Management of intramural hematoma and penetrating ulcers - what is different? D.Böckler University Hospital Heidelberg, Germany

Management of intramural hematoma and penetrating ulcers - what is different? D.Böckler University Hospital Heidelberg, Germany

Disclosure Speaker name: Dittmar Böckler I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Research Grant I do not have any potential conflict of interest

IMH & PAU - complex entities within Acute Aortic Syndrome Ref.: Ueda et al. Insights Imaging 2012

IMH vs. PAU - What is different?

# 1 Vessel wall anatomy / pathology Tunica intima Internal elastic lamina Tunica media External elastic lamina Tunica externa

# 1 Vessel wall anatomy / pathology IMH vs. PAU

# 2 Spontaneous course of PAU No reabsorption 20-30 % become symptomatic Annual growth rate unknown Pataras et al, Clinical Radiology 2013, Nathan et al, JVS 2012

# 2 Spontaneous course of PAU Ref.: Bischoff MS. Böckler D et al Heart 2011, Ganaha F, Dake M, Circulation 2002:106:342-8

# 2 Spontaneous course of IMH Reabsorption 40 % Aneurysm formation 50% Dissection 10% Type B 88% Type A 3 Nienaber CA Circulation 1995 and 2002 Cronenwett Rutherford s Texbook of Surgery, 7th Edition Hiratzka Fl et al, Circulation 2010; 6

# 2 Spontaneous course of IMH 7/28 (25%): TEVAR without further imaging 21/28 (75%): TEVAR because of dynamic changes in the early phase Ref.:Bischoff MS, Böckler et al, JVS 2016

# 3 (Over)- Sizing of Stentgrafts Ref.: Mehta M et al,endovascular Today 2009, January

# 3 Sizing of Stentgrafts IMH: hemorrhage in the media PAU: degenerative & atherosclerotic intima less radial force Oversizing 0-10% more radial force Oversizing 10-20 %

# 4 Landing zones for TEVAR in IMH Extended disease > long tx segments > risk for paraplegia

# 4 Landing zones for TEVAR in PAU Localized lesion > short tx segments > low risk for paraplegia

# 4 Spot-Stentgrafting to reduce Paraplegia

# 5 Management of IMH and PAU

# 5 Outcome of TEVAR in PAU In hospital mortality: 7%

# 5 Outcome of TEVAR in IMH & PAU

# 5 Survival of Patients with IMH & PAU P 0.03 1 Coady, Cardiol Clinics 1999

ORIGINAL ARTICLE Langenbecks Arch Surg Morphological risk factors of stroke during thoracic DOI 10.1007/s00423-012-0997-6 # 6 Risk for complications -Stroke ORIGINAL ARTICLE endovascular aor tic r epair Drosos Kotelis &Moritz S. Bischoff &Bertram Jobst & Hendrik von Tengg-Kobligk &Ulf Hinz & Philipp Geisbüsch &Dittmar Böckler Morphological risk factors of stroke during thoracic endovascular aortic repair Received: Drosos Kotelis 19 June &Moritz 2012 S. Bischoff / Accepted: &Bertram 27 August Jobst & 2012 # Hendrik Springer-Verlag von Tengg-Kobligk 2012 &Ulf Hinz & Philipp Geisbüsch &Dittmar Böckler Abstr act conditions. Seventeen percent of all patients had significant Purpose This study aims to identify independent factors arch atheroma (grade IV or V), and 43 % had a steep type III correlating Received: 19 June to2012 an/ Accepted: increased 27 August risk 2012 of perioperative stroke during thoracic endovascular aortic repair (TEVAR). median age, 73 years, range 31 78). Two strokes were lethal aortic arch. The perioperative stroke was 4 % (12 patients; # Springer-Verlag 2012 Methods A prospective maintained TEVAR database, medical Abstrecords, act and imaging studies of 300 patients conditions. (205 Seventeen men; percent imaging of all patients characteristics. had significant In eight patients, strokes were lo- (0.7 %). All strokes were classified as embolic based on median Purpose This age study of all, aims66 to identify years, independent range 21 89), factors who arch atheroma underwent (grade IV or V), cated and 43 in % had theasteep left type cerebral III hemisphere (seven of them in the TEVAR correlatingpau to between an increased March risk eventually of perioperative 1997 and strokefebruary during thoracic endovascular Preoperative aortic repair CT data (TEVAR). sets were reviewed median age, by 73 years, tworange 31 78). aortic at 2011, arch. Thewere perioperativeanterior stroke wasand 4 % (12 one patients; in the posterior circulation). Four stroke reviewed. patients Two strokeswerelethal (one in the left posterior circulation) underwent Methods A prospective maintained TEVAR database, medical records, and imaging studies of 300 patients (205 men; experienced radiologi sts with focus on the atheroma (0.7 %). All burden strokes were classified as embolic based on LSA coverage without revascularization. Three stroke in the aortic arch (grade I, normal, to grade imaging V, ulcerated characteristics. or In eight patients, strokes were located in the left cerebral hemisphere (seven of them in the patients had severe arch atheroma grade V. Five patients median age of all, 66 years, range 21 89), who underwent pedunculated atheroma). higher Aortic arch risk geometry (arch types TEVAR between March 1997 and February 2011, were suffering stroke were recognized to have a type III aortic anterior and one in the posterior circulation). Four stroke I III) was documented. Further parameters included in the reviewed. Preoperative CT data sets were reviewed by two arch. Strokes were equally distributed between zones 0 2 patients (one in the left posterior circulation) underwent univariate experienced radiologists analysis with were focus on age, the atheroma gender, burden urgency of repair, LSA coverage without revascularization. vs. 3 4(n06 1 % Three each, are stroke 5 vs. fatal 3.3 %). The highest incidence was duration in the aorticof arch procedure, (grade I, normal, adenosine-induced to grade V, ulcerated or cardiac patients had arrest severe or arch atheroma found grade in zone V. Five1 patients (11.4 %). In univariate analysis, grade V for stroke 1 rapid pedunculated pacing, atheroma). proximal Aortic arch landing geometry zone, (arch types left subclavian suffering stroke artery were recognized arch toatheroma have a type III (odds aortic ratios (OR), 5.35; 95 % confidence (LSA) I III) wascoverage, documented. Further and number parameters included of stent in the grafts. arch. Multivariate Strokes were equally distributed intervals between Depending (CI), zones 1.00 25.87; 0 2 P0on 0.035) PLZ and zone and 1 deployment %). The highest (OR, incidence 5.03; was 95 % CI, 1.19 20.03; P00.021) were logistic univariate regression analysis were age, analysis gender, urgency was performed of repair, vs. to3 4(n06 assess each, the 5 vs. 3.3 independent duration of procedure, correlations adenosine-induced of potential cardiac arrest risk or factors. found in zone 1 (11.4 %). In signifi univariate cantly analysis, associated grade V with perioperative stroke. In multivariate (OR), 5.35; analysis, atheroma 95 % confidence both parameters burden were confirmed as inde- Results rapid pacing, Atherosclerotic proximal landing zone, aneurysm left subclavian was artery the arch most atheroma common (odds ratios pathology (LSA) coverage, (44 and %). number One of stent hundred grafts. Multivariate and fifty-four intervals (CI), of1.00 25.87; our P00.035) pendent and significant zone 1 deployment or(or, emergent 5.03; 95 % CI, Conclusions 1.19 20.03; P00.021) Stroke wererisk during TEVAR isdirectly associat- risk factors for stroke during TEVAR. patients logistic regression (51 %) analysis were wastreated performed under to assessurgent the independent correlations of potential risk factors. significantly associated withed perioperative with the stroke. atheroma In multivariate analysis, both parameters proximal were confirmed landing as inde- zone. These factors should be considered burden of the aortic arch and the D. Results Kotelis Atherosclerotic (* ) : M. S. aneurysm Bischoff was: the P. Geisbüsch most common : D. Böckler Department pathology (44 of%). Vascular One hundred and Endovascular and fifty-four Surgery, of our pendent significant risk factors during for stroke patient during TEVAR. selection, planning, and implantation strate- 4-7 % embolic stroke rate 1,2 Ref. 1 Kotelis et al Langenbecks Arch Surg 2009, 2 Böckler et al, EJVES 2015 publication accepted

# 6 Risk for complications retro. AD Incidence is low 1,3 % but mortality is high : 42% Associated with proximal bare stent induced injury Ref. Ref.: 1 Kotelis Eggebrecht et al H Langenbecks et al, Circulation Arch 2009; Surg 2009, 120 (Suppl 2 Böckler 1):S276-S281 et al, EJVES 2015 publication accepted

# 6 Risk for complications retro. AD Ref.: Böckler D et al., Gefäßchirurgie 2005, Vol 4:

# 6 Risk for complications SINE Dong Z, J Vasc Surg 2010;52:1450-8 Stress induced injury Incidence 3.2 % 10 x higher in Marfan Mortality 26 % Oversizing rate?

Summary & Conclusions IMH & PAU are summarized with Aortic dissection in Acute Aortic Syndrome Nevertheless, there are differences regarding pathophysiology imaging TEVAR planing (oversizing) No comparative studies published comparing IMH vs. PAU Management is based on Level C evidence Personal experience: IMH is more challenging to manage