Acute non-complicated TBD Do need TEVAR treatment

Transcription

1 Acute non-complicated TBD Do need TEVAR treatment Prof. Dr. med. Christoph A. Nienaber Universität Rostock Universitäres Herzzentrum

2 Survival in type B dissection by acuity Booher M et al., Am J Med 2013

3 Type B aortic dissection: Survival and predictors Hypotension/Shock Malperfusion Tsai T, Nienaber C, et al. Circulation 2006, 114:

4 Medical: Survival after acute type B aortic dissection Acosta S, et al., Annals of Vascular Surgery 2007; 21:

5 Uncomplicated type B dissection over time Jia X et al. J Vasc Surg. 2013

6 ADSORB: Acute uncomplicated type B dissection / 1 year Mortality ADSORB trial No need for SG in first 2 weeks of uncomplicated type B dissection

7 Remodeling after Stentgraft 90% remodeling with TEVAR (p 0.001) after 2 years Nienaber CA et al. Circulation 2009;120:

8 Prospective RCT: Subacute type B dissection Stable type B Dissection: INvestigation of... instead...? STEnt-grafts in Aortic Dissection pre post Optimal medical treatment versus stent-graft + OMT

9 INSTEAD: Subacute uncomplicated type B dissection Primary endpoint All-cause mortality at 2 years Secondary endpoints Thrombosis of False Lumen Degree of Aortic Expansion Cardiovascular morbidity Quality of life Lenght of ICU and hospital stay Crossover Nienaber CA et al. Circulation 2009;120:

10 INSTEAD: Time from Impact to Randomization

11 INSTEAD: 2 years-outcomes after TEVAR in uncomplicated I year crossover 2 years crossover rate 14% (p=0.02) 20% (p=0,02) Nienaber C, Rousseau H, et al. Circulation Dec 22;120(25):

12 Medical management: False Lumen diameter: if FL < 22 mm Two patients with a small initial false lumen diameter at the upper descending thoracic aorta showed a complete resorption of the false lumen (left) or did not show an aneurysm for approximately 3 years (middle), while another patient with a large initial false lumen diameter developed an aorta aneurysm after approximately 2.5 years (right). Song JM, et al. JACC 2007; 50:

13 Medical therapy: False lumen is completely thrombosed 31.6% 3 years 22.6% 3 years Tsai T, Evangelista A, Nienaber C et al., N Engl J Med Jul 26;357(4):349-59

14 Current considerations Useful tools: + Functional imaging - TEE with color doppler interogation - TEE with contrast - Dynamic 4D-MRI - FDG-uptake on PET + Hemodynamics + Integration of Biomarkers - Serial d-dimer (>500 µg/l) - MMP-9 - SM myosin heavy chains

15 Medical therpay: In absence of Local Inflammation, Partial FL thrombosis Partial FL thrombosis Expanding FL Ongoing metabolic activity on FDG-PET Rupture? Nienaber C et al. Circ Cardiovas Imaging 2009; 2:

16 Low risk without inflammation on medical therapy FDG Favourable outcome FDG + Unfavourable outcome (rupture progression) Kato et al, J Nucl Med 2010

17 Medical therapy: In presence of small entries rather than one large entry Entry tear of aortic dissection visualized by 2-dimensional (left) and color-doppler (right) TEE Type B dissection with an entry tear located in the proximal part of the descending aorta (arrow) by tranverse view Type A dissection with an entry tear in the proximal part of the residual dissection (arrow) in the upper ascending aorta by longitudinal view Evangelista et al, Circulation 2012;125:

18 Long-term outcome of aortic dissection (Large, >15 mm) Cumulative survival free from sudden death and surgical/endovascular treatment by entry tear size Evangelista et al, Circulation 2012;125:

19 Long-term outcome of aortic dissection (repair) Cumulative survival free from sudden death and surgical/endovascular treatment by entry tear pattern (size and location) Evangelista et al, Circulation 2012;125:

20 INSTEAD at high risk! Primary endpoint All-cause mortality at 2 years Secondary endpoints Thrombosis of False Lumen Degree of Aortic Complication Expansion Cardiovascular according morbidity to recent criteria Quality of life Lenght of ICU and hospital stay Crossover Nienaber CA et al. Circulation 2009;120:

21 INSTEAD-XL / Landmark analysis Mortality (1st EP) Nienaber CA et al, Circ Cardiovasc Interv. 2013

22 INSTEAD-XL / Landmark analysis Progression (2nd EP) Nienaber CA et al, Circ Cardiovasc Interv. 2013

23 Longterm outcomes in IRAD TEVAR vs. medical management of type B dissection JACC (in press)

24 Medical: Survival after acute type B aortic dissection --- INSTEAD SG INSTEAD Medical Acosta S, et al., Annals of Vascular Surgery 2007; 21:

25 Rethinking TEVAR for Dissection Long-term follow-up of INSTEAD-XL and IRAD in type B aortic dissection reveals: - Uncomplicated type B dissection is a misnomer, is not stable and medical management is not safe - Isolation of the false lumen leads to remodeling to avoid new (late) acute scenarios - Successful remodeling (usually completed after 2 years) ensures longterm stability - Preemptive TEVAR in type B dissection sets the stage for remodeling and will become a therapeutic option for all candidates with a reasonable life expectancy

26 Nevertheless. INSTEAD-XL and IRAD-LT encourages stent-graft induced remodeling in any type B aortic dissection Ann Thorac Surg 2008

27 Rethinking TEVAR for Dissection Are there patients that should be treated with medical therapy alone?...may be a few! - Stable chronic patients with complete False Lumen thrombosis (IRAD; NEJM 2007) - Stable chronic patients with tiny entry tears (<10mm) and no FL expansion (Evangelista et al., Circulation 2012; Song et al., JACC 2007) - Stable patients with a life expectancy of less than 2 years (INSTEAD-XL, Circulation CVInt 2013) - Stable chronic dissection without FDG-uptake on PET imaging LIEGE/Rostock project (under review) - Need for proximal arch/zone 0 debranching/consider open surgery or branched TEVAR (Bünger et al., JVS 2013)

28 Unmet needs of current classification of aortic dissection What is relevant and who is at Risk? Anatomic Involvement of Aorta - Associated Dysfunction (AR, PE ) Time domain - Acuity versus Chronicity Relevant complications - Malperfusion, rupture, inflammation, pain Impact on outcomes & prognosis - Risk / benefit ratio Suitibility for Repair - Individualized score Contraindication for endovascular Options This mnemonic list maybe important!