The natural history of uncomplicated type B dissection, PAU and IMH: the IRAD knowledge. Santi Trimarchi, MD, PhD
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1 IRCCS Policlinico San Donato University of Milan Thoracic Aortic Research Center The natural history of uncomplicated type B dissection, PAU and IMH: the IRAD knowledge Santi Trimarchi, MD, PhD No COI
2 Uncomplicated Acute Type B: Definition Pts without such conditions: hemorragic shock, periaortic hematoma, spinal cord ischemia, acute renal failure, mesenteric ischemia/infarction, limb ischemia, recurrent pain, refractory pain, and/or refractory hypertension
3 Uncomplicated Acute Type B: Incidence 45-55% Trimarchi S, Nienaber C, Tsai TT, et al. Circulation 2006 Estrera et al. Ann Thor.Surg. 2007
4 Uncomplicated Acute Type B: in-h Mortality 1-10% in-hospital mortality Aortic Rupture Sudden Malperfusion Trimarchi S, Nienaber C, Tsai TT, et al. Circulation 2006 Estrera et al. Ann Thor.Surg. 2007
5 Uncomplicated Acute Type B: Outcome Predictors 1. Study design To identify primary risk factors and a risk stratification scheme correlating with the in-hospital outcome patients Type B aortic dissection patients included (45.5%) complicated (group I) (54.5%) uncomplicated (group II)
6 Risk Stratification: In-Hospital Outcome Predictors Variable Overall (%) Complicated (G I) Non-Complicated (G II) p-value N (%) 550 (100) 250 (45.5) 300 (54.5) Demographics Age-mean (+ SD), years 63.9 (13.6) 63.0 (14.0) 64.6 (13.2) Age > 70 years (%) 213 (38.7) 92 (36.8) 121 (40.3) Etiology and patients history Marfan syndrome (%) 19 (3.5) 13 (5.2) 6 (2.0) Hypertension (%) 419 (77.0) 199 (80.6) 220 (74.1) Atherosclerosis (%) 195 (36.3) 99 (40.2) 96 (33.0)
7 Risk Stratification: In-Hospital Outcome Predictors Variable Overall (%) Complicated (G I) Non-complicated (G II) p-value Back pain (%) 363 (68.0) 176 (71.8) 187 (64.7) Abrupt onset of pain (%) 456 (85.9) 219 (91.6) 237 (81.2) Migrating pain (%) 108 (21.1) 64 (27.4) 44 (15.8)
8 Risk Stratification: Outcome Variable Overall Complicated In-hospital Mortality (G I) Non-complicated (G II) p- value Overall (%) 68 (12.4) 50 (20.0) 18 (6.1) <0.001 Surgical (%) 27 (28.7) 20 (28.6) 7 (29.2) 0.96 Medical Rx (%) 33 (8.7) 23 (20.7) 10 (3.7) <0.001 Percutaneous (%) 8 (10.7) 7 (10.1) 1 (16.7) 0.50
9 Uncomplicated Acute Type B: Outcome Predictors 2. Study design To investigate predictors of aortic expansion during follow-up among ABAD patients managed medically patients Type B aortic dissection patients included - Available descending aortic diameter measurements at presentation, 6, 12 and/or 24 months FU
10 Initial aortic diameter and aortic expansion
11 Multivariate predictors of aortic expansion Variable Regression coefficient 95% Confidence Interval P value Age (years) Female gender White race Aortic diameter < 4.0cm <0.001 Patent false lumen Intramural hematoma* Beta-blocker therapy Calcium-channel blocker * Intramural hematoma included isolated IMH and combined IMH and ABAD
12 Multivariate predictors of aortic expansion Variable Regression coefficient 95% Confidence Interval P value Age (years) Female gender White race Aortic diameter < 4.0cm <0.001 Patent false lumen Intramural hematoma* Beta-blocker therapy Calcium-channel blocker * Intramural hematoma included isolated IMH and combined IMH and ABAD
13 Survival of patients on calcium channel blockers
14 Uncomplicated Acute Type B: IMH To identify risk factors of IMH B Study design IMH found in 107 (11.9%) of 897 total cases Incidence ranged from 0 to 25% between sites SCVS 2013
15 Uncomplicated Acute Type B: IMH Presenting symptoms IMH ABAD *P.05 SCVS 2013
16 Uncomplicated Acute Type B: IMH Management 1% ABAD 23% IMHB 7% 1% 5% Medical* Surgical* 14% 62% 87% Endovascular * Hybrid SCVS 2013
17 Uncomplicated Acute Type B: IMH Category Type B True IMH Classic AoD p-value In-hospital mortality 7 (6.5%) 84 (10.6%) Medical management 6 (6.4%) 44 (9.0%) Endovascular 0 (0.0%) 17 (11.9%) year follow-up Follow-up available (% of total) 45 (42% ) 274 (34.7%) Mortality 4 (8.9%) 19 (6.9%) Descending Aortic enlargement diameter 10 (38.5%) 90 (60.8%) SCVS 2013
18 Uncomplicated Acute Type B: IMH Category Type B True IMH Classic AoD p-value In-hospital mortality 7 (6.5%) 84 (10.6%) Medical management 6 (6.4%) 44 (9.0%) Endovascular 0 (0.0%) 17 (11.9%) year follow-up Follow-up available (% of total) 45 (42% ) 274 (34.7%) Mortality 4 (8.9%) 19 (6.9%) Descending Aortic enlargement diameter 10 (38.5%) 90 (60.8%) SCVS 2013
19 Uncomplicated Acute Type B: IMH Category Type B True IMH Classic AoD p-value In-hospital mortality 7 (6.5%) 84 (10.6%) Medical management 6 (6.4%) 44 (9.0%) Endovascular 0 (0.0%) 17 (11.9%) year follow-up Follow-up available (% of total) 45 (42% ) 274 (34.7%) Mortality 4 (8.9%) 19 (6.9%) Descending Aortic enlargement diameter 10 (38.5%) 90 (60.8%) SCVS 2013
20 Uncomplicated Acute Type B: IMH Category Type B True IMH Classic AoD p-value In-hospital mortality 7 (6.5%) 84 (10.6%) Medical management 6 (6.4%) 44 (9.0%) Endovascular 0 (0.0%) 17 (11.9%) year follow-up Follow-up available (% of total) 45 (42% ) 274 (34.7%) Mortality 4 (8.9%) 19 (6.9%) Descending Aortic enlargement diameter 10 (38.5%) 90 (60.8%) SCVS 2013
21 Uncomplicated Acute Type B: IMH Considerations Less frequently aortic enlargement during follow-up The risk associated with aortic IMH is similar to classic ABAD SCVS 2013
22 Uncomplicated Acute Type B: Long-term Outcome False Lumen Patency: Partial Thrombosis Independent predictor of death at 3 years (OR 2.69; 95% P=0.002) 3 year mortality of 31.6% Tsai TT, Evangelista A, Nienaber CA, et al. N Engl J Med. 2007;357:
23 Uncomplicated Acute Type B: Radiologic Predictor Study design To investigate the false lumen thrombosis as predictor of aortic expansion during follow-up among ABAD patients managed medically IRCCS Policlinico San Donato Yale University School of Medicine
24 Results 84 patients Mean age females Mean follow-up: 19.3 months (range 1-148) 273 aortic dissected segments were studied
25 Results: segments specific related Initial aortic diameter Final aortic diameter Mean Aortic growth P Value 39.3 ± ± < ± ± < ± ± < ± ± <.001
26 Results: false lumen status Patent Par'al Thrombosis Complete Thrombosis P- Value Ini%al aor%c diameter Final aor%c diameter Mean aor%c growth 32.0 ± ± ± 8.4 < ± ± ± 12.2 < ± ± ±
27 Results: false lumen status Patent Par'al Thrombosis Complete Thrombosis P- Value Ini%al aor%c diameter Final aor%c diameter Mean aor%c growth 32.0 ± ± ± 8.4 < ± ± ± 12.2 < ± ± ±
28 Results: false lumen status Patent Par'al Thrombosis Complete Thrombosis P- Value Ini%al aor%c diameter Final aor%c diameter Mean aor%c growth 32.0 ± ± ± 8.4 < ± ± ± 12.2 < ± ± ±
29 Results: false lumen status Patent Par'al Thrombosis Complete Thrombosis P- Value Ini%al aor%c diameter Final aor%c diameter Mean aor%c growth 32.0 ± ± ± 8.4 < ± ± ± 12.2 < ± ± ±
30 Multivariate analysis Variable Adj. es'mated difference (mm/ y) 95% Confidence interval P Value Lower Bound Upper Bound Constant 9.12 (2.84) Age at Presenta%on (0.04) <.001 Male gender 2.30 (1.01) Par%al thrombosis 2.05 (0.99) Ini%al aorta diameter 0.05 (0.05)
31 Uncomplicated Acute Type B: Outcome Predictors Long-term outcomes: uncomplicated acute type B dissection p<0,05 5-yr mortality TEVAR 11,2 % Medical 20,3 % Fattori R, et al. AHA 2010
32 Uncomplicated Acute Type B: IRAD Actual Conclusions Currently, Medical Management is still associated with better in-h results We already have some predictors of short, mid and long-term outcome: Ø Patient characteristics Ø Radiologic characteristics Ø Successful early intervention vs. medical management In the next years, IRAD might gives new evidences which will better clarify who may really benefit from an early intervention.
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