute Aortic Syndromes 3 Elefteriades JA. Thoracic aortic aneurysm: reading the enemy’s playbook. Curr Probl Cardiol. 2008;33:203–77.

4 Current literature/evidence 4

5 5

6 US and European Guidelines 6

7 Aim of the study To evaluate the long-term natural history and progression of intramural hematomas and penetrating aortic ulcers including clinical and radiological follow-up and survival analysis. 7

8 Progression of Lesions 8

9 9 Resolution

10 Progression of Lesions 10 Resolution No Change (Stable)

11 Progression of Lesions 11 Resolution No Change (Stable) Worsening

12 Patient profile 12 108 consecutive patients (1995-2014) 108 consecutive patients (1995-2014)

13 Patient profile 13 108 consecutive patients (1995-2014) 108 consecutive patients (1995-2014) 55 IMH patients (51%) 55 IMH patients (51%) 53 PAU patients (49%) 53 PAU patients (49%)

14 Patient profile 14 108 consecutive patients (1995-2014) 108 consecutive patients (1995-2014) 55 IMH patients (51%) 55 IMH patients (51%) 56% Female 53 PAU patients (49%) 53 PAU patients (49%) 57% Female

15 Patient profile 15 108 consecutive patients (1995-2014) 108 consecutive patients (1995-2014) 55 IMH patients (51%) 55 IMH patients (51%) 56% Female 53 PAU patients (49%) 53 PAU patients (49%) 57% Female All patients were symptomatic at presentation All patients were symptomatic at presentation

16 Age of IMH and PAU Patients 16 Mean age IMH — 70.3±10 yrs Mean age PAU — 71.4±10 yrs

17 Location Distribution 17

18 Intramural Hematoma 18

19 Hospital Course of IMH 19 55 Patients with IMH 55 Patients with IMH

20 Hospital Course of IMH 20 55 Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10)

21 Hospital Course of IMH 21 55 Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999;17:637-57. High incidence of rupture at presentation compared with 8% and 4% for classic Type A and B dissection previously observed (p<0.05)

22 Hospital Course of IMH 22 55 Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7)

23 Hospital Course of IMH 23 55 Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 20) 100% Survived to Discharge (n = 20)

24 Hospital Course of IMH 24 55 Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 20) 100% Survived to Discharge (n = 20) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 43% Survived to Discharge (n = 3) 43% Survived to Discharge (n = 3)

25 IMH does not occlude branch vessels No branch occlusion among any IMH patients Contrast with classic flap dissection 25

26 Radiologic Follow-up of Medically managed IMH 26 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months)

27 Radiologic Follow-up of Medically managed IMH 27 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4)

28 Radiologic Follow-up of Medically managed IMH 28 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4) 14% Stable (n = 2) 14% Stable (n = 2)

29 Radiologic Follow-up of Medically managed IMH 29 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4) 57% Worsening (n = 8) Mean time – 1.3 mo. 57% Worsening (n = 8) Mean time – 1.3 mo. 14% Stable (n = 2) 14% Stable (n = 2)

30 Radiologic Follow-up of Medically managed IMH 30 56% follow-up imaging available (n = 14, mean 9.4 months) 56% follow-up imaging available (n = 14, mean 9.4 months) 29% Resolution (n = 4) 29% Resolution (n = 4) 57% Worsening (n = 8) Mean time – 1.3 mo. 57% Worsening (n = 8) Mean time – 1.3 mo. 14% Stable (n = 2) 14% Stable (n = 2) 75% Underwent late surgery (n = 6) 75% Underwent late surgery (n = 6)

31 Surgical Treatment of IMH 31 Mean Post-Surgical Follow-up — 39.6 months (range 2-140)

32 Penetrating Aortic Ulcer 32

33 Hospital Course of PAU 33 53 Patients with PAU 53 Patients with PAU

34 Hospital Course of PAU 34 53 Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17)

35 Hospital Course of PAU 35 53 Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) High incidence of rupture at presentation compared with 8% and 4% for classic Type A and B dissection previously observed (p<0.001) Coady MA, Rizzo JA, Elefteriades JA. Pathologic variants of thoracic aortic dissections. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin 1999;17:637-57.

36 Hospital Course of PAU 36 53 Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12)

37 Hospital Course of PAU 37 53 Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 11) 100% Survived to Discharge (n = 11)

38 Hospital Course of PAU 38 53 Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 11) 100% Survived to Discharge (n = 11) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 87% Survived to Discharge (n = 10) 87% Survived to Discharge (n = 10)

39 Radiologic Follow-up of Medically managed PAU 39 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months)

40 Radiologic Follow-up of Medically managed PAU 40 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3)

41 Radiologic Follow-up of Medically managed PAU 41 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3) 55% Stable (n = 11) 55% Stable (n = 11)

42 Radiologic Follow-up of Medically managed PAU 42 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3) 30% Worsening (n = 6) Mean time – 18 mo. 30% Worsening (n = 6) Mean time – 18 mo. 55% Stable (n = 11) 55% Stable (n = 11)

43 Radiologic Follow-up of Medically managed PAU 43 80% follow-up imaging available (n = 20, mean 34.3 months) 80% follow-up imaging available (n = 20, mean 34.3 months) 15% Resolution (n = 3) 15% Resolution (n = 3) 30% Worsening (n = 6) Mean time – 18 mo. 30% Worsening (n = 6) Mean time – 18 mo. 55% Stable (n = 11) 55% Stable (n = 11) 100% Underwent late surgery (n = 6) 100% Underwent late surgery (n = 6)

44 Surgical Treatment of PAU 44 Mean Post-Surgical Follow-up — 42.9 months (range 1-150)

45 Long Term Survival of IMH and PAU 45

46 Comparison of IMH vs PAU Survival 46 p = 0.26

47 Comparison of IMH vs PAU Survival 47 p = 0.26

48 Medical vs Surgical Treatment of IMH 48

49 Medical vs Surgical Treatment of IMH 49 p = 0.10 (log-rank)

50 Medical vs Surgical Treatment of IMH 50 p = 0.028 (Gehan-Breslow-Wilcoxon test)

51 Medical vs Surgical Treatment of PAU 51

52 Medical vs Surgical Treatment of PAU 52 p = 0.037

53 Important points – IMH and PAU 1.Disease of the elderly population. 2.Female gender predominates. 3.High rupture rates upon initial presentation. 4.No branch occlusion. 5.True healing does occur, but worsening is more common. 6.Surgical approach is safe and yields improved survival. 7.Results of this study support an expectant, but aggressive approach towards IMH and PAU. 53

54

55

56 56

57 57

58 Worsening — Refers to deterioration in aortic condition, including significant increases in the thickness or depth of the lesion, progression of PAU to IMH (or vice versa), progression to classic dissection, or rupture. Intramural Hematoma 57% (n=8) of patients worsened: – 38% conversion to flap dissection, – 38% appearance of a concurrent penetrating ulcer, – 25% rapid expansion of the IMH The mean time to detection of worsening was 1.3 months (range 0.4-2.5) Penetrating Aortic Ulcers 30% (n=6) of patients worsened: – 33% conversion to flap dissection, – 66% expansion of the ulcer and appearance of associated intramural hematoma. The mean time to worsening was 18.0 months (range 1-92) 58

59 Causes of Death 59

60 Total Cohort Survival (IMH+PAU) 60 1-year — 77% 3-year— 70% 5-year — 58% 10-year — 33%

61 Rupture/Impending Rupture Rupture Defined as the presence of extra-aortic blood confirmed by: – Radiology, – Surgical examination, – Post-mortem examination. Impending Rupture Confirmed by an experienced aortic surgeon or radiologist, given the presence of the following: – Bloody effusion, – Rapid radiologic worsening, – Increase in effusion amount, – Persistent pain, – Intraoperative findings. 61

62 General Management Strategy Operate on all rupture state patients and all ascending lesions when clinically possible. For descending IMH and PAU, we provided standard initial non-surgical anti-impulse therapy, yet maintained a low threshold for surgical intervention in case of severe, recurrent symptoms or radiographic worsening upon follow-up. Our policy originated in the pre-endovascular era, and the majority of our operatively treated patients underwent open repair rather than endovascular treatment. 62

63 Surgical Treatment by Location (IMH) Initial ManagementLate Management 63

64 Thromboexclusion procedure 64

65 65

66 Hospital Course of IMH 66 55 Patients with IMH 55 Patients with IMH 82% Non-Rupture State (n = 45) 82% Non-Rupture State (n = 45) 18% Rupture State (n = 10) 18% Rupture State (n = 10) 56% Initial Medical Tx (n = 25) 56% Initial Medical Tx (n = 25) 44% Initial Surgical Tx (n = 20) 44% Initial Surgical Tx (n = 20) 30% Initial Medical Tx (n = 3) 30% Initial Medical Tx (n = 3) 70% Initial Surgical Tx (n = 7) 70% Initial Surgical Tx (n = 7) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 20) 100% Survived to Discharge (n = 20) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 43% Survived to Discharge (n = 3) 43% Survived to Discharge (n = 3)

67 Hospital Course of PAU 67 53 Patients with PAU 53 Patients with PAU 68% Non-Rupture State (n = 36) 68% Non-Rupture State (n = 36) 32% Rupture State (n = 17) 32% Rupture State (n = 17) 69% Initial Medical Tx (n = 25) 69% Initial Medical Tx (n = 25) 31% Initial Surgical Tx (n = 11) 31% Initial Surgical Tx (n = 11) 29% Initial Medical Tx (n = 5) 29% Initial Medical Tx (n = 5) 71% Initial Surgical Tx (n = 12) 71% Initial Surgical Tx (n = 12) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 25) 100% Survived to Discharge (n = 11) 100% Survived to Discharge (n = 11) 0% Survived to Discharge (n = 0) 0% Survived to Discharge (n = 0) 87% Survived to Discharge (n = 10) 87% Survived to Discharge (n = 10)

68 Comorbidities of IMH and PAU patients 68

Download ppt "Long-term Follow-up of Aortic Intramural Hematomas and Penetrating Ulcers Alan S. Chou, BA, Bulat A. Ziganshin, MD, Paris Charilaou, MD, Maryann Tranquilli,"

Similar presentations

Bovine Arch – A Marker for Thoracic Aortic Aneurysm Remo Moomiaie, MD a, Matthew Hornick, BA a, Hamid Mojibian, MD b, Esther S. Lee, BA b, Maryann Tranquilli,

Bovine Arch – A Marker for Thoracic Aortic Aneurysm Remo Moomiaie, MD a, Matthew Hornick, BA a, Hamid Mojibian, MD b, Esther S. Lee, BA b, Maryann Tranquilli,
Management of acute type b aortic dissection

Management of acute type b aortic dissection
KAREN L. WALKER MS JONATHAN J. SHUSTER PHD THOMAS M. BEAVER MD, MPH DIVISION OF THORACIC AND CARDIOVASCULAR SURGERY DIVISION OF BIOSTATISTICS UNIVERSITY.

KAREN L. WALKER MS JONATHAN J. SHUSTER PHD THOMAS M. BEAVER MD, MPH DIVISION OF THORACIC AND CARDIOVASCULAR SURGERY DIVISION OF BIOSTATISTICS UNIVERSITY.
(1) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Arch Debranching versus Elephant Trunk Procedures for Hybrid Repair.

(1) Arch Debranching vs. Elephant Trunk for Hybrid Repair of the Proximal Thoracic Aorta Arch Debranching versus Elephant Trunk Procedures for Hybrid Repair.
Aggressive Management of Chronic Deep Venous Thrombosis: Technical and Clinical Outcomes Mark J. Garcia M.D. FSIR C Grilli, M McGarry, M Ali, D Agriantonus,

Aggressive Management of Chronic Deep Venous Thrombosis: Technical and Clinical Outcomes Mark J. Garcia M.D. FSIR C Grilli, M McGarry, M Ali, D Agriantonus,
Angioclub Case Series: Aortic Pathology Candace L. White MA, MD Mount Sinai Medical Center of Florida.

Angioclub Case Series: Aortic Pathology Candace L. White MA, MD Mount Sinai Medical Center of Florida.
Aortic Root Conservative Repair in Acute Type A Aortic Dissection Involving Aortic Root: Fate of Aortic Root & Aortic Valve Function Joon Bum Kim, Su Kyung.

Aortic Root Conservative Repair in Acute Type A Aortic Dissection Involving Aortic Root: Fate of Aortic Root & Aortic Valve Function Joon Bum Kim, Su Kyung.
SIR RFS Aortic Angioclub October 24, 2013 Brandon Olivieri, MD Mount Sinai Medical Center of Florida.

SIR RFS Aortic Angioclub October 24, 2013 Brandon Olivieri, MD Mount Sinai Medical Center of Florida.
D-dimer level remains a highly sensitive test for acute aortic dissection beyond the first 24 hours after onset AATS Aortic Symposium 2010 ▪ New York ▪

D-dimer level remains a highly sensitive test for acute aortic dissection beyond the first 24 hours after onset AATS Aortic Symposium 2010 ▪ New York ▪
S L I D E 0 Effect of statin therapy on the natural history of thoracic aortic aneurysms. Louis H. Stein, Jessica Berger, Maryann Tranquilli, John A. Elefteriades.

S L I D E 0 Effect of statin therapy on the natural history of thoracic aortic aneurysms. Louis H. Stein, Jessica Berger, Maryann Tranquilli, John A. Elefteriades.
Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair: The STABILISE Concept Sophie C. Hofferberth 1, Andrew E.

Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair: The STABILISE Concept Sophie C. Hofferberth 1, Andrew E.
A Comparison Of Endovascular And Open Approaches To The Treatment Of Aneurysms Of The Descending Aorta: Outcomes Differ By Severity Of Co-morbid Diseases.

A Comparison Of Endovascular And Open Approaches To The Treatment Of Aneurysms Of The Descending Aorta: Outcomes Differ By Severity Of Co-morbid Diseases.
Quality of life after abdominal aortic aneurysm repair: endovascular repair vs open repair A Systematic Review.

Quality of life after abdominal aortic aneurysm repair: endovascular repair vs open repair A Systematic Review.
June ‘XX Presents to Beaumont A&E c/o Abdominal Pain B/G: Known AAA Radiating through to the back Constant for 24 hrs Vomit x 6 Fever, Malaise No Hx of.

June ‘XX Presents to Beaumont A&E c/o Abdominal Pain B/G: Known AAA Radiating through to the back Constant for 24 hrs Vomit x 6 Fever, Malaise No Hx of.
Echocardiographic Evaluation of Acute Aortic Syndromes

Echocardiographic Evaluation of Acute Aortic Syndromes
Matthew S. Slater, MD, Brian S. Diggs, PhD Frederick A. Tibayan, MD Steven G Guyton, MD, MPH Howard K. Song, MD, PhD The Department of Surgery, and the.

Matthew S. Slater, MD, Brian S. Diggs, PhD Frederick A. Tibayan, MD Steven G Guyton, MD, MPH Howard K. Song, MD, PhD The Department of Surgery, and the.
Minimal aortic injury of the thoracic aorta: imaging appearances and outcome Emerg Radiol, 2014 Harborview Medical Center, University of Washington.

Minimal aortic injury of the thoracic aorta: imaging appearances and outcome Emerg Radiol, 2014 Harborview Medical Center, University of Washington.
Department of Cardiolog Shenyang Northern Hospital

Department of Cardiolog Shenyang Northern Hospital
1 Wei Zhang, Wei-Guo Ma, Long-Fei Wang, Jun Zheng, Bulat A. Ziganshin, Paris Charilaou, Xu-Dong Pan, Yong-Min Liu, Jun-Ming Zhu, Qian Chang, John A. Elefteriades.

1 Wei Zhang, Wei-Guo Ma, Long-Fei Wang, Jun Zheng, Bulat A. Ziganshin, Paris Charilaou, Xu-Dong Pan, Yong-Min Liu, Jun-Ming Zhu, Qian Chang, John A. Elefteriades.
The only end-points of therapy that matter are mucosal healing, normal blood work, and negative radiologic studies. Robert N. Baldassano, MD Colman Family.

The only end-points of therapy that matter are mucosal healing, normal blood work, and negative radiologic studies. Robert N. Baldassano, MD Colman Family.

Similar presentations

Ads by Google