Acute non-complicated TBD Do need TEVAR treatment Prof. Dr. med. Christoph A. Nienaber Universität Rostock Universitäres Herzzentrum christoph.nienaber@med.uni-rostock.de
Survival in type B dissection by acuity Booher M et al., Am J Med 2013
Type B aortic dissection: Survival and predictors Hypotension/Shock Malperfusion Tsai T, Nienaber C, et al. Circulation 2006, 114:2226-2231
Medical: Survival after acute type B aortic dissection Acosta S, et al., Annals of Vascular Surgery 2007; 21:415-422
Uncomplicated type B dissection over time Jia X et al. J Vasc Surg. 2013
ADSORB: Acute uncomplicated type B dissection / 1 year Mortality ADSORB trial No need for SG in first 2 weeks of uncomplicated type B dissection
Remodeling after Stentgraft 90% remodeling with TEVAR (p 0.001) after 2 years Nienaber CA et al. Circulation 2009;120:2519-2528
Prospective RCT: Subacute type B dissection Stable type B Dissection: INvestigation of... instead...? STEnt-grafts in Aortic Dissection pre post Optimal medical treatment versus stent-graft + OMT
INSTEAD: Subacute uncomplicated type B dissection Primary endpoint 29.08.2003 05.09.2003 06.09.2004 All-cause mortality at 2 years Secondary endpoints Thrombosis of False Lumen Degree of Aortic Expansion Cardiovascular morbidity Quality of life Lenght of ICU and hospital stay Crossover Nienaber CA et al. Circulation 2009;120:2519-2528
INSTEAD: Time from Impact to Randomization
INSTEAD: 2 years-outcomes after TEVAR in uncomplicated patients @ I year crossover rate @ 2 years crossover rate 14% (p=0.02) 20% (p=0,02) Nienaber C, Rousseau H, et al. Circulation. 2009 Dec 22;120(25):2519-28
Medical management: False Lumen diameter: if FL < 22 mm Two patients with a small initial false lumen diameter at the upper descending thoracic aorta showed a complete resorption of the false lumen (left) or did not show an aneurysm for approximately 3 years (middle), while another patient with a large initial false lumen diameter developed an aorta aneurysm after approximately 2.5 years (right). Song JM, et al. JACC 2007; 50:799 804
Medical therapy: False lumen is completely thrombosed 31.6% mortality @ 3 years 22.6% mortality @ 3 years Tsai T, Evangelista A, Nienaber C et al., N Engl J Med. 2007 Jul 26;357(4):349-59
Current considerations Useful tools: + Functional imaging - TEE with color doppler interogation - TEE with contrast - Dynamic 4D-MRI - FDG-uptake on PET + Hemodynamics + Integration of Biomarkers - Serial d-dimer (>500 µg/l) - MMP-9 - SM myosin heavy chains
Medical therpay: In absence of Local Inflammation, Partial FL thrombosis Partial FL thrombosis Expanding FL Ongoing metabolic activity on FDG-PET Rupture? Nienaber C et al. Circ Cardiovas Imaging 2009; 2:499-506
Low risk without inflammation on medical therapy FDG Favourable outcome FDG + Unfavourable outcome (rupture progression) Kato et al, J Nucl Med 2010
Medical therapy: In presence of small entries rather than one large entry Entry tear of aortic dissection visualized by 2-dimensional (left) and color-doppler (right) TEE Type B dissection with an entry tear located in the proximal part of the descending aorta (arrow) by tranverse view Type A dissection with an entry tear in the proximal part of the residual dissection (arrow) in the upper ascending aorta by longitudinal view Evangelista et al, Circulation 2012;125:3133-3141
Long-term outcome of aortic dissection (Large, >15 mm) Cumulative survival free from sudden death and surgical/endovascular treatment by entry tear size Evangelista et al, Circulation 2012;125:3133-3141
Long-term outcome of aortic dissection (repair) Cumulative survival free from sudden death and surgical/endovascular treatment by entry tear pattern (size and location) Evangelista et al, Circulation 2012;125:3133-3141
INSTEAD at high risk! Primary endpoint 29.08.2003 05.09.2003 06.09.2004 All-cause mortality at 2 years Secondary endpoints Thrombosis of False Lumen Degree of Aortic Complication Expansion Cardiovascular according morbidity to recent criteria Quality of life Lenght of ICU and hospital stay Crossover Nienaber CA et al. Circulation 2009;120:2519-2528
INSTEAD-XL / Landmark analysis Mortality (1st EP) Nienaber CA et al, Circ Cardiovasc Interv. 2013
INSTEAD-XL / Landmark analysis Progression (2nd EP) Nienaber CA et al, Circ Cardiovasc Interv. 2013
Longterm outcomes in IRAD TEVAR vs. medical management of type B dissection JACC (in press)
Medical: Survival after acute type B aortic dissection --- INSTEAD SG INSTEAD Medical Acosta S, et al., Annals of Vascular Surgery 2007; 21:415-422
Rethinking TEVAR for Dissection Long-term follow-up of INSTEAD-XL and IRAD in type B aortic dissection reveals: - Uncomplicated type B dissection is a misnomer, is not stable and medical management is not safe - Isolation of the false lumen leads to remodeling to avoid new (late) acute scenarios - Successful remodeling (usually completed after 2 years) ensures longterm stability - Preemptive TEVAR in type B dissection sets the stage for remodeling and will become a therapeutic option for all candidates with a reasonable life expectancy
Nevertheless. INSTEAD-XL and IRAD-LT encourages stent-graft induced remodeling in any type B aortic dissection Ann Thorac Surg 2008
Rethinking TEVAR for Dissection Are there patients that should be treated with medical therapy alone?...may be a few! - Stable chronic patients with complete False Lumen thrombosis (IRAD; NEJM 2007) - Stable chronic patients with tiny entry tears (<10mm) and no FL expansion (Evangelista et al., Circulation 2012; Song et al., JACC 2007) - Stable patients with a life expectancy of less than 2 years (INSTEAD-XL, Circulation CVInt 2013) - Stable chronic dissection without FDG-uptake on PET imaging LIEGE/Rostock project (under review) - Need for proximal arch/zone 0 debranching/consider open surgery or branched TEVAR (Bünger et al., JVS 2013)
Unmet needs of current classification of aortic dissection What is relevant and who is at Risk? Anatomic Involvement of Aorta - Associated Dysfunction (AR, PE ) Time domain - Acuity versus Chronicity Relevant complications - Malperfusion, rupture, inflammation, pain Impact on outcomes & prognosis - Risk / benefit ratio Suitibility for Repair - Individualized score Contraindication for endovascular Options This mnemonic list maybe important!