The conundrum about complicated and uncomplicated type B dissection New concepts?

Transcription

1 The conundrum about complicated and uncomplicated type B dissection New concepts? Professor Christoph A. Nienaber The Royal Brompton and Harefield NHS Trust Cardiology and Aortic Centre C.Nienaber@rbht.nhs.uk

2 Brompton Aortic Centre 2018 Prof J Pepper cardiac surgeon Mike Rubens Imaging Ulrich Rosendahl cardiac surgeon Jullien Gaer cardiac surgeon Prof C Nienaber cardiologist Maz Mireskandari vascular surgeon

3 Models of Hemodynamic Stress and Aortic Dissection Shear stresses on the aortic wall are highest at sites of increased dilatation. dp/dt, which is affected by wave reflections, is greatest in areas of aortic dilatation (Yin FC et al. Circulation 1989;79:854).

4 UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Chronic type B dissection on drugs!

5 Patients with aortic dissection are at risk for late aortic events Medical management is expected to prevent rupture, aneurysm, aortic repair but does it really?

6 Importance of Blood Pressure Control After Repair of Acute Type A Aortic Dissection: 25-Year Follow-Up in 252 Patients 92% at 10 yrs 74% at 10 yrs 49% at 10 yrs Reoperation rates: SBP <120 mm Hg 3/85 (4%) SBP mm Hg 13/63 (21%) SBP >140 mm Hg 10/30 (33%) Melby S et al. J Clin Hyperten. 2013;15:63

7 What are the data on antihypertensive therapy after aortic dissection? RCT: none

8 Survival pattern of Aortic Dissection Surgery or Endo Group A included 2340 patients (25.74%) treated surgically for type A AD Medical only Group B included 1144 patients (12.58%) treated endo/surgically for type B AD Group C included 5608 patients (61.68%) with any type of AD treated with medical therapy only. Ting-Yu Yeh, et al. Epidemiology and Medication Utilization Pattern of Aortic Dissection in Taiwan: A Population-Based Study. Medicine (Baltimore) Feb;95(8):e200b

9 Universal Guidelines on Aortic Dissection Suzuki T,et al. Medical management in type B aortic dissection. Ann Cardiothorac Surg Jul;3(4):413-7.

10 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

11 IRAD (submitted) Survival in type A dissection Valve preserving Conduit Arch Replacement

12 Type B dissection with malperfusion

13 Survival after TEVAR in complicated TBAD N = 51 Remodelling is key to success; long-term surveillance still recommended! Leshnower BG et al. Ann Thorac Surg 2017

14 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

15 New high risk group: Pain & persisting hypertension Overall in hospital mortality In hospital mortality with medical management Trimarchi S et al. Circulation 2009

16 New high risk group: False Lumen diameter: FL > 22 mm Two patients with a small initial false lumen diameter at the upper descending thoracic aorta showed a complete resorption of the false lumen (left) or did not show an aneurysm for approximately 3 years (middle), while another patient with a large initial false lumen diameter developed an aorta aneurysm after approximately 2.5 years (right). UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Song JM, et al. JACC 2007; 50:

17 High risk: Partial false lumen thrombosis Tsai TT et al. for IRAD: NEJM 2007

18 New high risk group: Long-term outcome of aortic dissection? Entry tear of aortic dissection visualized by 2- dimensional (left) and color- Doppler (right) TEE Type B dissection with an entry tear located in the proximal part of the descending aorta (arrow) by tranverse view Type A dissection with an entry tear in the proximal part of the residual dissection (arrow) in the upper ascending aorta by longitudinal view Evangelista et al. Circulation 2012 Evangelista et al, Circulation 2012;125:

19 New high risk group: Aortic inflammation Baseline After TEVAR Biology CT PET-CT Sakalihasan N, Nienaber CA et al, EHJ 2015 TEVAR

20 Uncomplicated Type B Dissection: In-H mortality/compl. IRAD, unpublished

21 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

22 late advantage consistantly supported by RCT and registries RCT REGISTRY RCT INSTEAD-XL (n=140) Chinese IRAD(n=1129) registry (n=193) ADSORB (n=61) Circulation CV 2013; 6:407 Qin YL. JACC et al. Interv JACC 2013;6:876 Interv 2013;6:185 Eur J Vasc Endovasc Surg 2014;48:285 The initial RCT showed a long-term advantage of an intervention (stent-grafting the TL), with two large registry-based analyses confirming the signal from the RCT; findings are supported be short-term F/U of an independent RCT. On aggregate, all data are consistent! Very strong signal!

23 late advantage also supported by MGH Cohort study TEVAR for uncomplicated TBAD Natural history of uncomplicated TBAD Durham CA et al. JVS 2015

24 Remodeling with TEVAR Complete false lumen thrombosis in the descending thoracic aorta Pre-procedure Post-procedure 24 months

25 ..2 predictors of long-term stability: FL thrombosis and Remodeling! B SE p- valu e OR 95.0% CI for Hazard Ratio Age Female STJ diameter Complete FLT IRAD data on file Suenaga H. et al. EJCTS 2016

26 TEVAR in Complicated and uncomplicated TBAD is backed-up by Guidelines ESC Guidelies 2014

27

28 Estimation of risk in type B aortic dissection Sailer AM, et al. Circulation Cardiovascular imaging. 2017

29 Therapy 2018: Every patient should receive medical management, but that is almost never enough! + Risk calculator in low risk TBAD Nienaber CA and Clough RE, Lancet 2015

30 Uncomplicated type B aortic dissection: Survival & predictors Hypotension/Shock Malperfusion UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Tsai T, Nienaber C, et al. Circulation 2006, 114:

31 INSTEAD: 2 yrs outcomes after TEVAR in uncomplicated I year crossover 2 years crossover rate 14% (p=0.02) 20% (p=0,02) UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Nienaber CA, Rousseau H, Kische S et al Circulation 2009 Nienaber C, Rousseau H, et al. Circulation Dec 22;120(25):

32 Medical Management after Aortic Dissection E-A-S-Y-T-I-P Establish the underlying diagnosis Achieve normal blood pressure (regardless of drug!) Stop cigarette smoking Yearn to exercise moderately Test 1 st degree relatives for TAA disease Image the aorta over time Perform aortic repair when appropriate

33 Interventional Repair of type a aortic dissection A pre procedure (FLIRT) B CT and echo images pre-procedure (A), at discharge (B) and 6-month follow-up (C) showing entry closure false lumen thrombus and shrinkage with true lumen expansion (remodelling) (patient no.2). Star shows the ASD occluder. At discharge C 6 months F/U Yuan X et al (accepted 2018)

34 Individual approach false lumen management in type A dissection CT scan 3 days after procedure CT scan 6 months after procedure No contrast communication to the false lumen Device sealing in site precisely with excellent remodelling Yuan X et al. JEVT 2017

35 Survival with acute type B aortic dissection on drugs... Acosta S, et al., Annals of Vascular Surgery 2007; 21:

36 Figure 2 Annual Survey of Thoracic Aortic Surgery [ ] by Japanese Association for Thoracic Surgery. Modified from reference (2). DAA, Aortic dissection; A Acute, acute type A aortic dissection; B Acute, acute type B aortic dissection; A Chronic, chronic type A aortic dissection; B Chronic, chronic type B aortic dissection; non DAA, non dissecting aneurysm; non DAA ruptured, ruptured aneurysm. Yutaka Okita, Ann Cardiothorac Surg Jul;5(4):368-76

37 Models of Hemodynamic Stress and Aortic Dissection Shear stresses on the aortic wall are highest at sites of increased dilatation. dp/dt, which is affected by wave reflections, is greatest in areas of aortic dilatation (Yin FC et al. Circulation 1989;79:854).

38 Antihypertensive Therapy after Aortic Dissection (ESC GL 2014) Multiple guidelines: IV beta-blockers as first-line therapy based on theoretical ability to decrease aortic wall shear stress (Labetalol). - HR <60 bpm - Systolic BP of mm Hg or as tolerated while maintaining adequate end-organ perfusion CCB (diltiazem, verapamil) suggested as alternatives if intolerance to beta-blockers. If BP remains over target, ACE-inhibitors and other IV vasodilators can be used. Once stable, transition to oral medications and continue long-term. Beta-blockers are recommended long-term. Eur Heart Journal 2014

39 What are the data on antihypertensive therapy after aortic dissection? RCT: none

40 Importance of Blood Pressure Control After Repair of Acute Type A Aortic Dissection: 25-Year Follow-Up in 252 Patients 92% at 10 yrs 74% at 10 yrs 49% at 10 yrs Reoperation rates: SBP <120 mm Hg 3/85 (4%) SBP mm Hg 13/63 (21%) SBP >140 mm Hg 10/30 (33%) Melby S et al. J Clin Hyperten. 2013;15:63

41 Patients with aortic dissection are at risk for late aortic events Medical management is expected to prevent rupture, aneurysm, aortic repair but does it really?

42 UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Chronic type B dissection on drugs!

43 Survival pattern of Aortic Dissection Surgery or Endo Group A included 2340 patients (25.74%) treated surgically for type A AD Medical only Group B included 1144 patients (12.58%) treated endo/surgically for type B AD Group C included 5608 patients (61.68%) with any type of AD treated with medical therapy only. Ting-Yu Yeh, et al. Epidemiology and Medication Utilization Pattern of Aortic Dissection in Taiwan: A Population-Based Study. Medicine (Baltimore) Feb;95(8):e200b

44 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

45 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

46 Type B dissection with malperfusion

47 Survival after TEVAR in complicated TBAD N = 51 Remodelling is key to success; long-term surveillance still recommended! Leshnower BG et al. Ann Thorac Surg 2017

48 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

49 Survival in B dissection by acuity (with high risk features) Booher M et al., Am J Med 2013

50 Type B aortic dissection: Survival and predictors Hypotension/Shock Malperfusion Tsai T, Nienaber C, et al. Circulation 2006, 114:

51 New high risk group: Pain & persisting hypertension Overall in hospital mortality In hospital mortality with medical management Trimarchi S et al. Circulation 2009

52 New high risk group: False Lumen diameter: FL > 22 mm Two patients with a small initial false lumen diameter at the upper descending thoracic aorta showed a complete resorption of the false lumen (left) or did not show an aneurysm for approximately 3 years (middle), while another patient with a large initial false lumen diameter developed an aorta aneurysm after approximately 2.5 years (right). UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Song JM, et al. JACC 2007; 50:

53 High risk: Partial false lumen thrombosis Tsai TT et al. for IRAD: NEJM 2007

54 New high risk group: Long-term outcome of aortic dissection? Entry tear of aortic dissection visualized by 2- dimensional (left) and color- Doppler (right) TEE Type B dissection with an entry tear located in the proximal part of the descending aorta (arrow) by tranverse view Type A dissection with an entry tear in the proximal part of the residual dissection (arrow) in the upper ascending aorta by longitudinal view Evangelista et al. Circulation 2012 Evangelista et al, Circulation 2012;125:

55 New high risk group: Aortic inflammation Baseline After TEVAR Biology CT PET-CT Sakalihasan N, Nienaber CA et al, EHJ 2015 TEVAR

56 Uncomplicated Type B Dissection Total Diameter >44mm - bad long-term Outcome Ray HM, et al. J Vasc Surg Dec;64(6):

57 ..2 predictors of long-term stability: FL thrombosis and Remodeling! B SE p- valu e OR 95.0% CI for Hazard Ratio Age Female STJ diameter Complete FLT IRAD data on file Suenaga H. et al. EJCTS 2016

58 Pragmatic Classification of Acute Aortic Syndrome Complicated AAS (acute aortic syndrome) Any proximal dissection/imh Evidence of Malperfusion Imminent rupture (extraaortic blood collection) AAS with high risk features Uncontrolled blood pressure Recurrent episodes of pain Early false lumen expansion (>4.5 cm) Any FL expansion >4.5 cm Partial FL thrombosis Single entry tear; > 10 mm True lumen collapse Ongoing aortic inflammation on PET/CT AAS without high risk features Apply morphologic risk predictor score

59 Uncomplicated type B aortic dissection: Survival & predictors Hypotension/Shock Malperfusion UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Tsai T, Nienaber C, et al. Circulation 2006, 114:

60 INSTEAD: 2 yrs outcomes after TEVAR in uncomplicated I year crossover 2 years crossover rate 14% (p=0.02) 20% (p=0,02) UNIVERSITÄT ROSTOCK MEDIZINISCHE FAKULTÄT Nienaber CA, Rousseau H, Kische S et al Circulation 2009 Nienaber C, Rousseau H, et al. Circulation Dec 22;120(25):

61 late advantage consistantly supported by RCT and registries RCT REGISTRY RCT INSTEAD-XL (n=140) Chinese IRAD(n=1129) registry (n=193) ADSORB (n=61) Circulation CV 2013; 6:407 Qin YL. JACC et al. Interv JACC 2013;6:876 Interv 2013;6:185 Eur J Vasc Endovasc Surg 2014;48:285 The initial RCT showed a long-term advantage of an intervention (stent-grafting the TL), with two large registry-based analyses confirming the signal from the RCT; findings are supported be short-term F/U of an independent RCT. On aggregate, all data are consistent! Very strong signal!

62 late advantage also supported by MGH Cohort study TEVAR for uncomplicated TBAD Natural history of uncomplicated TBAD Durham CA et al. JVS 2015

63 Uncomplicated Type B Dissection: In-H mortality/compl. IRAD, unpublished

64 Remodeling with TEVAR Complete false lumen thrombosis in the descending thoracic aorta Pre-procedure Post-procedure 24 months

65 TEVAR in Complicated and uncomplicated TBAD is backed-up by Guidelines ESC Guidelies 2014

66 Current recommendations

67

68 Estimation of risk in type B aortic dissection Sailer AM, et al. Circulation Cardiovascular imaging. 2017

69 Outcomes and Economic Comparison of Strategies in Type B Aortic Dissection After 1:1:1 PS matching (n=3612) Medical Open surgery Endovascular Total costs $ (Median) Cost per day $ (Median) Open 54,371 5,007 Medical 10,149 2,391 Endo 46,907 5,748 TEVAR provided best short-term mortality benefit & may-be costeffective over open surgery and medical management! Hsieh RW et al. JTCVS 2018 (in press)

70 Therapy 2018: Every patient should receive medical management, but that is almost never enough! + Risk calculator in low risk TBAD Nienaber CA and Clough RE, Lancet 2015

71 Brompton Aortic Centre 2018 Prof J Pepper cardiac surgeon Mike Rubens Imaging Ulrich Rosendahl cardiac surgeon Jullien Gaer cardiac surgeon Prof C Nienaber cardiologist Maz Mireskandari vascular surgeon

72 Medical Management after Aortic Dissection E-A-S-Y-T-I-P Establish the underlying diagnosis Achieve normal blood pressure (regardless of drug!) Stop cigarette smoking Yearn to exercise moderately Test 1 st degree relatives for TAA disease Image the aorta over time Perform aortic repair when appropriate

73 Interventional Repair of type a aortic dissection A pre procedure (FLIRT) B CT and echo images pre-procedure (A), at discharge (B) and 6-month follow-up (C) showing entry closure false lumen thrombus and shrinkage with true lumen expansion (remodelling) (patient no.2). Star shows the ASD occluder. At discharge C 6 months F/U Yuan X et al (accepted 2018)

74 Individual approach false lumen management in type A dissection CT scan 3 days after procedure CT scan 6 months after procedure No contrast communication to the false lumen Device sealing in site precisely with excellent remodelling Yuan X et al. JEVT 2017

75 Survival with acute type B aortic dissection on drugs... Acosta S, et al., Annals of Vascular Surgery 2007; 21: