Unravelling the Literature on Aortic Dissection Tara M Mastracci, MD FRCS(C) FACS MSc (HRM) FRCS 1
Disclosures Cook Medical Inc -- Proctorship and Consultation All speaking and consultation fees are donated to the Royal Free Trust Aortic Charity (Fund 187) www.royalfreecharity.org
A patient should never be considered cured of this disease. -- E. Stanley Crawford
Progression of our Understanding Advances in Imaging Advances in Critical Care TEVAR Description and Observation Surgery 1965 Medical Management 2013 INSTEAD ADSORB
Modern Dissection Success Depends on How We define Goals 5
Survival as a Goal of Treatment Fattori et al, 2008
Swedish National Health Care Data Incidence of reoperation at 10 years was 7.8% Olsson, Circulation 2006
Suddenly False Lumen Flow Is Important x
Is False Lumen Flow Important?
INSTEAD Trial Nienaber et al., Circulation 2009; 120: 2519-2528 At least 2 weeks after index dissection 597 Chronic AD 140 Enrolled for Randomization 293 Refused Randomization 164 Not Eligible 72 Pt OMT and TEVAR 68 Pt OMT 1 Pt Died before TEVAR 1 Opted out of OMT 2 Pt opted out of TEVAR
Progression of Disease: False Lumen Thrombosis
False Lumen Thrombosis in Modern Dissection Series Total False Lumen Thrombosis Partial False Lumen Thrombosis % Wiedemann 2014 8/110 25/110 30% 75%* 24/28 4/28 100% Zhu 2015 Huang 2015 69/72 NR 95% Cambria 2015 20/50 6/50 52% F/u 19m, 237/600pts 43/61 70% Brunkwall (ADSORB) 2014 48/72 5/72 74% Nienaber (INSTEAD XL) *Eggebrecht et al, Eu Heart J 2006
Remodelling Occurs But only reliably in the Stented portions of the aorta
% Survival 1 and 5y Survival: Medical Management 100 95 90 85 80 Winnerkvist 2006 Nino 2009 75 Estrera 2007 Chemelli-Steingruber 2010 70 65 Pooled 30d Mortality 6.4%** Garbade 2010 Miyahara 2011 Fattori (IRAD 2013) 60 55 50 1yr 5yr **Fattori et a 2013
% Survival 1 and 5y Survival: Medical and TEVAR 100 95 90 Winnerkvist 2006 Nino 2009 85 Estrera 2007 Chemelli-Steingruber 2010 80 Garbade 2010 Miyahara 2011 75 Fattori (IRAD 2013) Wiedemann 70 Nathan Fattori (IRAD) 65 Bockler 2009 Chemelli-Steingruber 2010 60 Khoynezhad 55 50 Pooled 30d Mortality (Surgical) 10.2%** 1yr 5yr Erlich
% Freedom from Aortic Events Freedom From Aortic Events: Both 100 90 80 70 60 50 40 30 20 10 Winnerkvist 2006 Nino 2009 Chemelli-Steingruber 2010 Miyahara 2011 Wiedemann Nathan Fattori (IRAD) Bockler 2009 Erlich Minanmi 2015 0 1y 5y
x
Blaming your parents if youre a bad cook
Modern Dissection Preventing Disease Progression by Stenting the Whole Aorta Embolizing the False Lumen 20
Modern Dissection Preventing Disease Progression by Stenting the Whole Aorta Embolizing the False Lumen 21
22
Progression of True Lumen 08/2011 08/2013 08/2012 02/2012
Using B/FEVAR in Chronic Dissection
Reoperation after B/FEVAR for Dissection Reoperation in 15/61 25% Kamman et al, 2016
Modern Dissection Preventing Disease Progression by Stenting the Whole Aorta Embolizing the False Lumen 26
Coil Embolization Hofferberth et al, JEVT 2012
Placement of Plugs/Occluders Idrees et al, JVS 2014
Custom Occlusion Device
Collected Experience: Embolization Author Journal/Year Embolic Agent N Hussain Annals 2015 Coils and glue 1 Coils, glue and occlusion Hofferberth JEVT 2012 balloons 10 Idrees JVS 2015 Occluders and other things 21 Kolbel JEVT 2016 Coils 2 Kolbel JEVT 2013 Candyplug 1 Mendes JEVT 2015 Amplatzer 1 Ogawa JEVT 2016 Candyplug 1 Hager JVS 2008 Coils and covered stents 1 Smith EVT 2009 Coils 1 Riga JVIR 2009 Coils and Onyx 1 Norberto JVS 2011 Coils 5
Collected Experience: Embolization Author Journal/Ye ar Embolic Agent N F/U (months) Hussain Annals 2015 Coils and glue 1 NR Hofferberth JEVT 2012 Coils, glue etc 10 63 Occluders and other Idrees JVS 2015 things 21 25 Kolbel JEVT 2016 Coils 2 NR Kolbel JEVT 2013 Candyplug 1 3 Mendes JEVT 2015 Amplatzer 1 18 Ogawa JEVT 2016 Candyblug 1 14 Hager JVS 2008 Coils and covered stents 1 NR Smith EVT 2009 Coils 1 9 Riga JVIR 2009 Coils and Onyx 1 24 Norberto JVS 2011 Coils 5 11
Collected Experience: Embolization Author Hofferberth Idrees Norberto Journ al/yea r JEVT 2012 JVS 2015 JVS 2011 Emboli c Agent Coils, glue etc Occluder s etc N F/U (m) Complete Thrombosi s Sac Size same or greater Sac Size Smaller 10 63 90% 10% 21 25 60% 62% (5mm) Coils 5 11 60% 40%
2013 x 2014 2015 2016
2013 x 2014 2015 2016
Remodelling Occurs But only reliably in the Stented portions of the aorta
Conclusions Dissections are tough The Goals of Treatment have changed Progression of Disease continues to be an issue, and current techniques may not completely remove the risk of aortic reintervention 36
A patient should never be considered cured of this disease. -- E. Stanley Crawford