Gordon K. Stokes, MD, FACS Eastern Virginia Medical School Sentara Vascular Specialists Norfolk, VA Aortic Center of Excellence at Sentara April 25, 2014
Disclosures I have no disclosures relevant to this presentation.
It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has. William Osler, 1849-1919
Aortic Dissection
Intramural Hematoma
Penetrating Aortic Ulcer
Blunt Aortic Injury
Thoracic Aneurysm
TAD Incidence is Directly Related to Age 34,835,000 70,319,000 Increasing prevalence of thoracic aortic disease 80 60 40 20 100 0 1995 2000 2005 2010 2015 2020 2025 2030 Year U.S. population 65 yr old (millions)
Abdominal Aortic Aneurysm
AAA Rupture is the 15th leading cause of death in Men 160 140 120 100 80 60 40 20 0 25-34 35-44 45-54 55-64 65-74 75-84 85 AAA Death rate by age
AAA Rupture is the 15th leading cause of death in Men 160 140 120 100 2-5% of the population > 50 yr 6.3% men > 65 yr 80 60 40 20 0 25-34 35-44 45-54 55-64 65-74 75-84 85 AAA Death rate by age
Endo-Vascular Aneurysm Repair EVAR
Abdominal Aortic Aneurysm Repair
Thoracoabdominal Aneurysm Surgery
Complex Aortic Aneurysm Repair Aortic aneurysms were the primary cause of 10,597 deaths and a contributing cause in more than 17,215 deaths in the United States in 2009.
Spinal Cord Protection Anesthesiology Expertise in Spinal Drainage Vascular Intensive Care Unit Spinal drain management
TEVAR with Visceral De-branching
TEVAR with Visceral De-branching
Complex Hybrid TEVAR/EVAR
Thoracic Endovascular Aorta Repair (TEVAR) with Great Vessel Snorkel
Arch De-branching to Facilitate TEVAR
Fenestrated and Branched Stent Grafts TEVAR for Arch
Mortality by Hospital Volume after Surgical Repair of Thoraco-abdominal Aneurysms. John A Cowan Jr, Justin B Dimick, Peter K Henke, Thomas S Huber, James C Stanley, Gilbert R Upchurch Jr Journal of Vascular Surgery, Volume 37, Issue 6, 2003, 1169-1174
Mortality by Surgeon Volume after Repair of Thoraco-abdominal Aortic Aneurysms John A Cowan Jr, Justin B Dimick, Peter K Henke, Thomas S Huber, James C Stanley, Gilbert R Upchurch Jr Journal of Vascular Surgery, Volume 37, Issue 6, 2003, 1169-1174
Aortic Dissection Increasing incidence 5-30/1 million people/year 2-3 times as frequent as Ruptured AAA Male to Female 2:1
Aortic Dissection Etiology Atherosclerosis Increased wall stress Aortic Media abnormalities Iatrogenic Other
Aortic Dissection Etiology Atherosclerosis Increased wall stress Aortic Media abnormalities Iatrogenic Other
Type A Aortic Dissection repair
Type A Aortic Dissection repair
Type A Aortic Dissection repair
Patent false lumen 69.7% Aorta dilated >/= 1 cm 47.5% Shrinkage occurred in 95.8% with thrombosed false lumen Park et. al., Ann Thorac Surg 2009,87:103-8
Chronic Complex Arch Dissecting Aneurysm
Acute Type A Stented Elephant Trunk Pochettino, Szeto, and Bavaria; AnnThor Surg 2009
Chronic Distal Dissecting Aneurysm
Does TEVAR Prevent Aneurysmal Degeneration in Acute Uncomplicated Type B Aortic Dissection
INSTEAD TRIAL Randomized Trial 140 patients Acute un-complicated Type B Dissection TEVAR vs Optimal Medical Treatment Primary End Point All cause Death Secondary End Points Aorta related Death Progression aortic disease Aortic remodeling
Five year INSTEAD Data TEVAR Medical All Cause Mortality Aorta Specific Mortality Aortic Disease Progression Aortic Remodeling 11.1% 19.3% P=0.13 6.9% 19.3% P=0.04 27.0% 46.0% P=0.04 90.6% 19.4% P<0.0001
Complicated Aortic Dissection Mal-Perfusion
Intra Vascular Ultrasound (IVUS)
Zenith Dissection Clinical Study STABLE II Prospective nonrandomized study 67 patients 30 Global clinical centers Acute complicated Type B Dissection
Aortic Center of Excellence at Sentara High volume center Regionalize care Optimize outcomes Facilitate follow-up Easy access High Volume Quality
Aortic Center of Excellence at Sentara Protocols CTA Protocol Patient transfer Protocol Multidisciplinary Team Quality Outcomes Database Chronic Aortic Disease Management
Aortic Center of Excellence at Sentara Advanced Imaging CTA Chest Abdomen and Pelvis MRI/MRA TEE IVUS Carotid Duplex Head Neck CTA
Aortic Center of Excellence at Sentara Seamless Care Advanced Imaging Expert Evaluation Timely Intervention Long-term follow-up Coordinated and technologically advanced Multidisciplinary Team
Aortic Center of Excellence at Sentara 100 mile radius