La dissection aortique de type B : Dépistage et Suivi
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1 La dissection aortique de type B : Dépistage et Suivi Philippe Cluzel Département d Imagerie Cardiovasculaire et de Radiologie Interventionnelle et Thoracique (DICVRIT) Sorbonne Université Médecine, UMR S 1146 / UMR 7371 Hôpital Pitié-Salpêtrière, Paris, FRANCE
2 No financial disclosure
3 Life-threatening medical conditions Share common Pathophysiological pathways Clinical characteristics Diagnostic and therapeutic challenges (Lempel et al. Radiology 2014; 271: ) (Booher et al. Am J Med 2013; 126:730.e e24) (Mussa et al. JAMA 2016; 316: ) 1958 Hirst Acute Chronic Booher IRAD classification (Bossone et al. Eur Heart J. 2017)
4 (Bossone et al. Eur Heart J. 2017) (Erbel et al. Eur Heart J 2014; 35: )
5 Type A Type B Without ECG gating With ECG gating (McMahon et Squirrell RadioGraphics 2010; 30: )
6 Imbalance between Inflow and Outflow in the FL Dynamic Distension of the false lumen compresses true lumen Static Dissection extend into branch artery Malperfusion Williams et al, Radiology 1997; 203:37-44
7 Acute Aortic Dissection Malperfusion Syndrome Before Stent-Graft 24h after Stent-Graft
8 Spin-Echo Maximum Intensity Projection Multiplanar Reformation (Baliga et al. J Am Coll Cardiol Img 2014;7:406 24)
9 (Booher et al. Am J Med 2013; 126:730.e e24)
10 Medically treated Surgically treated Endovascularly managed Early Mortality 7.7%-9.6% 7.1%-32% 1.4%-7.9% Long-term survival 77.6% 83% 77%-98% (Booher et al. Am J Med 2013; 126:730.e e24)
11 C D B A E J F I H G A B C D E F G H I J A B C D E F G H I J 10-year survival rate: 30% to 60% AAS : lifelong problem Clinical monitoring Imaging monitoring Patient education Screening family members Risk of aortic complications (false lumen expansion) Substantial in first few months CT or MRI surveillance before discharge At 1, 3, 6, and 12months Annually thereafter Similar techniques Same institution direct comparison Standardized reports at given landmarks (Bossone et al. Eur Heart J. 2017)
12 (Tsai et al. N Engl J Med 2007;357:349-59) (Tolenaar et al. J Vasc Surg 2013;58:1220-5) Variable Patient characteristics Medical history Blood test Radiologic signs Predictor Age<60 yrs, White race, HR > 60 b/min Marfan syndrome FDP > 20µg/mL on admission Aortic diameter > 40 mm acute phase Patent FL Partially thrombosed FL (debated) Proximal FL > 22 mm One entry tear FL/intimal tear inner aortic curvature Elliptic configuration TL/round FL Degree fusiform dilatation Large entry tear > 10 mm proximal (Kempel et al. Radiology Jun;271: ) (Marui et al J Thorac Cardiovasc Surg 2007;134: ) 906 articles, 18 full-text articles selected (Cheng et al. J Biomech Eng. 2010;132:05100) (van Bogerijen et al. J Vasc Surg 2014;59: )
13 58- year-old female Stanford type B AD Computational simulations of blood flow highly disturbed, turbulent, flow with strong recirculation. High values of wall shear stress Perhaps increasing the likelihood of expanding the tear Particle paths of blood flow Time-Averaged Wall-Shear-Stress TAWSS contours Oscillatory Shear Index OSI contours Peak systole Pressure contours (Cheng et al. J Biomed Eng 2010;132:051007)
14 8 type B dissection cases, with 4 in each group Time-averaged wall shear stress (TAWSS) contours t2: peak systole; t3: mid-systolic Medically treated Stented cases (Cheng et al. Ann Biomed Engineering 2015; 43: )
15 (Markl et al. Clin Radiol 2016)
16 Target parameter Description Potential applications Wall Shear Stress (WSS) Pulse Wave Velocity (PWV) Turbulent Kinetic Energy (TKE) Viscous shear forces of flowing blood acting tangentially to the vessel wall Propagation speed of systolic pressure pulse in the arterial system Energy content of turbulent flow and direction-independent measure of intensity of turbulent velocity fluctuations Indicator for impact of flow alterations on endothelial cell and extracellular matrix function and risk for vessel wall remodelling Marker of arterial stiffness and predictive of cardiovascular disease. Estimate of turbulence-related loss of energy or pressure. Indicator of impact of turbulent flow on blood constituents or vessel wall. Relative Pressure Fields Relative blood pressure field Noninvasive estimation of pressure differences Volume and Kinetic Energy of Ventricular Flow Components/Compartments Separation of blood that transits heart chambers according to compartmental origin and fate Indicator of ventricular dysfunction. Risk stratification and optimization and individualization of treatment heart failure (Dyverfeldt et al. J Cardiovasc Magn Reson 2015; 17:72-85)
17 May help provide insights into the pathophysiology, effects of flow alterations, and establish prognostic indicators for development of complications or aneurysm growth in patients with aortic dissection (François et al. J Thorac Cardiovasc Surg. 2013; 145: )
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23 4D flow cardiovascular magnetic resonance Advantages Provides clinicians with key diagnostic and surgical planning information Facilitates the systematic assessment of blood flow in multiple vessels Evaluates the status of the false lumen and depicts intimal tears Allows non-invasive imaging follow-up (hemodynamic assessment) Drawbacks Not yet in routine clinical practice Time-consuming processing Financial issues Decisionnal value needs to be confirmed by further clinical studies
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