Acute dissections: who should we treat, and how?
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1 Acute dissections: who should we treat, and how? J Sobocinski, R Azzaoui, B Maurel, R Spear, T Martin-Gonzalez, A Hertault, S Haulon Centre de l Aorte, Chirurgie vasculaire, Hôpital Cardiologique, CHRU Lille, Fr
2 Epidemiology 3 5 cases per inhabitants/y Olendorf D, The Gale Encyclopaedia of Medicine. Stamford, Conn: Gale, 2008 mean Age at onset y.o. Male 65% Trimarchi S, Circulation 2006 Tsai TT, Circulation 2006 International Registry of Acute Aortic Dissection (IRAD) Since 1996 in 18 centres (6 countries) Largest available updated Database
3 Patients at risk Vs. Type A: Older more atherosclerosis Nienaber CA, Lancet2015
4 At the onset, diagnosis and treatment strategy established on: Previous condition Clinical report Morphological Findings Adequate Therapy
5 Which Therapy(ies) can be provided?
6 What are we preventing? Early stage Aortic Rupture Malperfusion Late objective Aortic Rupture
7 Acute type B in 2005 Complicated Uncomplicated Medical therapy Β-blockers Medical therapy Β-blockers Endovascular therapy: Fenestration Aortic stentgrafting Selective Stenting Open surgery: Bypass / aortic reconstuction Hybrid surgery: Bypass / aortic Stentgrafting
8 Acute type B in 2015 What is acute? What is complicated?
9 Which Patients need to be treated? Identification of Predictors = Risk evaluation Anticipation and better selection of patients Improve outcomes
10 Acute? 14 DAYS < Acute, > Chronic Medicine (Baltimore)1963 Subacute: 14d to 3 mths Steuer J, EJEVS 2013 Hyperacute 0 to 48h Acute 2 to 7d; Subacute 7 to 30d Chronic >30j Booher AM, Am J Med 2013
11 At the onset Complicated? Rupture Malperfusions Resistant hypertension (OR 3.5) Persistent / refractory pain (OR 3.3) Age >70 (OR 5) max Diam >55mm (OR 6) [Gurin NYStateJMed1935] [trimarchi Circ2010] Circ2014 Circ2014
12 Obvious complications at the early stage Aortic Rupture OR = 6.43; 95% CI[ ; P=.001] [Tolenaar J, Circ2014] Malperfusions [Cambria R, JVS Clair DG, Semin Vasc Surg 2002] 25 à 40% in AD [Greenberg RK, EJVES 2003] related Mortality= 16-25%
13 Less described but still obvious Rapid growth within 1st week
14 Later on Significant dilatation / rupture with imaging FU Complicated? 25 à 50% of patients [Sasaki Cardiovasc Surg 2000, Lansmann ATS 2002] Irremediable [Kelly Clin Radio 2007] 40% at 7y [Halstead JTCS 2007, Zierer ATS 2007]
15 Late complications Morphological factors depicted at the onset Total aortic Diameter >40 mm, RR=9 [Kato M, Circ1995] >45mm [Genoni, EJCTS2002] [Kunishige H, 2006] False lumen diameter >22mm [van Bogerijen GH, JVS2014] Ratio FL/Total aorta > 70% (OR 4.3) [Immer FF Circulation 2005] Entry tear size >10mm (HR 5,8) [Evangelista, Circ2012] Nb (1) [van Bogerijen GH, JVS2014][Tolenaar J, ATS2013] Proximal location (P<.0001) [Kato M, Circ1995][Evangelista, Circ2012]
16 Late complications Hemodynamical factors depicted at any time during FU False lumen patency Completely thrombosed = nb aortic events [Dake M NEJM 1999] Partially thrombosed [Yeh Chest 2003] = nb aortic events [Tsai T NEJM 2007; Qin YL, JVS2012; Lansman SL, ATS2002]
17 Late complications other factors JVS 2013 Demographics Age <60 Caucasian Marfan Medical therapy including Calcium channel blockers [Jonker FH, ATS2005] Clinics Heart beat rate >60/min [Kodama, Circ2008]
18 Late complications Screening Time-resolved MRA with flow dynamics assessment Nienaber CA, Lancet2015
19 18 F-FDG PET/CT Late complications Screening Favourable unfavourable Kato K, J Nucl Med2010
20 Biomarkers Late complications Screening D-dimer and fibrin degradation products [Kitada S, Am J Cardiol2008; Suzuki T, Circ2009] MMP-9 [Wen D, Clin Chim Acta2011] Aortic Remodeling Elastin degradation products, calponin (SML tropo), TGF-β
21 Invasive Treatment for all patients? N=298 Only 41% F-F- Reintervention at 6y
22 TEVAR in Uncomplicated ACUTE type B AD ADSORB trial BMT vs BMT + TEVAR 61 patients No 30d death Positive remodeling for the thoracic aorta at 1Y??
23 TEVAR in complicated ACUTE type B AD VIRTUE registry BMT + TEVAR 50 acute patients 12% of 30d death Positive remodeling in acute & subacute patients
24 TEVAR in complicated ACUTE type B AD 30d death =9-12% SCI=2-14%
25 TEVAR in ACUTE & SUBACUTE type B AD PETTICOAT
26 STABLE Study Feasibility study to Assess the Utility of the TX2 Thoracic Endograft & Zenith Dissection Stent for the treatment of complicated aortic dissection < 3 months Inclusion Criteria TBAD Inclusion criteria Branch vessel obstruction Periaortic effusion/hematoma Refractory Hypertension Persistent Pain/Symptoms Transaortic diameter > 40 mm 5 mm aortic growth within 3 months from onset Really complicated?
27 BMT + TEVAR No randomisation 55 acute patients 5.5% of 30d death Positive remodeling in acute patients STABLE Study
28 Complicated & Acute type B AD TEVAR > BMT TEVAR+BMT > BMT Similar 30d death rates (8.1% TEVAR vs. 9.8% BMT, P=.604) but 5y mortality rate intevar group (15% vs. 29%, P=.018)
29 Complicated & Acute type B AD open surgery Hagan JAMA2010
30 Algorythm EJEVS 2013 Duration Intimal tear location Size of the aorta SE Segmental extent Clinical complications (malperfusions) Thrombosis of the false lumen
31 Conclusion Acute Aortic Dissection = complex disease Evolving strategy therapy Endovascular strategy = first line treatment Define the best population of patients According to predictors
32 Thank you
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