University of Milan Thoracic Aortic Research Center Update on IRAD Santi Trimarchi, MD, PhD Associate Professor of Vascular Surgery, University of Milan Head, Unit of Vascular Surgery II Director, Thoracic Aortic Research Center IRCCS Policlinico San Donato
IRAD Disclosures W.L. Gore & Associates, Inc. Active Sites Medtronic Varbedian Aortic Research Fund The Hewlett Foundation The Mardigian Foundation UM Faculty Group Practice Terumo Ann and Bob Aikens
Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD
Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD
Active IRAD Sites [49] IRAD: 1996-2016
IRAD Total Patients Type A Type B
IRAD Total Follow-Up Follow-up defined as a patient having at least one completed follow-up form. 8000 7333 7000 6100 (83.2%) 6000 5000 4000 3168 (57.3%) 3000 2000 1000 0 Total Survived Followed Up
IRAD InterVentional Cohort IVC: 2010-2016 Active IRAD IVC Sites [26]
IRAD InterVentional Cohort - IVC Aim: to better address surgical variables 131 variables
IRAD InterVentional Cohort - IVC Cases Enrolled to Date 2251 2251 1759 1492 1505 1544 1348 cases enrolled 970 816 616 668 462 284 AHA ACC AHA ACC AHA ACC AHA ACC AHA ACC AHA ACC 2010 2011 2011 2012 2012 2013 2013 2014 2014 2015 2015 2016
IRAD InterVentional Cohort - IVC 18,43% 81,56% Type A Type B 1836 Type A cases 1751 surgical 39 endovascular 45 hybrid 1 surgical + endo 415 Type B cases 104 surgical 280 endovascular 29 hybrid
Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD
Retrograde Extension of Type B Dissection in Arch
Retrograde Extension of Type B Dissection in Arch XXXX Incidence 16.5%
Retrograde Extension of Type B Dissection in Arch G 1: 337 pts G 2: 67 pts
Retrograde Extension of Type B Dissection in Arch No difference in management
Retrograde Extension of Type B Dissection in Arch No difference in mortality
Retrograde Extension of Type B Dissection in Arch No difference in 5-year survival
Retrograde Extension of Type B Dissection in Arch No difference in 5-year survival
Retrograde Extension of Type B Dissection in Arch No difference in 5-year survival
Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD
Retrograde Extension of Type B Dissection in Ascending Aorta Sem Thor Cardiovasc Surg, in press
Retrograde Extension of Type B Dissection in Ascending Aorta
Retrograde Extension of Type B Dissection in Ascending Aorta Methods and Results: between 1996 and 2014 were analyzed 99 patients (67 men; 63.2±14.0 years) with an entry tear in the DTA and retrograde extension into the arch or ascending aorta.
Retrograde Extension of Type B Dissection in Ascending Aorta Methods and Results: between 1996 and 2014 were analyzed 99 patients (67 men; 63.2±14.0 years) with an entry tear in the DTA and retrograde extension into the arch or ascending aorta. Independent predictors of retrograde type A AD were: increasing age (OR 1.0; 95% CI, 1.0 to 1.0; P=0.004) history of cocaine abuse (OR 4.9; 95% CI, 1.7 to 13.6; P=0.003) back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002) non-white race (OR 0.4; 95% CI, 0.2 to 0.6; P<0.001).
Retrograde Extension of Type B Dissection in Ascending Aorta Results: MED SURG ENDO 44 33 22 Early mortality (30-day or in-hospital) 9.1% 18.2% 13.6% P=0.51 5-year survival (mean follow-up, 3.3 years) 86.7% 80.0% 90.9% P=0.67 Initial management A trend of favorable early mortality was observed in patients with retrograde extension till zone 1 (8.6%) versus into zone 0 (18.6%, P=0.14). Early mortality 18.6% P
Retrograde Extension of Type B Dissection in Ascending Aorta Results: Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04).
Retrograde Extension of Type B Dissection in Ascending Aorta Results: Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04). The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extension confined to zone 1 (proximal arch, P<0.001) MED 72.7% ENDO 86.4%
Retrograde Extension of Type B Dissection in Ascending Aorta Results: Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04). The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extension confined to zone 1 (proximal arch, P<0.001) Most of the SURG patients (71.8%) presented with AD extension into zone 0 (proximal to the innominate artery, P<0.001). SURG 71.8%
Retrograde Extension of Type B Dissection in Ascending Aorta Results: Retrograde Type A Type A AD P Early mortality (30-day or in-hospital) 12.9% 20.0% P=0.001 5-year survival (mean follow-up, 3.3 years) 86.8% 89.5% P=0.96
Retrograde Extension of Type B Dissection in Ascending Aorta Details of endovascular treatment Variable ENDO Dissection flap fenestration (%) 7 (31.8) Descending thoracic aortic stent graft (%) 6 (27.3) SMA stent (%) 2 (9.1) Renal artery stent (%) 3 (13.6) Iliac artery stent (%) 3 (22.7)
Retrograde Extension of Type B Dissection in Ascending Aorta Tear in Descending Aorta
Retrograde Extension of Type B Dissection in Ascending Aorta Thrombosed FL in Ascending Aorta Tear and patent FL in Descending Aorta 2 month F-Up: Thrombosed FL
Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD
Uncomplicated Type B Dissection: In-H mortality/compl. IRAD, unpublished
Uncomplicated Type B Dissection: In-H mortality/compl.
Uncomplicated Type B Dissection: In-H mortality/compl. Results Patients in group I showed a trend for higher BMI
Uncomplicated Type B Dissection: In-H mortality/compl. Results The maximum aortic diameter at any level on initial imaging studies was significantly larger in group I compared to group II
Uncomplicated Type B Dissection: In-H mortality/compl. Results The maximum aortic diameter at any level on initial imaging studies was significantly larger in group I compared to group II patients in group I were more likely to have multiple intimal tears
Uncomplicated Type B Dissection: In-H mortality/compl. Results The in-hospital mortality rate in Group I was 17.4%
Presentation Outline IRAD and IRAD-IVC actual data Retrograde Extension of Type B Dissection in Arch Retrograde Extension of Type B Dissection in Ascending Aorta Uncomplicated Type B Dissection: In-H mortality/complications Trend in Surgical Treatment of Type A-AD
IRAD InterVentional Cohort - IVC 18,43% 81,56% Type A Type B 1836 Type A cases 1751 surgical 39 endovascular 45 hybrid 1 surgical + endo 415 Type B cases 104 surgical 280 endovascular 29 hybrid
IRAD IVC Trends
IRAD IVC Trends Methods From patients enrolled in IRAD-IVC, only TAAD surgically repaired were included. Type B aortic dissection and those with endovascular/hybrid management were excluded. Patients were split into three equal groups based on time of intervention (T1: 1996-2003; T2: 2004-2009; T3: 2010-2016).
IRAD IVC Trends Results
IRAD IVC Trends Results In-hospital mortality
IRAD IVC Trends Cerebral perfusion management Results Cereb ral p erfu s ion Antegrade Retrograde Ov erall T im e 1 T im e 2 T im e 3 587(84.8) pv alu e <.001 T rend p v alu e <.001 1256 (84.2) 461 (61.9) 461 (38.9) 141 (67.1) 528 (89.5) 76 (55.9) 303 (58.8) 369 (66.1).015.005 60 (44.1) 212 (41.2) 189 (33.9).015.005
IRAD IVC Trends Cerebral perfusion management Results H y p otherm ic CircArres t Ov erall T im e 1 T im e 2 T im e 3 1257 (85.5) 173 (80.1) 483 (85.9) 601 (86.8) pv alu e.045 T rend p v alu e.030
IRAD IVC Trends Results Arterial Cannulation management R Ax illary artery cannu lation Fem oral cannu lation 313 (55.7) pv alu e <.001 T rend p v alu e <.001 169 (30.1) <.001 <.001 Ov erall T im e 1 T im e 2 T im e 3 527(40.4) 39 (18.0) 175 (33.2) 615 (47.1) 165 (76.0) 281 (53.3)
IRAD IVC Trends Aortic Valve management Results d
IRAD IVC Trends Aortic Valve management Results d
IRAD IVC Trends Aortic Root management Results d
IRAD IVC Trends Ascending management Results Op en p rocedu re Sim p le as c. rep lacem ent Ov erall T im e 1 T im e 2 T im e 3 pv alu e T rend p v alu e 1455 (92.4) 205 (94.9) 565 (89.8) 685 (938).007.486 1172 (77.6) 165 (76.4) 392 (72.5) 615 (81.7) <.001.004
IRAD IVC Trends Results Aortic Arch management
IRAD IVC Trends Results Aortic Arch management
IRAD IVC Trends Results Aortic Arch management
Update on IRAD Conclusions
Update on IRAD Conclusions Retrograde extension of type B dissection into the Arch might be treated similarly to those with no retrograde extension X X X X
Update on IRAD Conclusions Retrograde extension of type B dissection into the Arch might be treated similarly to those with no retrograde extension There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. X X X X
Update on IRAD Conclusions Retrograde extension of type B dissection into the Arch might be treated similarly to those with no retrograde extension There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. This implies that a selective approach may be reasonable, particularly among those with proximal extension limited to the arch distal to the innominate artery. X X X X
Update on IRAD Conclusions Initially uncomplicated type B dissection may in hospital complicate in up to 10% patients
Update on IRAD IVC Conclusions Utilization of adjunctive are associated with improved outcome in acute type A dissection
Update on IRAD IVC Conclusions IRAD IVC can be useful for addressing surgical and endovascular issues in the management of acute dissection.