Asymptomatic Radiology / Clinical data Report / Cohort bias Referral bias. UCSF Vascular Symposium April 7-9, Acute Aortic Dissection
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1 Aortic Dissection: Natural History What is the Natural History of Aortic Dissection? UCSF Vascular Symposium April 7-9, 2011 Asymptomatic Radiology / Clinical data Report / Cohort bias Referral bias Stephen W.K. Cheng Natural History is Largely Unknown Acute Aortic Syndromes Intramural Hematoma Acute Aortic Dissection Intramural Hematoma Penetrating Ulcer One in eight patients with AAD has a IMH or PAU Contained hemorrhage Absence of intimal tear Ruptured vasa vasorum 1
2 Intramural Hematoma Hospital Mortality for IMH Age Hypertension Atherosclerosis Differential rigidity of media and shear stress Resolution (10%) Rupture (20-35%) Dissection (28-47%) n=58 Evamgelista D (IRAD) Circulation 2005 Type A Intramural Hematoma Type B Intramural Hematoma IMH n=30 IMH n=53 AD n=57 Hospital mortality = 7% vs 34% 1 late deaths 13 progression AD n=101 p=0.004 Hospital mortality = 0 3 late deaths 11 progression p=0.009 Kaji Circulation 2002 Kaji Circulation
3 Progression of Type B IMH to Type A IMH: Progression Early Progression (30 days, 40%): Ascending involvement Diameter >5.5cm Penetrating ulcers Hematoma >10mm Persistent / recurrent pain Late Progression: Age No ß Blockers Penetrating Ulcer Focal ulceration of aortic intima Breaches internal elastic lamina and involves media Often assocatied with IMH Often multiple 3
4 Ruptured Type B Dissection & Tamponade Penetrating Ulcer Older Atherosclerosis Often in dilated aorta Rupture: 42.1%? Mortality higher in ascending aorta Poor prognosis if associated with IMH Symptomatic: 1/4 to pseudoaneurysm 1/3 to rupture % IRAD: 30 Day Mortality (Type A) Hospital mortality = 32.5% A/Med A/Surg Days Hagan & Nienaber JAMA
5 Aortic Dissection Ruptured Aortic Dissection % 30 IRAD: 30 Day Mortality (Type B) Type B Dissection with Visceral Ischemia Hospital mortality = 13% B/Med B/Surg Nov Oct Days Hagan & Nienaber JAMA
6 Aortic Dissection: Predictors of Acute Mortality Aortic Dissection: Late Survival TYPE A Age >70 Female Abrupt pain Hypotension Tamponade ECG abnormality Renal failure TYPE B Hypotension Absent chest / back pain Branch malperfusion Arch extension Aorta >6cm All Discharged Fann & Miller Circulation 1995 Aortic Dissection: Late Mortality Events Ruptured Dissecting Thoracic Aneurysm Dissection progression Re-dissection Aneurysm Reoperation July 2008 Dec 2008 Apr
7 Late Aortic Events Fate of Distal Aorta after Type A Repair False Lumen Patency Aneurysm Re-operation Survival Song SW: J Thoracic Cardiovasc Surg 2010 False Lumen Patency Pre-op Hypertension + Pre-op Size >35mm + Distal Dilatation (Aneurysm) Male + Re-operation Young + + Marfan + + Arch involvement + Malperfusion + Primary entry unresected + + Distal dissection + Aortic diameter + FL >70% + FL Patency + + Partial FL Thrombosis + + SBP / Pulse P + + Anticoagulation + 7
8 Patency of False Lumen Patency of False Lumen DTA Diameter Survival Freedom from Reoperation Survival Freedom from Endo/Surgical Treatment Sakaguchi 2007 Chronic Phase Enlargement in Type B Dissection Chronic Enlargement >6cm N= mm/yr Sueyoshi
9 Can we Predict Late Complications? False Lumen Patency and Survival >0.64 = predictor of late aortic events Marui A et al. J Thorac Cardiovasc Surg Tsai 2007 False Lumen Patency and Survival Partial Thrombosis and Survival / Reoperation Mortality = 31.6% at 3 years N=201 Tsai 2007 Song 2009 J Thoracic Cardiovasc Surg 9
10 False Lumen Patency Pre-op Hypertension + Pre-op Size >35mm + Distal Dilatation (Aneurysm) Male + Re-operation Young + + Marfan + + Arch involvement + Malperfusion + Primary entry unresected + + Distal dissection + Aortic diameter + FL >70% + FL Patency + + Partial FL Thrombosis + + SBP / Pulse P + + Anticoagulation + Reoperation of Distal Aorta 4-28% 30% in 10 years False Lumen Patency Pre-op Hypertension + Pre-op Size >35mm + Distal Dilatation (Aneurysm) Re-operation Male + + Young + + Marfan + + Arch involvement + Malperfusion + Primary entry unresected + + Distal dissection + Aortic diameter + FL >70% + FL Patency + + Partial FL Thrombosis + + SBP / Pulse P + + Anticoagulation + What has Changed? Imaging revolution Multislice/ gated CT scans, MRA, transoesophageal echo, IVUS Endoluminal revolution Covered stents/ stent-grafts Bare stents Fenestration procedures 10
11 Endograft for Type A Aortic Dissection Djumbodis Aortic Dissection System Dietrich et al Zenith Dissection Endovascular System Conclusions All patients with aortic dissection require follow up surveillance Medical management is essential: Control of blood pressure and heart rate Imaging and endovascular revolution may change the natural history 11
12 12
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