Unravelling the Literature on. Aortic. Dissection. Tara M Mastracci, MD FRCS(C) FACS MSc (HRM) FRCS
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1 Unravelling the Literature on Aortic Dissection Tara M Mastracci, MD FRCS(C) FACS MSc (HRM) FRCS 1
2 Disclosures Cook Medical Inc -- Proctorship and Consultation All speaking and consultation fees are donated to the Royal Free Trust Aortic Charity (Fund 187)
3 A patient should never be considered cured of this disease. -- E. Stanley Crawford
4 Progression of our Understanding Advances in Imaging Advances in Critical Care TEVAR Description and Observation Surgery 1965 Medical Management 2013 INSTEAD ADSORB
5 Modern Dissection Success Depends on How We define Goals 5
6 Survival as a Goal of Treatment Fattori et al, 2008
7 Swedish National Health Care Data Incidence of reoperation at 10 years was 7.8% Olsson, Circulation 2006
8 Suddenly False Lumen Flow Is Important x
9 Is False Lumen Flow Important?
10 INSTEAD Trial Nienaber et al., Circulation 2009; 120: At least 2 weeks after index dissection 597 Chronic AD 140 Enrolled for Randomization 293 Refused Randomization 164 Not Eligible 72 Pt OMT and TEVAR 68 Pt OMT 1 Pt Died before TEVAR 1 Opted out of OMT 2 Pt opted out of TEVAR
11 Progression of Disease: False Lumen Thrombosis
12 False Lumen Thrombosis in Modern Dissection Series Total False Lumen Thrombosis Partial False Lumen Thrombosis % Wiedemann /110 25/110 30% 75%* 24/28 4/28 100% Zhu 2015 Huang /72 NR 95% Cambria /50 6/50 52% F/u 19m, 237/600pts 43/61 70% Brunkwall (ADSORB) /72 5/72 74% Nienaber (INSTEAD XL) *Eggebrecht et al, Eu Heart J 2006
13 Remodelling Occurs But only reliably in the Stented portions of the aorta
14 % Survival 1 and 5y Survival: Medical Management Winnerkvist 2006 Nino Estrera 2007 Chemelli-Steingruber Pooled 30d Mortality 6.4%** Garbade 2010 Miyahara 2011 Fattori (IRAD 2013) yr 5yr **Fattori et a 2013
15 % Survival 1 and 5y Survival: Medical and TEVAR Winnerkvist 2006 Nino Estrera 2007 Chemelli-Steingruber Garbade 2010 Miyahara Fattori (IRAD 2013) Wiedemann 70 Nathan Fattori (IRAD) 65 Bockler 2009 Chemelli-Steingruber Khoynezhad Pooled 30d Mortality (Surgical) 10.2%** 1yr 5yr Erlich
16 % Freedom from Aortic Events Freedom From Aortic Events: Both Winnerkvist 2006 Nino 2009 Chemelli-Steingruber 2010 Miyahara 2011 Wiedemann Nathan Fattori (IRAD) Bockler 2009 Erlich Minanmi y 5y
17 x
18 Blaming your parents if youre a bad cook
19 Modern Dissection Preventing Disease Progression by Stenting the Whole Aorta Embolizing the False Lumen 20
20 Modern Dissection Preventing Disease Progression by Stenting the Whole Aorta Embolizing the False Lumen 21
21 22
22 Progression of True Lumen 08/ / / /2012
23 Using B/FEVAR in Chronic Dissection
24 Reoperation after B/FEVAR for Dissection Reoperation in 15/61 25% Kamman et al, 2016
25 Modern Dissection Preventing Disease Progression by Stenting the Whole Aorta Embolizing the False Lumen 26
26 Coil Embolization Hofferberth et al, JEVT 2012
27 Placement of Plugs/Occluders Idrees et al, JVS 2014
28 Custom Occlusion Device
29 Collected Experience: Embolization Author Journal/Year Embolic Agent N Hussain Annals 2015 Coils and glue 1 Coils, glue and occlusion Hofferberth JEVT 2012 balloons 10 Idrees JVS 2015 Occluders and other things 21 Kolbel JEVT 2016 Coils 2 Kolbel JEVT 2013 Candyplug 1 Mendes JEVT 2015 Amplatzer 1 Ogawa JEVT 2016 Candyplug 1 Hager JVS 2008 Coils and covered stents 1 Smith EVT 2009 Coils 1 Riga JVIR 2009 Coils and Onyx 1 Norberto JVS 2011 Coils 5
30 Collected Experience: Embolization Author Journal/Ye ar Embolic Agent N F/U (months) Hussain Annals 2015 Coils and glue 1 NR Hofferberth JEVT 2012 Coils, glue etc Occluders and other Idrees JVS 2015 things Kolbel JEVT 2016 Coils 2 NR Kolbel JEVT 2013 Candyplug 1 3 Mendes JEVT 2015 Amplatzer 1 18 Ogawa JEVT 2016 Candyblug 1 14 Hager JVS 2008 Coils and covered stents 1 NR Smith EVT 2009 Coils 1 9 Riga JVIR 2009 Coils and Onyx 1 24 Norberto JVS 2011 Coils 5 11
31 Collected Experience: Embolization Author Hofferberth Idrees Norberto Journ al/yea r JEVT 2012 JVS 2015 JVS 2011 Emboli c Agent Coils, glue etc Occluder s etc N F/U (m) Complete Thrombosi s Sac Size same or greater Sac Size Smaller % 10% % 62% (5mm) Coils % 40%
32 2013 x
33 2013 x
34 Remodelling Occurs But only reliably in the Stented portions of the aorta
35 Conclusions Dissections are tough The Goals of Treatment have changed Progression of Disease continues to be an issue, and current techniques may not completely remove the risk of aortic reintervention 36
36 A patient should never be considered cured of this disease. -- E. Stanley Crawford
37
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