La sindrome aortica acuta oggi
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1 University of Milan Thoracic Aortic Research Center La sindrome aortica acuta oggi Santi Trimarchi, MD, PhD Professore Associato di Chirurgia Vascolare, Università degli Studi di Milano Direttore, Divisione di Chirurgia Vascolare II Responsabile, Centro di Ricerca sulle Malattie dell Aorta Toracica IRCCS Policlinico San Donato
2 Disclosures Grants: San Donato Foundation, Gore WL, Medtronic inc. Consultant and Speaker: Gore WL, Medtronic inc.
3 Acute Thoracic Aortic Syndromes: definitions Definitions of Acute AS according to ESVS Classic AD IMH PAU 2017
4 Acute Thoracic Aortic Syndromes: definitions Definitions of Acute AS according to ESC Classic AD IMH Subtle or Discrete AD Iatrogenic AD PAU 2014
5 Acute Thoracic Aortic Syndromes: definitions Chest Pain and Media Discruption define the Acute Entities
6 Acute Thoracic Aortic Syndromes pts / / yr Cause of death in the population: 0.5% Rate M/F 2/1-5/1 Aortic Dissection IMH PAU Linee Guida SICVE
7 Acute Thoracic Aortic Syndromes / 15 pts / / yr 27 pts / / yr in aged yrs 35 pts / / yr in older > 75 yrs
8 Aortic Dissection
9 Acute B Dissection Uncomplicated 55% Complicated 45%
10 Complicated Type B Dissection: Guidelines ESC 2014
11 Complicated Acute B Dissection: Guidelines ESVS 2017 EJVES, in press
12 Complicated Acute B Dissection
13 Complicated Acute B Dissection: Rupture
14 Complicated Acute B Dissection: Rupture
15 Complicated Acute B Dissection: Rupture
16 Complicated Acute B Dissection: Rupture
17 Endovascular Techniques for Visceral Malperfusion
18 Endovascular Techniques for Visceral Malperfusion Aortic Stent-graft + Abdominal bare metal stent
19 Endovascular Techniques for Visceral Malperfusion Percutaneous Fenestration Branch Vessel Stenting
20 Complicated Acute B Dissection: Lower Limb Malperfusion Incidence of LLM is 19-48% of complicated TBAD 50-73% of TBAD with Malperfusion Syndrome
21 45-55% Uncomplicated Type B Dissection: Incidence
22 Uncomplicated Type B Dissection: Incidence 55% 300/550 pts 55% 294/532 pts 53% 65/123 pts
23 Uncomplicated Type B Dissection: TEVAR
24 Predictors of Late Aortic Growth Diameter of Proximal Entry Tear Circular shape FL Partial Lumen Thrombosis Saccular FL formation Total initial diameter > 40 mm F L > 22 mm
25 Predictors of NO Aortic Growth Increasing age > 60 yrs IMH B Heart rate < 60 Calcium Channel B Circular TL Thrombosed FL Increased number of ET
26 Intramural Haematoma
27 Intramural Haematoma Pts with IMH tended to be older (68.7 versus 61.7 years; p<0.001) and more likely to have distal aortic involvement (60.3% versus 35.3%; p<0.0001).
28 IMH-B: Uncomplicated
29 IMH-B: Complicated
30 IMH Evolution over time 17 (34%) Resorbed Completely 50 Patients 12 (24%) Pseudoaneurysm 6 (12%) Classic Dissection 11 (22%) Fusiform Aneurysm 4 (8%) Saccular Aneurysm Evangelista A et al. Circulation Consensus Document, ATS 2008
31 Insight IMH B
32 Penatrating Aortic Ulcer
33 PAU Relatively recent recognition as entity (1986) Atheroma Intimal ulcer Intima Media Adventitia Aortic atheroma Plaque ulceration Intimal plaque ulceration Medial hematoma Adventitial false aneurysm Transmural rupture
34 A closer look at PAU Histologically, abrupt interruption of medial layer Associated with atherosclerotic ulcer Can be associated with intramural hematoma (IMH) Imaging criteria: ulcer = localized collection of contrast extending from lumen
35 A closer look at PAU Histologically, abrupt interruption of medial layer Associated with atherosclerotic ulcer Can be associated with intramural hematoma (IMH) Imaging criteria: ulcer = localized collection of contrast extending out the lumen
36 PAU: Indications for Treatment - Descending
37 Conclusions: Complicated B Dissections Complicated type B dissection benefits primarily of endovascular mng TEVAR can be effective also as bridge therapy
38 Conclusions: Uncomplicated B Dissections Diameter of Prox. E T Circular shape FL Heart rate < 60 Saccular FL formation IMH B Total initial diameter > 40 mm F L > 22 mm Partial Lumen Thrombosis Calcium Channel B Circular TL
39 Conclusions: Uncomplicated B Dissections. Indication by the anatomy?
40 Conclusions: IMH and PAU IMH and PAU are uncommon, but potentially lethal thoracic aortic pathologies. IMH does not seem to have a more favorable outcome than classic dissection. IMH B may have unpredictable evolution.
41 Acute Thoracic Aortic Syndromes: Open Issues PAU Acute in terms or Chronic in real life? PAU
42 Acute Thoracic Aortic Syndromes: Open Issues What about these Acute Thoracic Aortic Events? TAI Ruptured DTAA
43 Acute Thoracic Aortic Syndromes: definitions What about these Acute Thoracic Aortic Events? AEF / ABF complicating DTAA
44 Acute Thoracic Aortic Syndromes: definitions What about these Acute Thoracic Aortic Events? AEF / ABF after TEVAR RAAD after TEVAR
45 Acute Thoracic Aortic Syndromes: definitions What about these Acute Thoracic Aortic Events? Is it time for a new definition?
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