Comparisons of Aortic Remodeling and Outcomes after Endovascular Repair of Acute and Chronic Complicated Type B Aortic Dissections I-Hui Wu, M.D. Ph.D. Clinical Assistant Professor Cardiovascular Surgical Department National Taiwan University Hospital
Disclosure Speaker name: I-Hui Wu M.D.,Ph.D... I do not have any potential conflict of interest
Thoracic endovascular aortic repair (TEVAR) for the management of complicated type B aortic dissections has become more commonplace despite some controversy Area of interest: Comparison between acute vs chronic short and midterm outcome reintervention rate remodeling process
between June 2008 and November 2014 49 patients underwent TEVAR for the management of complicated type B dissection Acute: (n=26) Chronic: (n =23)
Acute complicated type B dissection Treatment duration less than 14 days of onset of symptoms Malperfusion Impending rupture Uncontrolled pain Refractory hypertension Shock
Chronic complicated type B dissection Treatment duration greater than 14 days of onset of symptoms Malperfusion Aneurysmal degeneration (>55mm) Rapid growth (>10mm/y)
atypical dissection connective tissue disease residual type A dissection trauma patients
preoperative computed tomography (CT) scans that encompassed the entire aorta, including the bilateral carotid and pelvic arteries postoperative CT scans were routinely performed within 1 month, 12 months, and yearly the entire descending aorta was evaluated at six different levels of thoracic aorta
A B C F E D Gorlitzer M, Weiss G, Meinhart J, Waldenberger F, Thalmann M, Folkmann S, et al. Fate of the false lumen after combined surgical and endovascular repair treating Stanford type A aortic dissections. Ann Thorac Surg 2010;89:794-9.
Complications procedure related device related In-hospital mortality All cause and aneurysmal related mortality Re-intervention rate Extent of false lumen (FL) thrombosis 0: designates some retrograde FL perfusion along stent graft I: designates thrombosis along length of stent graft II: designates thrombosis of FL throughout thoracic aorta III: designates complete thrombosis of FL throughout native aorta True and false lumen aortic remodeling by diameter
Demographics and Comorbidities Total ACTBAD CCTBAD P- value Total population 49 26 23 Age 62.3±11.1 61.0±14.0 63.9±7.9 Male 40(81.6%) 20(76.9%) 20(86.9%) 0.37 Onset 6.0±4.3 597.9±334.1 0.00 Comorbidities Hypertension 42(85.7%) 24(92.3%) 18(78.2%) 0.75 Smoking 12(24.5%) 6(23.0%) 6(26.0%) 0.63 COPD 6(12.2%) 3(11.5%) 3(13.0%) 0.71 CKD 15(30.6%) 8(30.7%) 7(30.4%) 0.82 CAD 9(18.4%) 5(19.2%) 4(17.3%) 0.90 PAOD 3(6.1%) 2(7.7%) 1(4.3%) 0.77 CVA 5(10.2%) 3(11.5%) 2(8.6%) 0.90 DM 5(10.2%) 3(11.5%) 2(8.6%) 0.86 Medication Antiplatelet 16(32.7%) 10(38.4%) 6(26.0%) 0.36 Anticoagulant 9(18.4%) 4(15.3%) 5(21.7%) 0.58 Statin 9(18.4%) 4(15.3%) 5(21.7%) 0.58 Abbreviation: COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease,(cr:>2.0 mg/dl),cad: coronary artery disease; PAOD: peripheral artery occlusive disorder; CVA: cerebral vas:ular accident; DM: diabetes mellitus
Stent graft type Total(49) ACTBAD(26) CCTBAD(23) P-value TAG 22 (44.9%) 10 (38.4%) 12 (52.1%) 0.35 Zenith 14 (28.6%) 9 (34.6%) 5 (21.7%) 0.33 Talent 2 (4%) 1 (3.8%) 1 (4.3%) 0.93 Valiant 10 (20.4%) 6 (23.0%) 4 (17.3%) 0.63 Relay 1 (2%) 0 1 (4.3%) 0.33 Length of aortic coverage* Type A 36 (73.5%) 21 (80.7%) 15 (65.2%) 0.23 Type B 13 (26.5%) 5 (19.3%) 8 (34.8%) 0.88 Proximal landing zone Zone 0 2 (4%) 0 2 (8.7%) 0.16 Zone 1 8 (16.3%) 3 (11.5%) 5 (21.7%) 0.35 Zone 2 28 (57.1%) 15 (57.7%) 13 (56.5%) 0.94 Zone 3 7 (14.3%) 5 (19.2%) 2 (8.7%) 0.29 Zone 4 4 (8.1%) 3 (11.5%) 1 (4.3%) 0.36 *Length of aortic coverage: Type A: LSCA to T6, Type B: LSCA to celiac axis
Stent graft Total (49) ACTBAD(26) CCTBAD(23) P-value Proximal (mm) 37.5±3.53 38.2±3.2 36.7±3.9 0.15 Distal (mm) 34.67±3.93 35.7±3.6 33.5±4.3 0.04 Tapered 17 (34.7%) 11(42.3%) 6 (26.1%) 0.24 Associated procedures Left C-S bypass 10(20.4%) 2 (7.7%) 8 (34.7%) 0.02 VA transposition 1 (2%) 0 1 (4.3%) 0.33 C-C-S bypass 6 (12.2%) 2 (7.7%) 4 (17.7%) 0.32 Left SCA chimney 13 (26.5%) 10 (38.5%) 3 (13.0%) 0.04 Left CCA chimney 2 (4.1%) 0 2 (8.7%) 0.16 Supraortic debranching 1 (2%) 0 1 (4.3%) 0.33 Elephant trunk 1 (2%) 0 1 (4.3%) 0.33 Procedure details General anesthesia 48 (98%) 25 (96.1%) 23 (100%) 0.33 CSF drainage 3 (6%) 2 (7.7%) 1 (4.3%) 0.63 Left SCA coverage 4 (8.1%) 2 (7.7%) 2 (8.7%) 0.90 Percutaneous 1 (2%) 1 (3.8%) 0 0.33 Operation time (min) 272.5±155.6 260.2±128.9 286.4 ± 185.8 0.55 Contrast medium (ml) 265.7±174.8 276.9± 229.8 253.0 ±112.7 0.61 Fluoroscopic time (min) 20.6±14.3 22.1 ±17.3 18.9 ±10.9 0.39
Total (49) ACTBAD (26) CCTBAD(23) P-value Technical success 49 (100%) 26 (100%) 23 (100%) N/A 30-day mortality 2 (4%) 2 (7.7%) 0 0.16 Procedure-related complication Paraplegia 2 (4%) 1(3.8%) 1(4.3%) 0.93 CVA 0 0 0 N/A MI 3 (6%) 2(7.7%) 1(4.3%) 0.63 Pneumonia 2 (4%) 1(3.8%) 1(4.3%) 0.93 Renal insufficiency 7 (14.3%) 4 (15.4%) 3 (13%) N/A Without H/D 5 3 2 0.86 Temporary H/D 2 1 1 0.93 Long term H/D 0 0 0 N/A Distal limb ischemia 0 0 0 N/A Vascular access bleeding 2 (4%) 1(3.8%) 1(4.3%) 0.93 Device-related complications Proximal SINE 2 (4%) 2(7.7%) 0 0.16 Immediate 1 1 0 0.33 Delayed 1 1 0 0.33 Distal SINE 1 (2%) 1(4.1%) 0(0%) 0.33 Immediate 0 0 0 N/A Delayed 1 1 0 0.33
Total (49) ACTBAD (26) CCTBAD(23) P-value Extent of false lumen thrombosis* 0 7 (14.9%) 1 (4.2%) 6 (26.0%) 0.03 I 11 (23.4%) 7 (29.1%) 4 (15.3%) 0.28 II 17 (36.1%) 8 (33.3%) 9 (39.1%) 0.38 III 12 (25.5%) 8 (33.3%) 4 (17.3%) 0.28 *: 0: some retrograde FL perfusion along stent graft; I: FL thrombosis along the stent graft; II: FL thrombosis to the celiac artery; III: complete FL thrombosis
True lumen diameter <.0001 <.0001 <.0001 0.0337 0.1699 0.2114
False lumen diameter 0.0011 0.0007 0.0067 0.1910 0.7647 0.8345
True lumen diameter: Acute vs. Chronic 0.6442 0.1598 0.3736 0.5392 0.9736 0.8966
False lumen diameter: Acute vs. Chronic 0.3871 0.0449 0.4434 0.2243 0.3913 0.9907
True lumen diameter: Taper vs. Non-taper 0.0033 0.4341 0.3897 0.3736 0.6237 0.7916
False lumen diameter: Taper vs. Non-taper 0.2285 0.7860 0.8882 0.9157 0.8917 0.9811
True lumen diameter: Above T6 vs. Below T6 0.2767 0.8532 0.2695 0.8896 0.5968 0.8180
False lumen diameter: Above T6 vs. Below T6 0.8262 0.8478 0.7325 0.7159 0.7250 0.9081
TEVAR for both ACTBAD and CCTBAD Safe and effective With low rate early and midterm mortality, reintervention rate Aortic remodeling No difference The length of endograft coverage ( above vs below T6) The length of TEVAR stent should be justified with the risk of spinal cord ischemia Between the acute and chronic cases Between the taper and non-taper stent graft configuration
Proximal aortic remodeling is favorable in both acute and chronic dissection but no difference was noted between ACTBAD and CCTBAD Distal aortic remodeling is not as favorable as proximal aorta in both acute and chronic dissection multiple reentry tears in the distal abdominal aorta All patients with residual vulnerable aorta must undergo serial imaging for their lifetime
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Comparisons of Aortic Remodeling and Outcomes after Endovascular Repair of Acute and Chronic Complicated Type B Aortic Dissections I-Hui Wu, M.D. Ph.D. Clinical Assistant Professor Cardiovascular Surgical Department National Taiwan University Hospital