Thoracic Aortic Disease Update

Transcription

1 Thoracic Aortic Disease Update Cardiology Fellows Teaching May 12, 2015 Jehangir Appoo

2 I. Ao Dissection I. Dx Ao Dissection vs. ACS II. Medical Treatment III. Surgical Treatment II. III. Thoracic Aortic Aneurysms I. Indications for intervention, referrals II. Risk stratification III. Screening Endovascular Repair

3 Aortic Dissection Variable presentation Variable acuity Great Masquerader 1%/hr

4 Pt. #1 48 y.o female Previously well Hx of Cig smoking Sudden onset of CP radiating to back Thursday April 30, called EMS but refused to come in to hospital GP visit & CXR next day Trop neg; R hilar opacity CXR results back after weekend, repeat study requested

5 Pt. #1 Ongoing retrosternal discomfort, feeling restless, unwell Does not go in for repeat investigation 6 days post pain presents for repeat CXR bilat pleural effusions, increased atelectasis, increased heart size CT PE CTA

6 Distal entry tear with retrograde extension

7 IRAD in press 1427 patients 954 male mean age 61.7 years 11% 47% 11% 7% 4% 20% (n=157) (n=673) (n=161) (n=98) (n=58) (n=280)

8 Immediate surgery Hybrid Ascending, Arch and Descending Ao Reconstruction Intraop: massive amt of hematoma in ascending aorta, innominate artery and left carotid artery thrombosed FL causing compression of true lumen

9 Pt. # 2 54y.o male Presented to PLC at 03:00 with CP Trop T slightly positive lateral T wave changes Positive D-Dimer CCU consult ASA & Ticagralor, admitted to CCU 06:30; CT 08:20; 08:28 Vasc Surg consult completed on chart Cardiac Surg consult Arrives at FMC at 10:00 codes upon arrival

10 Aortic Dissection has variable urgency and variable presentation Difficult to distinguish between Acute Coronary Syndrome and Dissection

11 Presenting symptoms of Aortic Dissection How to attempt to distinguish from ACS: PAIN: Abrupt onset of CP Maximal intensity at time of onset CP more often sharp than tearing CP radiating to back or abdomen Can be painless!

12 Great Masquerader SBP difference >20mmHg Signs and symptoms of Aortic Dissection other than chest pain RCA more commonly involved

13 In one study looking at patients with acute chest or back pain, >90% of aortic dissections could be identified with some combination of following 3 findings: 1)Abrupt onset of thoracic or abdominal pain with a sharp, tearing and/or ripping character 2)Mediastinal and/or aortic widening on chest radiograph 3)A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmhg difference between the right and left arm) Probability of having an aortic dissection with none of above: 7% Probability of having an aortic dissection with all 3 of above: >83% Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160(19):2977

14 Lab Tests D-Dimer v. sensitive for ao dissection; not specific if d-dimer not elevated, pt. does not have ao dissection Biomarkers currently under development.may be coming soon Aortic Dissection Aortic Aneurysm Ascending, Descending

15 Imaging CTA CAP Dissection protocol Noncontrast and contrast fine cut CTA Apart from presence of dissection, tells surgeon: location of primary intimal tear in asc., arch or desc. aorta location of re-entry tears malperfusion of viscerals, renals, peripheral extremeties dissection of arch vessels and subclavian arteries anomalous arch anatomy bovine or 4 branch arch size of aortic arch and descending thoracic aorta size of true and false lumens in descending aorta pericardial effusion coronary calcifications distal rupture TEE done in OR AV assmt Flow in false lumen LV/RV assmt Pericardial effusion Re-expansion of TL Residual fenestrations Assmt of endoleaks

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20 Imaging CTA CAP Dissection protocol Noncontrast and contrast fine cut CTA Apart from presence of dissection, tells surgeon: location of primary intimal tear in asc., arch or desc. aorta location of re-entry tears malperfusion of viscerals, renals, peripheral extremeties dissection of arch vessels and subclavian arteries anomalous arch anatomy bovine or 4 branch arch size of aortic arch and descending thoracic aorta size of true and false lumens in descending aorta pericardial effusion coronary calcifications distal rupture TEE done in OR AV assmt Flow in false lumen LV/RV assmt Pericardial effusion Re-expansion of TL Residual fenestrations Assmt of endoleaks

21 Goals of Acute Medical Management: BP dp/dt LV ejection force invitro models of artificial aortas Strength of pulsation led to progression of dissection Never validated in humans B Blockers before vasodilators

22 Medical Treatment of Ao Dissection Anti-impulse therapy 60/100 rule : Suggest IV B-blockers and Nipride to drop: HR to 60bpm SBP to 100mmHg Pain control Arterial line in arm with higher blood pressure For Type B dissections: close observation for complications secondary to branch vessel involvement

23 If Hypotensive: role of pericardiocentesis? in OR? Fluid Resuscitation

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26 Natural History of Type A Dissection has a High Mortality Traditional Thinking Modern ICU Rx & Anti-impulse therapy

27 IRAD >4000 Dissection Patients Foothills Medical Centre, Calgary Aug % survival with medical therapy of Type A Dissection

28 >85y.o Hemorrhagic Transformation Previous sternotomy Rupture Shock

29 Surgery for Type A Dissection Standard of care surgical replacement ascending aorta Operative mortality ~20% Often with a residual Type B dissection Persistent post-op malperfusion in 50%

30 Type A Dissection Goals of surgical repair Resect 1 o intimal tear (PIT) Replace ascending aorta Restore aortic valve competence Occlude false lumen Limit distal dissection

31 Type A Dissection Outcomes for survivors of surgery for Type A dissection Long Term survival ~50% at 10 years (often young population) Patent false lumen up to 80% of patients need for distal operation 20-50% at 10 years Mortality from distal operation ~20-30%

32 Type A Dissection Select aortic centers now advocate extended hybrid distal aortic repair in the acute setting to prevent early and long term complications of the residual dissection

33 2013 Type A Dissection Select aortic centers now advocate extended hybrid distal aortic repair in the acute setting to prevent early and long term complications of the residual dissection Frozen elephant trunk with total arch

34 2013 Type A Dissection Select aortic centers now advocate extended hybrid distal aortic repair in the acute setting to prevent early and long term complications of the residual dissection Branched

35 2013 Type A Dissection Select aortic centers now advocate extended hybrid distal aortic repair in the acute setting to prevent early and long term complications of the residual dissection Frozen Elephant Trunk with Hemi-Arch

36 2013 Type A Dissection Select aortic centers now advocate extended hybrid distal aortic repair in the acute setting to prevent early and long term complications of the residual dissection Zone 0 Type II

37 Surgical Principles of our Type II Hybrid Arch Technique Arch debranching after asc ao replacement Left subclavian vs. axillary Single stage antegrade delivery of endovascular prosthesis under fluouroscopy

38 Brachiocephalic Trunk Branch Left Common Carotid and Left Subclavian Branches Endovascular System Delivery Branch 28 mm Tube Graft

39 69y.o male with Type A dissection and Distal Arch Tear Type A Dissection Type II Hybrid Arch Repair Primary entry tear in arch Zone 0 TypeII Hybrid Repair

40 Type A Dissection 46 year old male OSH Visceral ischemia Lower extremity ischemia

41 Type A Dissection Ascending aorta/hemiarch open repair Frozen elephant trunk Radiographic resolution of visceral ischemia

42 Type A Dissection Persistent profound LE ischemia

43 Type A Dissection Persistent profound LE ischemia

44 Thoracic Aortic Aneurysms

45 Symptomatic Asymptomatic Size Growth Rate CT d/o; Bicuspid

46 Risk of dissection or rupture of the Ascending Aorta Risk of dissection or rupture of the Descending Aorta

47 Predicting Risk of Aortic Rupture is not an Exact Science Relative size Frozen Mediastinum Valvular Issues Indolent but Catastrophic Operative Risks Important to look at films

48 5.5cm 5.0cm 4.5cm Screening Referral to Thoracic Aortic Clinic

49 What I do today for asymptomatic proximal thoracic aortic aneurysms: Aortic 90 o to angle of blood flow 5.5cm Diameter 5.0cm with moderate valvular dysfxn or intact BAV Diameter 4.5cm CT d/o Screen 1 st Degree Relatives: Echo CT

50 Where we are going with Thoracic Aortic Aneurysm Assessment? Size by itself is a primitive and crude estimate of rupture/dissection risk Half of all type A dissection have Ao diameter <5cm Yet, many patients with Ao diameters >5cm stay stable for a long time Trying to identify further nuances to create a fingerprint

51 Aorta at Risk Project to correlate: preop imaging Stress, Strain and CFD assessments intraop pathology Assmt of degree of loss of elastin ratio of collagen to elastin benchtop biaxial strength testing

52 Elefteriades et al. Guilt by association: paradigm for detecting a Silent Killer (thoracic aortic aneurysm). Open Heart Journal 2015

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55 Screening

56 37 year old female 3 young kids Presents to ER with cough Abnormal CXR CTA Chest Options?

57 37 year old female 3 young kids Presents to ER with cough Abnormal CXR CTA Chest Options? Open Repair Morbid Prolonged Recovery Pain Syndrome

58 37 year old female 3 young kids Presents to ER with cough Abnormal CXR CTA Options? TEVAR 1.5 inch groin incision Home in 2 days

59 Aortic Coarctation Traditional open repair with conduit or patch aortoplasty

60 2013 Aortic Coarctation 30 year old male Bicuspid aortic valve

61 2013 Aortic Coarctation 30 year old male Bicuspid aortic valve Discharged home next day

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64 Aortic Dissection Delamination of aortic wall layers True lumen and false lumen Intimal tear allows flow between lumens

65 Aortic Dissection Stanford Classification Type A Type B Ascending aorta Surgical repair Evolving endovascular options? Descending aorta Medical management (uncomplicated) Endovascular treatment (complicated) Complicated rupture aneurysmal enlargement malperfusion pain

66 Complicated Type B Dissection 56 year old male Acute malperfusion ischemic gut ischemic leg renal failure

67 Rt. Iliac SMA Rt. Renal Artery

68 Lower extremity, visceral & renal Resolution of malperfusion malperfusion resolved

69 Complicated Type B Dissection 63 year old female Acute Type B Static right renal malperfusion

70 Complicated Type B Dissection 63 year old female Acute Type B Static right renal malperfusion

71 Complicated Type B Dissection 63 year old female Acute Type B Static right renal malperfusion

72 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair Enlarging false lumen with intimal tear in abdominal aorta

73 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair and post-op residual Type B Enlarging false lumen with primary intimal tear in abdominal aorta

74 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair Enlarging false lumen with intimal tear in abdominal aorta

75 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair Enlarging false lumen with intimal tear in abdominal aorta

76 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair Enlarging false lumen with intimal tear in abdominal aorta

77 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair Enlarging false lumen with intimal tear in abdominal aorta

78 Complicated Type B Dissection 72 year old male Prior Type A with standard surgical repair Enlarging false lumen with intimal tear in abdominal aorta Small stentgraft from right arm to open innominate true lumen (and efface adjacent false lumen outflow)

79 Complicated Type B Dissection 72 year old male

80 Complicated Type B Dissection 72 year old male

81 Current Endovascular Options Descending Thoracic Aortic Aneurysms Aortic Coarctation Trauma Complicated Type B Aortic Dissection Ascending Aorta Current Hybrid (Surgical/Endovascular) Options Type A Dissection Aortic Arch Pathology Future Direction Endovascular Type A Branched Arch Branched Thoraco-Abdominal

82 Aortic Arch Aneurysms

83 Branched Arch 64 y.o male Type A repair 2009 Complicated course Aorta growing at rate of 1cm/year Arch dissected Large residual primary intimal tear in arch True lumen effaced

84 Branched Arch Custom built branched arch graft

85 Branched Arch

86 Branched Arch

87 Branched Arch

88 Branched Arch

89 Branched Arch VR image 3 months post op

90 Ascending Aorta Prior conventional Type A open repair Delayed anastamotic leak ascending aorta

91 Ascending Aorta Prior conventional Type A open repair Delayed anastamotic leak ascending aorta

92 Ascending Aorta Prior conventional Type A open repair Delayed anastamotic leak ascending aorta

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94 Good judgement comes from experience... Experience comes from bad judgement C. Walton Lillehei,

95 Indications for Repair of the Thoracic Aorta Risk of dissection or rupture of the Descending Aorta Elefteriades et al., Yale database

96 Open Surgical Procedures High procedure morbidity High mortality risks Significant pain syndromes

97 TEVAR

98 TEVAR Small incisions Reduced pain Reduced hospital stay Reduced risk of morbidity and mortality

99 Indications for TEVAR Descending thoracic aortic aneurysms Acute complicated type B aortic dissection Blunt traumatic aortic injury Absolute contraindication: Allergy to the device material Relative contraindications: Unsuitable vascular access Lack of landing zone Systemic infection

100 Descending Thoracic Aortic Aneurysms

101 Indications for TEVAR Descending thoracic aortic aneurysms Acute complicated type B aortic dissection Blunt traumatic aortic injury Absolute contraindication: Allergy to the device material Relative contraindications: Unsuitable vascular access Lack of landing zone Systemic infection

102 Type B Aortic Dissection

103 Acute complicated type B aortic dissection 56yo male 12hours postpresentation to ER Severe Malperfusion: Ischemic leg Ischemic gut Renal failure

104 Malperfusion Syndrome Rt. Iliac SMA Rt. Renal Artery

105 TEVAR

106 Acute Type B Dissection Mortality In hospital mortality: Medical Rx (10%) TEVAR (10%) Open Surgery (34%) Fattori R et al. J Am Coll Cardiol Intv 2008;1:

107 Uncomplicated Type B Aortic Dissection Nienaber, C. et al. Circ Cardiovascular Inter Aug; 6(4):407-16

108 Indications for TEVAR Descending thoracic aortic aneurysms Acute complicated type B aortic dissection Blunt traumatic aortic injury Absolute contraindication: Allergy to the device material Relative contraindications: Unsuitable vascular access Lack of landing zone Systemic infection

109 Complications of TEVAR In-hospital mortality (5-6%) Stroke (3-5%) Spinal cord ischemia (2-3%) Retrograde type A aortic dissection (1-6%) Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

110 Complications of TEVAR In-hospital mortality (5-6%) Stroke (3-5%) Spinal cord ischemia (2-3%) Retrograde type A aortic dissection (1-6%) Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

111 Complications of TEVAR In-hospital mortality (5-6%) Stroke (3-5%) Spinal cord ischemia (2-3%) Retrograde type A aortic dissection (1-6%) Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

112 Spinal Cord Ischemia

113 Left Subclavian Artery Bypass Left internal mammary bypass grafts Left-sided dialysis arteriovenous fistulas Left hand dominance Supra-aortic vascular pathology ACSSurgery, Section 6, Chapter 15: Upper Extremity Revascularization Procedures

114 Lumbar CSF Drains CPP = MAP - ICP

115 Complications of TEVAR In-hospital mortality (5-6%) Stroke (3-5%) Spinal cord ischemia (2-3%) Retrograde type A aortic dissection (1-6%) Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

116 Retrograde Type A Dissection Procedure related Device related Progression of native aortopathy Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

117 Current Directions

118 The Young Patient Smaller aortic diameter in the landing zone Potential for aortic growth Risk if delayed endoleak Smaller access vessels Hyperangulation of the aortic arch Cumulative radiation exposure Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

119 Adult Coarctation Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

120 Hybrid Procedures Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

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122 Brachiocephalic Trunk Branch Left Common Carotid and Left Subclavian Branches Endovascular System Delivery Branch 28 mm Tube Graft

123 Type II Hybrid Arch Repair Kent WDT, Wong JK, Herget EJ, Bavaria JE, Appoo JJ. An alternative approach to diffuse thoracic aortomegaly: on-pump hybrid total arch repair without circulatory arrest. Ann Thorac Surg. 2012;93(1): doi: /j.athoracsur

124 The Cutting Edge: Total Endovascular Approach to Zone 0 Repair

125 Aortic Arch Replacement without Sternotomy Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca Multiple branch arch grafts

126 Aortic Arch Replacement without Sternotomy Single branch arch grafts Appoo JJ, Tse LW, Pozeg ZI, et al. Thoracic aortic frontier: review of current applications and directions of thoracic endovascular aortic repair (TEVAR). Can J Cardiol. 2014;30(1): doi: /j.cjca

127 Aortic Arch Replacement without Sternotomy Fenestrated arch grafts

128 Aortic Arch Replacement without Sternotomy Multilayer Aortic Repair Systems (MARS)

129 The Ascending Aorta Mewhort HE, Appoo JJ, Sumner GL, Herget E, Wong J. Alternative surgical approach to repair of the ascending aorta. Ann Thorac Surg. 2011;92(3): doi: /j.athoracsur

130 Deployment in the Ascending Aorta for Type A Dissection

131 Type A Aortic Dissection Medical Mgmt Imaging Evolving surgical therapies