Thoracic Aortic Research Center. University of Milan

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1 University of Milan Thoracic Aortic Research Center Update on IRAD Santi Trimarchi, MD, PhD Associate Professor of Vascular Surgery, University of Milan Head, Unit of Vascular Surgery II Director, Thoracic Aortic Research Center IRCCS Policlinico San Donato

2 IRAD Disclosures W.L. Gore & Associates, Inc. Active Sites Medtronic Varbedian Aortic Research Fund The Hewlett Foundation The Mardigian Foundation UM Faculty Group Practice Terumo Ann and Bob Aikens

3 Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD

4 Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD

5 Active IRAD Sites [49] IRAD:

6 IRAD Total Patients Type A Type B

7 IRAD Total Follow-Up Follow-up defined as a patient having at least one completed follow-up form (83.2%) (57.3%) Total Survived Followed Up

8 IRAD InterVentional Cohort IVC: Active IRAD IVC Sites [26]

9 IRAD InterVentional Cohort - IVC Aim: to better address surgical variables 131 variables

10 IRAD InterVentional Cohort - IVC Cases Enrolled to Date cases enrolled AHA ACC AHA ACC AHA ACC AHA ACC AHA ACC AHA ACC

11 IRAD InterVentional Cohort - IVC 18,43% 81,56% Type A Type B 1836 Type A cases 1751 surgical 39 endovascular 45 hybrid 1 surgical + endo 415 Type B cases 104 surgical 280 endovascular 29 hybrid

12 Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD

13 Retrograde Extension of Type B Dissection in Arch

14 Retrograde Extension of Type B Dissection in Arch XXXX Incidence 16.5%

15 Retrograde Extension of Type B Dissection in Arch G 1: 337 pts G 2: 67 pts

16 Retrograde Extension of Type B Dissection in Arch No difference in management

17 Retrograde Extension of Type B Dissection in Arch No difference in mortality

18 Retrograde Extension of Type B Dissection in Arch No difference in 5-year survival

19 Retrograde Extension of Type B Dissection in Arch No difference in 5-year survival

20 Retrograde Extension of Type B Dissection in Arch No difference in 5-year survival

21 Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD

22 Retrograde Extension of Type B Dissection in Ascending Aorta Sem Thor Cardiovasc Surg, in press

23 Retrograde Extension of Type B Dissection in Ascending Aorta

24 Retrograde Extension of Type B Dissection in Ascending Aorta Methods and Results: between 1996 and 2014 were analyzed 99 patients (67 men; 63.2±14.0 years) with an entry tear in the DTA and retrograde extension into the arch or ascending aorta.

25 Retrograde Extension of Type B Dissection in Ascending Aorta Methods and Results: between 1996 and 2014 were analyzed 99 patients (67 men; 63.2±14.0 years) with an entry tear in the DTA and retrograde extension into the arch or ascending aorta. Independent predictors of retrograde type A AD were: increasing age (OR 1.0; 95% CI, 1.0 to 1.0; P=0.004) history of cocaine abuse (OR 4.9; 95% CI, 1.7 to 13.6; P=0.003) back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002) non-white race (OR 0.4; 95% CI, 0.2 to 0.6; P<0.001).

26 Retrograde Extension of Type B Dissection in Ascending Aorta Results: MED SURG ENDO Early mortality (30-day or in-hospital) 9.1% 18.2% 13.6% P= year survival (mean follow-up, 3.3 years) 86.7% 80.0% 90.9% P=0.67 Initial management A trend of favorable early mortality was observed in patients with retrograde extension till zone 1 (8.6%) versus into zone 0 (18.6%, P=0.14). Early mortality 18.6% P

27 Retrograde Extension of Type B Dissection in Ascending Aorta Results: Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04).

28 Retrograde Extension of Type B Dissection in Ascending Aorta Results: Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04). The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extension confined to zone 1 (proximal arch, P<0.001) MED 72.7% ENDO 86.4%

29 Retrograde Extension of Type B Dissection in Ascending Aorta Results: Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04). The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extension confined to zone 1 (proximal arch, P<0.001) Most of the SURG patients (71.8%) presented with AD extension into zone 0 (proximal to the innominate artery, P<0.001). SURG 71.8%

30 Retrograde Extension of Type B Dissection in Ascending Aorta Results: Retrograde Type A Type A AD P Early mortality (30-day or in-hospital) 12.9% 20.0% P= year survival (mean follow-up, 3.3 years) 86.8% 89.5% P=0.96

31 Retrograde Extension of Type B Dissection in Ascending Aorta Details of endovascular treatment Variable ENDO Dissection flap fenestration (%) 7 (31.8) Descending thoracic aortic stent graft (%) 6 (27.3) SMA stent (%) 2 (9.1) Renal artery stent (%) 3 (13.6) Iliac artery stent (%) 3 (22.7)

32 Retrograde Extension of Type B Dissection in Ascending Aorta Tear in Descending Aorta

33 Retrograde Extension of Type B Dissection in Ascending Aorta Thrombosed FL in Ascending Aorta Tear and patent FL in Descending Aorta 2 month F-Up: Thrombosed FL

34 Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD

35 Uncomplicated Type B Dissection: In-H mortality/compl. IRAD, unpublished

36 Uncomplicated Type B Dissection: In-H mortality/compl.

37 Uncomplicated Type B Dissection: In-H mortality/compl. Results Patients in group I showed a trend for higher BMI

38 Uncomplicated Type B Dissection: In-H mortality/compl. Results The maximum aortic diameter at any level on initial imaging studies was significantly larger in group I compared to group II

39 Uncomplicated Type B Dissection: In-H mortality/compl. Results The maximum aortic diameter at any level on initial imaging studies was significantly larger in group I compared to group II patients in group I were more likely to have multiple intimal tears

40 Uncomplicated Type B Dissection: In-H mortality/compl. Results The in-hospital mortality rate in Group I was 17.4%

41 Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD

42 IRAD InterVentional Cohort - IVC 18,43% 81,56% Type A Type B 1836 Type A cases 1751 surgical 39 endovascular 45 hybrid 1 surgical + endo 415 Type B cases 104 surgical 280 endovascular 29 hybrid

43 IRAD IVC Trends

44 IRAD IVC Trends Methods From patients enrolled in IRAD-IVC, only TAAD surgically repaired were included. Type B aortic dissection and those with endovascular/hybrid management were excluded. Patients were split into three equal groups based on time of intervention (T1: ; T2: ; T3: ).

45 IRAD IVC Trends Results

46 IRAD IVC Trends Results In-hospital mortality

47 IRAD IVC Trends Cerebral perfusion management Results Cereb ral p erfu s ion Antegrade Retrograde Ov erall T im e 1 T im e 2 T im e 3 587(84.8) pv alu e <.001 T rend p v alu e < (84.2) 461 (61.9) 461 (38.9) 141 (67.1) 528 (89.5) 76 (55.9) 303 (58.8) 369 (66.1) (44.1) 212 (41.2) 189 (33.9)

48 IRAD IVC Trends Cerebral perfusion management Results H y p otherm ic CircArres t Ov erall T im e 1 T im e 2 T im e (85.5) 173 (80.1) 483 (85.9) 601 (86.8) pv alu e.045 T rend p v alu e.030

49 IRAD IVC Trends Results Arterial Cannulation management R Ax illary artery cannu lation Fem oral cannu lation 313 (55.7) pv alu e <.001 T rend p v alu e < (30.1) <.001 <.001 Ov erall T im e 1 T im e 2 T im e 3 527(40.4) 39 (18.0) 175 (33.2) 615 (47.1) 165 (76.0) 281 (53.3)

50 IRAD IVC Trends Aortic Valve management Results d

51 IRAD IVC Trends Aortic Valve management Results d

52 IRAD IVC Trends Aortic Root management Results d

53 IRAD IVC Trends Ascending management Results Op en p rocedu re Sim p le as c. rep lacem ent Ov erall T im e 1 T im e 2 T im e 3 pv alu e T rend p v alu e 1455 (92.4) 205 (94.9) 565 (89.8) 685 (938) (77.6) 165 (76.4) 392 (72.5) 615 (81.7) <

54 IRAD IVC Trends Results Aortic Arch management

55 IRAD IVC Trends Results Aortic Arch management

56 IRAD IVC Trends Results Aortic Arch management

57 Update on IRAD Conclusions

58 Update on IRAD Conclusions Retrograde extension of type B dissection into the Arch might be treated similarly to those with no retrograde extension X X X X

59 Update on IRAD Conclusions Retrograde extension of type B dissection into the Arch might be treated similarly to those with no retrograde extension There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. X X X X

60 Update on IRAD Conclusions Retrograde extension of type B dissection into the Arch might be treated similarly to those with no retrograde extension There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. This implies that a selective approach may be reasonable, particularly among those with proximal extension limited to the arch distal to the innominate artery. X X X X

61 Update on IRAD Conclusions Initially uncomplicated type B dissection may in hospital complicate in up to 10% patients

62 Update on IRAD IVC Conclusions Utilization of adjunctive are associated with improved outcome in acute type A dissection

63 Update on IRAD IVC Conclusions IRAD IVC can be useful for addressing surgical and endovascular issues in the management of acute dissection.

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