UC SF. Disclosures. Thoracic Endovascular Aortic Repair 4/24/2009. Management of Acute Dissections: Is There Still a Role for Open Surgery?

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1 UC SF Management of Acute Dissections: Is There Still a Role for Open Surgery? Darren B. Schneider, M.D. Assistant Professor of Surgery and Radiology Division of Vascular Surgery University of California San Francisco Disclosures W.L. Gore - research funding; speaker Cook, Inc. - research funding Boston Scientific - research funding; advisory panel Cordis - research funding; advisory panel EV3 - consultant UCSF Vascular Symposium San Francisco, CA April, 2009 Is There a Role for Open Surgery in the Management of Acute Dissections? Yes, for acute Type A dissections And definitely, for hybrid debranching But, preferred management of acute Type B dissections is now endovascular! Thoracic Endovascular Aortic Repair Yes TAA Penetrating ulcer Trauma Complicated Acute Type B Maybe IMH Not Yet: Uncomplicated Acute Type B Chronic Type B Type A dissection 1

2 Combined TAG & TX2 Results JVS ,549 TAA repairs NIS database Mortality 18% 10% Intact TAA, 45% Ruptured TAA Stroke 3%, other neurologic events 2% Poorer outcomes associated with age, renal failure, low-volume centers Acute Type B Dissections In-hospital mortality 13% Rupture 70% Visceral ischemia 19% Neurologic 8% 85% of deaths occur in first week Surgical mortality 32% Standard treatment is medical Chronic aneurysmal dilatation 30% to 50% within 3 years Mortality 25% within 3 years Suzuki (IRAD) Circulation 2003 Hagan (IRAD) JAMA 2000 Acute Type B Dissection: Results of Open Surgical Graft Replacement Study N Mortality (%) SCI Jex Verdant Glower NA Miller Neya NA Fann NA Svennson Cosseli

3 Acute Type B Dissections Suzuki (IRAD) Circulation 2003 Endovascular Management of Acute Type B Dissection Complicated Dissections Rupture Malperfusion Rapid enlargement Persistent Pain Acute Type B Dissection 9 Month Post CT 3

4 Ruptured Type B Dissection Ruptured Type B Dissection Mechanism of Branch Malperfusion Dynamic Malperfusion from True Lumen Compression Therasse, E. et al. Radiographics 2005 Schoder et al. Ann Thor Surg

5 Aortic Fenestration Celiac SMA Atkins JVS 2008 Renal Artery IVUS 5

6 Results of Stent Grafts for Type B Aortic Dissection Metanalysis (1999 to 2004; n = 609) Technical success 98.5% Major complications 11.1% Neurologic complications 2.9% CVA 1.8% Paraplegia 0.8% 30d mortality 5.3% 2-year survival 88.8% INSTEAD Trial The INvestigation of STEnt grafts in Type B Aortic Dissection Prospective randomized study comparing endovascular stent graft to optimal medical therapy n = 136 patients Uncomplicated Type B dissections (2 to 52 weeks time of randomization) Eggebrecht Eur Heart J 2005 INSTEAD Trial 1 year results No difference in overall survival 91% vs. 97% No difference in aorta-related survival 94% vs. 97% No difference in event-free survival 79% vs. 83% Nienaber CA VEITH SYMPOSIUM 2007 INSTEAD Trial Uncomplicated Type B dissections should be treated with medical therapy plus surveillance with deferred stent graft treatment for patients with late complications Need to identify patients at high risk for progression and complications who may benefit from early intervention Nienaber CA VEITH SYMPOSIUM

7 INSTEAD Trial This was a trial of treatment of subacute dissections, most significantly more than 30 days old and not requiring treatment However, 91% survival at year suggests that TEVAR can be performed with relative safety in patients with aortic dissections High Risk Dissection: False Lumen > 22mm Song, et al. JACC pts 51 Type A, 49 Type B Imaging f/u mean 31 mos 28% developed TAA > 60mm FL diameter > 22mm highly predictive of adverse outcome TAA 42% vs. 5% (p<0.001) Mortality 12% vs. 5% (p=0.09) High Risk Dissection: Partial False Lumen Thrombosis 31.6% Song JM JACC 2007 Tsai TT NEJM

8 High Risk Dissection: Partial False Lumen Thrombosis Is there a role for anticoagulation? Need for Dissection-Specific Devices Currently available devices were not designed for treatment of aneurysms and not acute dissections Needs for treatment of dissection: Coverage & seal of entry tear Maintenance of L subclavian artery patency Reexpansion of true lumen False lumen thrombosis Reestablishment of branch vessel patency Petticoat Concept: STABLE Trial Eliminated Flares Single stent Increased wire diameter Gore C-TAG Device 9-Apex sinusoidal pattern Uncovered proximal apices Expanded treatment range (18 42 mm) 8

9 Chronic Dissections Debranching 9

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12 Conclusions TEVAR has become standard therapy for complicated acute type B aortic dissection Some patients with uncomplicated acute type B dissection may benefit from early intervention We need to identify which patients are at risk for late complications Until then, patients with uncomplicated acute type B dissections are best managed medically Dissection-specific devices are needed and will improve results 12