AORTIC DISSECTIONS Current Management. TOMAS D. MARTIN, MD, LAT Professor, TCV Surgery Director UF Health Aortic Disease Center University of Florida
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1 AORTIC DISSECTIONS Current Management TOMAS D. MARTIN, MD, LAT Professor, TCV Surgery Director UF Health Aortic Disease Center University of Florida
2 DISCLOSURES Terumo Medtronic Cook Edwards Cryolife
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4 AORTIC DISEASE CENTER
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6 AORTIC DISSECTIONS ETIOLOGY MEDIAL DEGENERATIVE DISEASE GENETIC ( MARFANS ) HYPERTENSION ASSOCIATED PATHOLOGY (AORTIC STENOSIS, COARCTATION) PREGNANCY IATROGENIC (CATH, CANNULATION, CROSS-CLAMP) COCAINE
7 AORTIC DISSECTIONS PRESENTATION SEVERE CHEST / BACK PAIN ( TEARING ) SYNCOPE / COLLAPSE TIA / STROKE PARALYSIS PULSE / PRESSURE DIFFERENTIAL MURMUR
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9 AORTIC DISSECTIONS PRESENTATION RIPPING, TEARING, 12/10 CHEST PAIN AGE YEARS SEX 3 : 1 MALE : FEMALE RACE BLACK > WHITE > ASIAN
10 AORTIC DISSECTIONS DIAGNOSIS CHEST X-RAY ECHOCARDIOGRAPHY CT SCAN MRI AORTOGRAPHY IVUS
11 CHEST X-RAY
12 ECHOCARDIOGRAPHY
13 INTRAVASCULAR ULTRASOUND - IVUS
14 AORTOGRAHPY GOLD STANDARD OF THE PAST
15 CT SCAN GOLD STANDARD OF TODAY
16 CT SCAN GOLD STANDARD OF TODAY
17 CT SCAN 3D RECONSTRUCTION
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19 AORTIC DISSECTION CLASSIFICATION DEBAKEY DEBAKEY
20 Classification Schemes Classification Methods Aortic Segment Involvement Type 1,2,A: Ascending aorta involvement Type 3,B: Ascending not involved Duration from Clinical Onset Acute: Within first 14 days SubAcute: Between 14 days and 3 months Chronic: Greater than 3 months Complications (yes/no) Uncomplicated Complicated
21 ACUTE AORTIC DISSECTION NATURAL HISTORY ASCENDING INVOLVEMENT MORTALITY 1 ST 24 HOURS 33% 48 HOUR -- 45% (1% per hour) 14 DAYS 48% 30 DAYS- 52%
22 ACUTE AORTIC DISSECTION TREATMENT ASCENDING AORTIC INVOLVEMENT SURGICAL (DEBAKEY I,II EMERGENCY / STANFORD A)
23 DEBAKEY I, II / STANFORD A CAUSE OF DEATH RUPTURE / TAMPONADE CORONARY ISCHEMIA / MI ACUTE AORTIC INSUFFICIENCY CHF / ARRYTHMIA
24 ACUTE AORTIC DISSECTION MEDICAL MANAGEMENT TYPE B MORTALITY 1 ST 24 HOURS 3% 48 HOUR 5% 14 DAYS 8% 30 Days 9%
25 Clinical Complications related to dissection Rupture Branch vessel malperfusion (cerebral, spinal, visceral, renal, lower extremity) Progression of aortic involvement with proximal or distal extension Other: Uncontrollable hypertension Uncontrollable symptoms Rapid false lumen dilation Trans-aortic enlargement of > 10mm within the first 2 weeks Image courtesy of Jean Panneton, MD
26 SURGICAL TREATMENT (DISSECTIONS) ALL ACUTE TYPE I OR II /A TYPE III/B LEAK OR RUPTURE COMPROMISE OF VISCERAL OR PERIPHERAL VESSELS, ie, MALPERFUSION
27 ASCENDING DISSECTION PREOP SURGICAL CONSIDERATIONS ANESTHESIA / ANESTHESIOLOGIST CANNULATION / PERFUSION VALVULAR INVOLVEMENT CORONARY ARTERY DISEASE / ISCHEMIA PERIPHERAL OR VISCERAL ISCHEMIA
28 ASCENDING DISSECTION PREOP ANESTHESIA CONSIDERATIONS HEMODYNAMIC INSTABILITY TAMPONADE PHYSIOLOGY SURGEON IN THE ROOM DURING INDUCTION
29 ASCENDING DISSECTION ANESTHESIA MONITORING CONSIDERATIONS TRANSESOPHAGEAL ECHO (TEE) SWAN GANZ PULMONARY ARTERY CATHETER
30 ASCENDING DISSECTION CANNULATION OPTIONS FEMORAL AXILLARY ASCENDING AORTA LEFT VENTRICULAR APEX
31 ASCENDING DISSECTION CEREBRAL PROTECTION PROFOUND HYPOTHERMIA ANTEGRADE PERFUSION RETROGRADE PERFUSION PHARMACOLOGIC PROTECTION
32 ASCENDING DISSECTION BASIC INTRAOPERATIVE GOALS RELIEF OF TAMPONADE ALLEVIATION OF ISCHEMIA RESECTION ASCENDING / PROXIMAL ARCH AORTIC VALVE SALVAGE
33 ASCENDING DISSECTION INTRAOPERATIVE TECHNIQUES FELT? GLUE? BOTH?
34 ACUTE ASCENDING DISSECTION SPECIAL CONSIDERATION AORTIC VALVE MANAGEMENT VALVE RESUSPENSION ROOT REPLACEMENT VALVE REPLACEMENT VALVE SALVAGE
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36 AORTIC VALVE SALVAGE DAVID 1 FLORIDA SLEEVE
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38 ACUTE AORTIC DISSECTION MANAGEMENT OF THE ARCH Partial Replacement vs Total Replacement
39 ACUTE ASCENDING DISSECTION MORTALITY OVERALL 8-36% STANFORD 24% CLEVELAND CLINIC 14% MT SINAI NY 14% U OF FLORIDA 16%
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41 ACUTE AORTIC DISSECTION DEBAKEY III / STANFORD B CONSERVATIVE MEDICAL MANAGEMENT vs OPEN SURGICAL MANAGEMENT VS?? ENDOVASCULAR STENT GRAFTING??
42 ACUTE DEBAKEY III DISSECTION MEDICAL MANAGEMENT UNCOMPLICATED DISSECTIONS NO EVIDENCE OF LEAK OR RUPTURE NO (ACCEPTABLE) VISCERAL ISCHEMIA NO LIMB / LEG ISCHEMIA
43 ACUTE DEBAKEY III DISSECTION MEDICAL MANAGEMENT WHAT IS MEDICAL MANAGEMENT? AGGRESSIVE BP CONTROL AGGRESSIVE PAIN CONTROL AGGRESSIVE SURVEILLANCE FOR MALPERFUSION
44 ACUTE DEBAKEY III DISSECTION SURGICAL MANAGEMENT INDICATIONS EVIDENCE OF LEAK OR RUPTURE SIGNIFICANT VISCERAL ISCHEMIA CONTINUOUS OR INTERMITTENT LEG ISCHEMIA ACUTE AORTIC EXPANSION > 6 CM
45 ACUTE DEBAKEY III DISSECTION MEDICAL VS SURGICAL TREATMENT RESULTS MEDICAL MORTALITY 0 10% SURGICAL MORTALITY 0 60%? IN HOSPITAL COMPLICATIONS, PROCEDURES FOR ISCHEMIA, EARLY EXPANSION REQUIRING SURGERY?
46 ACUTE DEBAKEY III DISSECTION SURGICAL VS MEDICAL HOSPITAL MORTALITY (%) 1 YEAR SURVIVAL (%) 5 YEAR SURVIVAL (%) SURGICAL 17 MEDICAL Schor, J, et. al., Ann Thor Surg, May 1996, Mt. Sinai Med Ctr, NY, NY
47 ACUTE DEBAKEY III DISSECTION SURGICAL MANAGEMENT DESCENDING REPLACEMENT PARTIAL UPPER DESCENDING ONLY EXTREMELY FRAIL SALVAGE PROCEDURE TOTAL TOTAL DESCENDING YOUNGER / HEALTHIER
48 ACUTE DEBAKEY III DISSECTION INTRAOPERATIVE CONSIDERATIONS DISTAL PERFUSION YES NO
49 ACUTE DEBAKEY III DISSECTION INTRAOPERATIVE CONSIDERATIONS DISTAL PERFUSION LEFT ATRIAL TO FEMORAL ARTERY BYPASS FEMORAL ARTERY /FEMORAL VEIN CARDIOPULMONARY BYPASS PASSIVE DISTAL SHUNT (AORTA TO AORTA)
50 ACUTE DEBAKEY III DISSECTION INTRAOPERATIVE CONSIDERATIONS INTERCOSTAL REIMPLANTATION EXTREMELY DIFFICULT - CONTRAINDICATED
51 ENDOVASCULAR STENT GRAFTS A NEW ERA
52 Endovascular Stent Grafts A New Era
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55 Diagnosis Chest X-ray: Wide mediastinum, cardiomegaly, pleural effusion CT Scan: Identifies intimal flap rapidly, requires contrast media, identifies rupture 2-D ECHO/TEE: Identifies intimal flap, no contrast media, bedside Cath: Used to be Gold Standard MRI: highly sensitive, but takes time
56 Acute Dissections Felt? Glue? Both?
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