High Risk Uncomplicated Type B Dissection
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1 High Risk Uncomplicated Type B Dissection Ali Azizzadeh, MD, FACS Director, Vascular Surgery Vice Chair, Department of Surgery Associate Director, Heart Institute Cedars-Sinai Medical Center Los Angeles, CA
2 Treatment of ATBAD 3 Referral Center Multi-specialty team: CT, Vasc Surg Critical care Consultants Advanced imaging: CT, MR, IVUS, TEE Hybrid OR s Monitoring MEP, SSEP Full spectrum of open/endovascular procedures
3
4 Protocol Admit CVICU CVC, arterial line, UOP B-Blocker Ca +2 Blocker Nitroglycerin Nitroprusside Anti-impulse Therapy SBP<120, HR<60 Control pain Respiratory DVT prevent Nutrition Mobilization Reassessment Blood pressure Pain
5 Protocol Percutaneous Intervention Surgical Intervention Rupture/ Leak Malperfusion (renal, visceral, peripheral) Acute Expansion Refractory Symptoms
6 Acute Type B Aortic Dissection 2000 to pts AD 532 ATBAD 60% Male Mean age 60.6 ± 13.6 yrs Median age = 60.5 yrs Range yrs Average Follow up: 3.7 yrs
7 Aortic Dissection 1079 DISSECTIONS
8 Aortic Dissection 535 TYPE A 532 TYPE B 1079 DISSECTIONS
9 Aortic Dissection 294 UNCOMPLICATED 535 TYPE A 238 COMPLICATED 1079 DISSECTIONS
10 Acute Type B Aortic Dissections 532 PATIENTS WITH ACUTE TYPE B DISSECTION 294 UNCOMPLICATED 238 COMPLICATED Inadequate Imaging Abdominal IMH / PAU 156 WITH ADEQUATE IMAGING DATA ANALYSIS
11 Measurement: Methods TeraRecon(Foster City, CA) Multi-planar reconstruction Double orthogonal oblique measures Proximal descending aorta FL diameter and area: level of main pulmonary artery Maximum aortic diameter on admission Measurements by specialized cardiovascular radiologist
12 Overall Survival: Max Aortic Diameter
13 Overall Survival: Age
14 Intervention-free Survival: Max Aortic Diameter
15 Intervention-free Survival: False Lumen Diameter
16 Intervention-free Survival: Max Aortic Diameter (Quartiles)
17 Intervention Rates Intervention Rate (%) Admission Aortic Diameter (mm) 1 year 5 years 10 years > Overall Intervention rate: >44mm: 34.4% 44mm: 11.3% (OR 4.12, p=0.02)
18 Incidence of Risk Factors in AUTBAD Risk Factors TAD >44mm / FLD >22 / Age >60 1 Risk Factor 44% 2 Risk Factors 19% 3 Risk Factors 6% Total 69%
19 Conclusions Aortic diameter >44mm is a predictor of mortality after adjustment for significant risk factors. Age >60 years is a risk factor for mortality. Decreased intervention-free survival in those with FL>22mm and/or max aortic diameter >44mm on admission. Patients with Aortic diameter >44mm, FL>22mm, and/or age>60 should be considered for TEVAR.
20 Cohort 6/2000 to 1/ uatbad 245 any available CT 131 CTA available for review 60% male 53% caucasian Mean age 60.9 ±13.4 years Median follow up: 6.9 years
21 Contrast enhanced CT imaging TeraRecon(Foster City, CA) Methods Multi-planar reconstruction Measurements by cardiovascular radiologist Max ascending diameter Max ascending area
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24 Proximal Aortic Intervention as predicted by Max Ascending Aortic Area
25 Proximal Aortic Intervention as predicted by Max Ascending Aortic Diameter
26 Proximal Aortic Interventions 24 pts total aortic interventions on f/u 6 pts proximal aortic intervention 5: Type A dissection Repair 1: Ascending/ Arch Aneurysm Repair Need for proximal aortic intervention predicted by Max asc area >12.1cm 2 (p<0.03) Max asc diameter >40.8mm (p=0.03)
27 Stratified Analysis: Interventionfree Survival Max Ascending Aortic Diameter > 40.8mm (HR 2.01, p=0.04) Max Ascending Aortic Area >12.1cm 2 (HR 1.99, p=0.04) Controlled for: Max Aortic Diameter along aorta >44mm (HR 3, p<0.01) Syncope on admission (HR 26, p<0.01) Pleural effusion on admission (HR 3, p<0.01)
28 Conclusion uatbad patients w/ max asc area >12.1 cm 2 and/ or max asc diameter >40.8mm on admission are at high risk of subsequent arch/proximal progression Ascending aortic size (diameter and area) predicts decreased intervention-free survival in uatbad Max aortic diameter >44mm predicts increased mortality Patients with these high-risk characteristics may benefit from closer follow-up or earlier intervention with TEVAR
29 Thank You
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