WHICH PLACE FOR EMERGENT INTERVENTION IN COMPLICATED ACUTE TYPE B DISSECTION (ctbaod)
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1 WHICH PLACE FOR EMERGENT INTERVENTION IN COMPLICATED ACUTE TYPE B DISSECTION (ctbaod)
2 Epidemiology of type B Aortic Dissection TYPE B dissection: 0,5-2,1/ /year (40% of all dissection) Hospital mortality of BMT 3 18 % Complicated 15-47% Meszaros I. Chest 2000 Estrera AL Circulation 2006 Costa S. Ann Vas Surg 2007 Criado F.Tex Heart Iinst J Hiratzka L. Circulation 2010
3 WHAT IS COMPLICATED? Rapid expansion (>5 mm) 33% (over days/over months?) BMT failure hypertention 3-62% pain 17-87% Impending rupture/rupture 16-56% Malperfusion (visc/periph/neurol) 11-87
4 MEDICAL TREATMENT IS NOT AN OPTION MORTALITY > 50%
5 IRAD open endovasc In-hospital mortality 33.9% 10.6% Complications 40.0% 20.8% Fattori R, Tsai TT, Myrmel T et al. JACC Intv 2008.
6 INTERDISCIPLINARY EXPERT CONSENSUS DOCUMENT TBAoD 1529 OR / 2058 TEVAR open endovasc In-hospital mortality 17,5% 10,2% Complications STROKE 5,9% 4,9% SCI 3,3% 4,2% Fattori R. Journal of The American College of Cardiology 2013
7 TIMING OF INTERVENTION O Donnell S.JVS 2011 Steuer J. ESVS 2011 Ryan C. JVS 2013 Sobocinsky J. ESVS pts 2,9 days(4,8h-10d) 50 pts 1,5 days 61 pts 2,5 days 52 pts <14 days Rupture/malperfusion in emergency 1-2 days- stabilize pts and complete evaluation for other situations
8 TEVAR CONCEPT for uncomplic/ TBAoD COVER OF THE PROX/ TEAR 15 cm TRUE LUMEN FLOW RESTOR FALSE LUMEN DEPRESSUR LONG TERM COMPLICATIONS (ANEURYSM, DISS EXTENSION)
9 TEVAR CONCEPT for ctbaod Aortic Expan & BMT fail Hypertention 3-62% Pain 17-87% COVER OF THE PROX/ TEAR 15 cm TRUE LUMEN FLOW RESTOR FALSE LUMEN DEPRESSUR PREVENT CATASTROPHIC AORTIC EVENTS & AGGRESSIVE MEDICAL THERAPY
10 BMT FAILURE Day 1 45 mm Day 2 48 mm
11 BMT FAILURE DAY 1 ET: 7 mm, ø 36 DAY 6 ET: 10 mm, ø 38 DAY 9 ET: 13 mm, ø 40
12 BMT FAILURE
13 BMT failure in the long run 2003 (lost to FU) 2010
14 BMT failure in the long run
15 BMT failure in the long run
16 BMT failure in the long run
17 ctbaod IMPEND/ RUPT - RUPTURE 17-56% ABOLISH FALSE LUMEN PERFUSION COVER MOST OF THE ENTRY TEARS (MOST/ALL OF THE DTA) TRUE LUMEN FLOW RESTORATION
18 #1- RUPTURE PREOP 2002 POSTOP 5 YRS 11 YRS
19 #2 - RUPTURE
20 #3 - RUPTURE
21 ctbaod MALPERFUSION 11-87% ORGAN REPERFUSION & VIABILITY! COVER UNTIL MALPERFUSION IS SOLVED
22 ctbaod MALPERFUSION DYNAMIC OBSTRUCTION SEPTUM PROLAPSE DURING CARDIAC SYSTOLE USUALLY SOLVED BY ENDOGRAFTING STATIC OBSTRUCTION THE CLEAVAGE PLANE EXTENDS INTO THE OSTIUM AND COMPROMISE IN-FLOW RISK OF THROMBOSIS OFTEN UNSOLVED BY ENDOGRAFTING
23 ctbaod MALPERFUSION WHEN ENDOGRAFTING NOT RELIEVE MALPERFUSION BRANCH FENESTRATION & STENTING (20-73%) SZETO WY. Ann Thorac Surg 2008 FEEZOR RJ. J VS 2009
24 #1 - Limb ischemia
25 #1 - Limb ischemia
26 #2 - L-Renal malperfusion
27 #2 - L-Renal malperfusion
28 FENESTRATION ALONE IS A BAD STRATEGY? AORTA LEFT UNTREATED INABILITY TO ALLOW REMODELLING DO NOT LOWER THE RISK OF RUPTURE 71 TREATED PTS o AORTIC GRADIENT 44 8 mmhg o MORTALITY 7.2% Patel JVS 2009
29 ENTRY TEAR > 1 CM IS THIS COMPLICATED TOO?
30 False lumen flow and geometric parameters of tear SIZE(18-33mm) LOCATION(1,2-20 mm) Zhuo Cheng. JVS 2013
31 Day 1 40 mm Entry tear > 1 cm BMT failure Day 2 43 mm
32 BMT failure
33 REINTERVENTION RATE in ctbaod 18%-49% 1 yr 27%-35% 5 yrs FALSE LUMEN REPERFUSION/EXPANSION TYPE I E-LEAK Stent graft Induced New Entry Prox/Dist(SINE) RETROGRADE TYPE A DISSECTION Fattori R - JACC 2013
34 Immediate/Delayed FL reperfusion TYPE II EL
35 SINE Marfan Syndrome 33% Dong Z. JVS 2010
36 SINE Marfan Syndrome 33% 1 m LATER LSA TRASP & SG-EXT Dong Z. JVS 2010
37 SINE 3,4% 12 months f-up reintervention UNTREATED: MORTALITY 26,1% Dong Z. JVS 2010
38 RETROGRADE DISSECTION % Mortality 20-57% Review of Litterature
39 SAFER PROXIMAL LZ Carotido-LSCA bypass 2-39%** Carotid-carotid-LSCA bypass 8% Carotid-carotid bypass 7-21 Total Debranching 8-21% ENDODEBRANCHING!?!? **LSA Occlusion/ predictor of decrease survival (STABLE) 3-62% Review of litterature
40 GRAFT FOR DISSECTION (IFU) ATRAUM FIX / RADIAL FORCE/TAPERED OVERSIZING<10%
41 Remodelling of the aorta after TEVAR in ctbaod 33 pts/24 months Chih-Pei Ou Yang. JVS 2012
42 Remodelling of the aorta after TEVAR in ctbaod 36/52 pts Sobocinski J. ESVS; 2013
43 Remodelling of the aorta after TEVAR+RBS 465 pts (266 Acute, 199 chronic) Feng J. JVS 2013
44 ctbaod:our experience : 38/95 PTS Presentation N PTS % Failure BMT 21 55,2 Impending rupture/rupture 12 31,7 Distal Malperfusion 3 7,9 Renal Malperfusion 2 5,2 Total
45 ctbaod : 38/95 PTS DEBRANCHING N PTS % Emiarch deb 10 26,3 LSA byp 9 23,7 LCCA chimney 4 10,5 LSA chimney 4 10,5 ENDOGRAFT N PTS % GORE TAG/C-TAG 25 65,7 COOK/Diss TX2 6 15,8 BOLTON 6 15,8 VALIANT 1 2,6
46 ctbaod : 38/95 PTS MALPERFUSION 5/38 pts MALPERFUSION N PTS TREATMENT Renal 2 Stenting Distal 3 1 Kissing stent 2 monolat stent
47 ctbaod : 38/95 PTS EARLY COMPLICATION N PTS % MORTALITY 0 0 COMPLICATION 12 31,6% Stroke 1 Type 2 EL (LSA) 3* ARF 1 Disphagia 1 Paraparesi/Paraplegia 3** Respir Failure (Ventil/dependent) 3 *TREATED **2 REGRESSED
48 ctbaod : 38/95 PTS FOLLOW-UP 43,8 mths (1-98 mths) MORTALITY 3 pts 7.8% COMPLICATIONS 9 23,7% Type IA 2 Embolization Type IB 2 Distal Extention Type II 1 Untreated Type IV 1 Relining Migration 1 Debranc proximal LSA bypass occl 1 Redo Congestive Heart Failure 1
49 TEVAR IN COMPLICATED ACUTE TYPE B DISSECTION MORTALITY COMPLICATIONS PROMOTE FALSE LUMEN THROMBOSIS AORTIC REMODELLING REDUCE LONG TERM COMPLICATIONS ANEURYSMAL DILATATION
50 REFERENCES Nienaber CA. N Engl J Med 1999 Dake D. N Engl J Med 1999 Mesz. JVS 2009 Conrad M. JVS 2009 Huptas S. J Endovasc Ther 2009 Feezor RJ. JVS aros I. Chest 2000 Hagan G. JAMA 2002 Estrera AL Circulation 2006 Costa S. Ann Vasc Surg 2007 Fattori R. JACCI 2008 Cambria RP2009 Patel HJ. J Thorac Cardiovasc Surg 2009 Khoynezhad A. JVS 2010 Hiratzka L. Circulation 2010 Dong Z. JVS 2010 Criado F. Tex Heart Iinst J 2011 Nienaber CA. JVS 2011 Criado FJ. Tex Heart Inst J 2011 Boyle J. EJVES 2011
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