Objectives. Non Traumatic Aortic Emergencies. Thoracic Aortic Anatomy Acute Aortic Syndrome Dissection PAU IMH

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1 Non Traumatic Aortic Emergencies Gregory D. Rushing, MD Assistant Professor, Division of Cardiac Surgery September 15, 2017 Thoracic Aortic Anatomy Acute Aortic Syndrome Dissection PAU IMH Surgical/Medical Intervention Historical Current Future Objectives Remember, Surgery is Cool.. 2 1

2 Anatomy 3 Anatomy 70% 15% 10% 4 2

3 Anatomy Eat more chicken 5 Pathology Dissection Intramural hematoma Penetrating atherosclerotic ulcer 6 3

4 Dissection Diagnosis ACC/AHA Guidelines: 7 Aortic Dissection 60% 10-15% 25-30% 8 4

5 Type A Dissection Still a true surgical emergency! 10 5

6 Priorities of surgical repair: 1. Operative survival 2. Stable aortic root 3. Competent valve 4. Normal coronary perfusion 5. Resection of intimal tear 6. Normal size arch 7. Obliteration descending false lumen 11 Type A Aortic Dissection (Basic Minimum Strategy) Axillary cannulation Reconstruct dissected layers Re-suspend aortic valve Supracoronary graft Open hemi-arch Resect intimal tear in ascending +/- arch 12 6

7 Mortality 7+/- 5% for ascending. (overall operative mortality was 23%) - Miller, (Shumway) Circulation 1984 Survival after: 30d 10 yr 20 yr Ascending repair 97% 61% 39% Arch repair 84% 48% 31% - Crawford 1992, JTCVS 13 43% had patent false lumen on post-op CT Hospital Mortality Rate 14% 10 year survival 66% vs 77% of matched controls. Growth rates (mm/yr): Arch 0.8 Descending 1 Abdominal

8 Type B Dissection Medical Treatment Blood Pressure Control: 140/90 mmhg or 130/80 mmhg (DM) Use Beta blockers, ACE inhibitors, and ARB s when tolerated Statin to reduce LDL less than 70mg/dl Smoking cessation 15 Type B Dissection Malperfusion Syndrome Inability to control blood pressure with oral agents Continued pain 16 8

9 Type B Dissection TEVAR approved Operative Mortality : 3% versus 11% Spinal cord Ischemia: 3% versus 14% Renal failure: 1% versus 13%. JTCVS 2007, 133(2): STABLE Trial for Type B Dissection Cook Zenith Dissection Endovascular System From the Society for Vascular Surgery Aortic remodeling after endovascular treatment of complicated type B aortic dissection with the use of a composite device design Joseph V. Lombardi, MD,a Richard P. Cambria, MD,b Christoph A. Nienaber, MD,c Roberto Chiesa, MD,d Peter Mossop, MD,e Stéphan Haulon, MD,f Qing Zhou, PhD,g and Feiyi Jia, PhD,g on behalf of the STABLE investigators, Camden, NJ; Boston, Mass; Rostock, Germany; Milan, Italy; Melbourne, Victoria, Australia; Lille, France; and West Lafayette, Ind 30 Day Mortality Rate 4.7% Freedom from all cause mortality 1 year: 88.3% 2 year: 84.7% 18 JOURNAL OF VASCULAR SURGERY Volume 59, Number 6 9

10 TEVAR for Type B Dissection INSTEAD trial - Medtronic Talent System Randomized Comparison of Strategies for Type B Aortic Dissection The INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) Trial Christoph A. Nienaber, MD, PhD; Hervé Rousseau, MD, PhD; Holger Eggebrecht, MD;Stephan Kische, MD; Rossella Fattori, MD, PhD; Tim C. Rehders, MD; Gunther Kundt, PhD; Dierk Scheinert, MD, PhD; Martin Czerny, MD, PhD; Tilo Kleinfeldt, MD; Burkhart Zipfel, MD; Louis Labrousse, MD, PhD; Hüseyin Ince, MD, PhD;for the INSTEAD Trial Failed to improve survival and SAE rates at 2 years despite favorable aortic remodeling. Freedom from all cause Mortality 2 year: 88.9% (95%) DOI: /CIRCULATIONAHA Endovascular Repair of Type B Aortic Dissection Long-term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial Christoph A. Nienaber, MD, PhD; Stephan Kische, MD; Hervé Rousseau, MD, PhD; Holger Eggebrecht, MD; Tim C. Rehders, MD; Guenther Kundt, MD, PhD; Aenne Glass, MA; Dierk Scheinert, MD, PhD; Martin Czerny, MD, PhD; Tilo Kleinfeldt, MD; Burkhart Zipfel, MD; Louis Labrousse, MD; Rossella Fattori, MD, PhD; Hüseyin Ince, MD, PhD; for the INSTEAD-XL trial DOI: /CIRCINTERVENTIONS Uncomplicated Type B Medical Management Alone vs. TEVAR & Medical management Instead XL Circ Cardiovasc Int 2013 ADSORB European J Vasc Endovasc Surg 2014 IRAD Ann Cardiothorac Surg 2014 RCT -140 pts OMT vs. OMT + TEVAR RCT 61 pts OMT vs. OMT + TEVAR Retrospective review of registry patients Improved aortic remodelling & aorta specific survival in TEVAR group at 5 years Improved aortic remodeling at 1 year Improved aorta related survival at 5years 10

11 Intramural Hematoma versus Penetrating Ulcer

12 Endovascular stent grafting for ascending aorta repair in high-risk patients Eric E. Roselli, MD, Jahanzaib Idrees, MD, Roy K. Greenberg, MD, Douglas R. Johnston, MD, and Bruce W. Lytle, MD N= 22 patients (mean age 72 years) Mortality 27% Re-intervention rate of 36% Best results in pseudoaneurysm and PAU 23 JTCVS 2015;149: Thank You! 24 12

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