2014 ESC Guidelines on the Diagnosis & Treatment of AORTIC DISEASES

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1 2014 ESC Guidelines on the Diagnosis & Treatment of AORTIC DISEASES Prof. Fausto J. Pinto, FESC, FACC, FASE President, ESC University Hospital Sta Maria University of Lisbon, Portugal

2 Professor Fausto J. Pinto, MD, PhD, FESC, FASE, FACC, FSCAI Disclosures: Consultancy, advisory boards and lecture fees: Abbott, Astra Zeneca, Bayer, Bial, BMS, Benecke, Biotronik, Boehringher Ingelheim, Covidien, GE, Irokio, Medtronic, Menarini, Merck, MSD, Novartis, Pfizer, Sanofi, Servier, St Jude Medical, Tabuk

3 2014 ESC guidelines on the diagnosis and treatment of aortic diseases Document covering acute & chronic aortic diseases of the thoracic & abdominal aorta of the adult Chairpersons: Raimund Erbel (Germany), Victor Aboyans (France) Authors/Task Force members: Catherine Boileau (France), Eduardo Bossone (Italy), Roberto Di Bartolomeo (Italy), Holger Eggebrecht (Germany), Arturo Evangelista (Spain), Volkmar Falk (Switzerland),Herbert Frank (Austria), Oliver Gaemperli (Switzerland), Martin Grabenwöger (Austria),Axel Haverich (Germany), Bernard Iung (France), Athanasios John Manolis (Greece), Folkert Meijboom (Netherlands), Christoph A. Nienaber (Germany), Marco Roffi (Switzerland),Herve Rousseau (France), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Regula S von Allmen (Switzerland), and Christiaan JM Vrints (Belgium).

4 2014 ESC Guidelines on the Diagnosis & Treatment of AORTIC DISEASES Chairpersons: Raimund Erbel (Germany) & Victor Aboyans (France) - Acute aortic syndrome - Aortic aneurysm - Genetic aortic diseases - Congenital diseases like aortic coarctation - Atherosclerotic lesions - Aortitis and aortic tumors 2014 version European Heart Journal (2014):doi: /eurheartj/ehu281

5 Acute Aortic Syndromes (AAS) Acute aortic dissection (AAD) Intramural hematoma (IMH) Penetrating aortic ulcer (PAU) Aortic pseudoaneurysm (Contained) rupture of aortic aneurysm Traumatic aortic injury 1. Diagnosis challenging 2. Untreated may be rapidly deadly

6 Class 1: Classic AD Class 2: Intramural haematoma (IMH) Classification of Acute Aortic Syndromes (AAS) According to Pathophysiology Class 3: Subtle or discrete AD with bulging of the aortic wall Class 4: European Penetrating Heart Journal aortic (2014):doi: /eurheartj/ehu281 ulcer (PAU) Class 5: Iatrogenic/traumatic AD

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8 Aortic Dissection Type A Type B

9 Clinical Presentations and Complications of AAD

10 Laboratory Testing in Suspected AD D Dimers Should always be considered along with the pretest clinical probability Immediately very high in AAD May be negative in IMH and PAU

11 Clinical Probability Score of AAS Risk score 0-3 according to the number of positive categories (1 point per column)

12 Diagnostic imaging in acute aortic syndromes

13 Aortic Dissection Type A

14 2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases - Imaging Techniques - For work up usually more than one technique is used

15 2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases - Recommendations for Imaging -

16 Decision-Making in Patients with Suspected AD

17 Recommendations for Diagnostic Work-Up in AAS

18 Recommendations for Diagnostic Work-Up in AAS

19 Treatment of Acute Type-A AD Untreated 50% mortality within 48 hours, 90% at 1 month. Urgent surgery treatment of choice 25% perioperative mortality, 18% neurologic complications age increases the perioperative morbidity and mortality but age per se not an exclusion criterion for surgery. controversial for patients with major neurologic deficit or coma; prognosis poorer but recovery possible if time from symptom onset to surgery <5 hours. Mesenteric malperfusion surgical/hybrid approach, fenestration of the intimal flap.

20 Treatment of Complicated Type-B AD Persisting/recurrent pain, uncontrolled HTN on full medication, early aortic expansion, malperfusion, signs of rupture (haemothorax, periaortic and mediastinal hematoma ) Thoracic endovascular aortic repair (TEVAR) treatment of choice closure of the primary entry tear decompression and thrombosis of the false lumen malperfusion (if present) may resolve aortic remodeling and stabilization Surgery reserved for patients not candidate for TEVAR TEAVAR in Type-B AD Nienaber CA et al. Circ Cardiovasc Interv. 2013;6:407-16

21 Treatment of Uncomplicated Type-B AD Medical therapy to control pain and blood pressure Repetitive imaging (MRI/CT) TEVAR INSTEAD (XL) trials 140 pts, randomized TEVAR + OMT vs OMT alone At 2 y TEVAR better aortic remodeling but no difference in mortality Retrospective analysis of extended FU at 5y Progression plus aorta-related adverse events (deaths, conversion, ancillary interventions)

22 INSTEAD-XL Trial: TEVAR vs. Medical Management in Stable Type-B AD 11.1% versus 19.3% 6.9% versus 19.3% All-cause mortality Aorta-specific mortality Nienaber CA et al. Circ Cardiovasc Interv. 2013;6:

23 Treatment of Type A/B Acute Aortic Dissection

24 TEVAR for Acute Aortic Syndromes Indications for TEVAR

25 TEVAR for Acute Aortic Syndromes Indications for TEVAR Recommendation for management of intramural haematoma(imh) (TAI)

26 Follow-up after thoracic aortic intervention (1) Clinical and imaging are both necessary to limit and detect complications, not only at the operated site but also the remaining aorta. After TEVAR or surgical thoracic aortic repair, first F-U should be performed at 1 month to exclude the presence of early complications. Surveillance should be repeated. Follow-up includes risk factors control. Blood pressure should be monitored closely, as >50% of cases may have resistant hypertension.

27 Follow-up after thoracic aortic intervention (2) If, after TEVAR for TAA, patients show a stable course without evidence of endoleak over 24 months, it may be safe to extend imaging intervals to every 2 years; however, clinical follow-up of the patient s symptom status and accompanying medical therapy should be maintained at yearly intervals. Patients with TEVAR for AD should receive yearly imaging, since the FL of the abdominal aorta is usually patent and prone to disease progression.

28 Intramural Hematoma (IMH) Hematoma develops in the media of the aortic wall in the absence of a false lumen or intimal tear. Diagnosis: circular or crescentic thickening >5 mm of the aortic wall in the absence of detectable blood flow % of AAS 30% ascending aorta 10% arch 60-70% descending TA Type-A (Type-B)

29 Intramural Hematoma (IMH) Diagnosis CT/MRI Unenhanced acquisition + contrast-enhanced aquisition in CT sensitivity 96% Type-A IMH In-hospital mortality similar to type-a AD 30-40% evolve into AD Type-B IMH In-hospital mortality similar to type-b AD

30 Intramural Hematoma

31 Predictors of IMH Complications

32 Management of Intramural Hematoma (IMH) Complicated IMH recurrent pain, IMH expansion, periaortic hematoma, tears

33 Penetrating Aortic Ulcer (PAU) Ulceration of an atherosclerotic plaque penetrating through the internal elastic lamina into the media. 2-7% of all AAS. Propagation IMH, pseudoaneurysm, aortic rupture, AD. Natural history: progressive TAA. Most commonly located in the middle and lower distal thoracic aorta (type-b PAU). Elderly patients, smokers, HTN, associated CAD, COPD, AAA Diagnosis unenhanced/contrast enhanced CT

34 Management of Penetrating Aortic Ulcer (PAU) Complicated PAU Refractory pain or signs of contained rupture (rapidly growing ulcer, periaortic hematoma, pleural effusion)

35 Conclusions Acute Thoracic Aortic Syndromes (1) Potentially deadly but at the same time treatable conditions to be considered in the differential diagnosis of acute chest pain. Decision making in suspected AAS should be based on the a priori probability based on a clinical score and according to the score results it should include biomarkers (D-dimers) and imaging. TTE: initial imaging investigation, frequently complemented by TOE/CT/MRI. Type-A AD urgent surgery. Type-B AD complicated TEVAR uncomplicated TEVAR to be considered.

36 Conclusions Acute Thoracic Aortic Syndromes (2) IMH Type-A surgery recommended Type-B OMT; if complicated TEVAR should be considered PAU Type-A surgery should be considered Type-B OMT; if complicated TEVAR should be considered (Contained) rupture of TAA and traumatic aortic injury If anatomy favorable and expertise available TEVAR preferred over surgery

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