Extended Arch Techniques for Acute Aortic Dissection: a systematic review and classification Holly Smith PGY2 Thoracic Aortic Rounds, Foothills Hospital September 25, 2015 Libin Cardiovascular Institute of Alberta University of Calgary
Outline Background Classification system Results of a systematic review of the data The Calgary experience Future directions
Case 49M presented to hospital feelings as though he s been hit in the chest with a hammer PMHX: HTN, smoker, dyslipidemia HR 95, BP 100/70, SpO2 93% ORA O/E: tender abdomen Lactate = 4
Initial CT
Initial CT
Initial CT
What operation would be the most appropriate for this patient?
Type A Aortic Dissection High morbidity and mortality Requires surgical correction Current standard is to resect the intimal tear, reconstruct proximal arch, and deal with complications Overall results are sub-optimal
Registry Data IRAD 2005: operative mortality 25.1% GERAADA 2015: operative mortality 16.9% CTAC 2015: operative mortality 17.8%
We are improving, but not enough Pape 2015 J Am Coll Cardiol
Long term results Ten year survival estimates vary Geirsson (2007 Ann Thorac Surg): 46% Olsson (2013 J Vasc Surg): 64% Fattouch (2009 Ann Thorac Surg): 60% if false lumen remains patent but 90% if false lumen occluded Reoperation ~20% at 10 years
Who does this happen to? Tsai 2006 Circulation
The problem High short term morbidity and mortality that has remained relatively stagnant + Compromised long term survival
How can we improve short term and long term outcomes in these patients?
A solution? Select centres around the world are trying different types of operations Extended arch replacement may improve long term prognosis without a rise in short term morbidity and mortality More surgery = better results?
Classification of Surgical Technique
Type 0 Total arch replacement without stent graft
Rylski (2014) Total arch vs. hemiarch vs. ascending aortic replacement No significant difference in hospital mortality J Thorac Cardiovasc Surg
Type 1 Total arch plus frozen elephant trunk Stent graft is placed through open arch at time of circulatory arrest
Uchida (2011) 80 patients Patients were younger or had a distal entry tear 10 year survival was 75% with freedom from reoperation of 95% Compared to hemi-arch replacement, with a long term survival benefit Eur J Cardiothorac Surg
Tsagakis (2010) 68 patients implanted with the E-Vita graft Hospital mortality = 13% J Thorac Cardiovasc Surg
Type 2 Hemi-arch plus frozen elephant trunk Stent graft is placed through open arch at time of circulatory arrest
Pochettino (2009)
Pochettino (2009) Type 2 compared to standard repair no significant difference in: Mortality (14% vs 14%) Stroke (3% vs 10%) SCI (8% vs 2%) Re-intervention (25% vs 12%) Ann Thorac Surg
Chen (2015) Triple branched stent graft place under direct visualization then deployed J Thorac Cardiovasc Surg
Chen (2015)
Type 3 Total arch plus warm elephant trunk Stent is placed after coming off CPB with aid of fluoroscopy
Chang (2013) Single stage operation 21 patient cohort with one death (4.8%) J Thorac Cardiovasc Surg
Chang
Systematic review 596 studies identified 37 studies met inclusion criteria for final review
Recall the registry data.. IRAD 2005: operative mortality 25.1% GERAADA 2015: operative mortality 16.9% CTAC 2015: operative mortality 17.8%
Total arch replacement
Total arch replacement Study No of patients Hospital Mortality (%) Stroke (%) SCI (%) Cho (2009) 28 1 (3.6) 3 (10.7) 1 (3.6) Di Eusanio (2015) 53 12 (22.6) 4 (7.5) - Kim (2011) 44 6 (13.4) 10 (22.7) 1 (2.3) Ochiai (2005) 46 3 (6.5) 1 (2.2) 0 Rylski (2014) 14 4 (28.6) 1 (7) - Shiono (2006) 29 2 (6.9) 3 (10.3) - Takahara (2002) 37 3 (8.1) 0 2 (5.4) Tan (2003) 17 4 (23.5) - - Watanuki (2007) 54 2 (3.7) 3 (5.6) - TOTAL 322 37 (11.5) 25 (8.2) 4 (2.6)
Total arch plus FET
Total arch plus FET Study No of patients Hospital Mortality (%) Stroke (%) SCI (%) Chen (2010) 28 4 (14.3) 3 (10.7) - Katayama (2015) 120 7 (5.8) 4 (3.3) 2 (1.7) Liu (2008) 15 1 (6.7) 2 (13.3) - Lu (2015) 21 2 (9.5) 0 0 Ma (2013) 398 31 (7.8) 10 (2.5) 10 (2.5) Mizuno (2002) 9 1 (11.1) 1 (11.1) 2 (22.2) Shen (2012) 22 2 (9.1) 0 1 (4.5) Shi (2014) 41 3 (7.3) 0 0 Shi (2014) 84 5 (5.9) 0 0 Shrestha (2015) 52 8 (15.4) 6 (11.5) 2 (3.8) Uchida (2011) 80 4 (5) 2 (2.5) 0 Xiao (2014) 33 6 (18.2) 0 0 Yang (2014) 86 5 (5.8) 2 (2.3) 2 (2.3) TOTAL 989 79 (8.0) 30 (3.0) 19 (2.0)
Hemi-arch plus FET
Hemi-arch plus FET Study No of patients Hospital Mortality (%) Stroke (%) SCI (%) Chen (2014) 122 6 (4.9) 2 (1.6) - Chen (2015) 105 5 (4.8) 2 (1.9) 0 Fleck (2002) 8 1 (12.5) 0 0 Hua (2013) 34 2 (5.9) 0 2 (5.9) Jakob (2008) 22 2 (9.1) 2 (9.1) - Pan (2013) 27 0 - - Panos (2005) 5 0 0 - Pochettino (2009) 36 5 (13.9) 1 (3) 3 (9) Preventza (2014) 25 3 (12) 3 (12) 2 (8) Roselli (2013) 17 0 2 (11.8) 2 (11.8) Shen (2012) 16 1 (6.2) 0 1 (6.2) Shi (2014) 54 2 (3.7) 0 0 Shi 2 (2014) 71 3 (4.2) 0 0 Vallabhajosyula (2014) 62 6 (9.7) 3 (4.8) 0 TOTAL 604 36 (6.0) 15 (2.6) 10 (2.3)
Total arch plus warm ET
Total arch plus warm ET Study No of patients Hospital Mortality (%) Stroke (%) SCI (%) Chang (2013)* 21 1 (4.8) 0 0 Esposito (2015) 89 8 (8.9) 3 (3.4) 0 Glauber (2011) 23 1 (4.3) 0 - Marullo (2010) 24 1 (4.2) 0 - TOTAL 157 11 (7.0) 3 (1.9) 0
Summary of results Surgical Technique Hospital Mortality (%) Stroke (%) SCI (%) Total Arch 11.5 8.2 2.6 Total Arch plus FET Hemi arch plus FET Total arch plus warm ET 8.0 3.0 2.0 6.0 2.6 2.3 7.0 1.9 0
2014 ESC Guidelines
The Calgary Experience Kent (2014) published results of 20 patients J Thorac Cardiovasc Surg
The Calgary Experience Hospital mortality = 5% Stroke = 5% SCI = 20% All transient
Back to the case
Procedure Performed Total arch replacement with warm elephant trunk New approach: Zone 2 arch replacement
Intraoperative angiogram
Intraoperative angiogram
Post-operative CT
Post-operative CT
Summary Extended arch surgery for type A dissection has comparable peri-operative mortality to established registry data These results are based on early data There is a substantial learning curve Further study is needed to compare techniques
Thank you!