high risk uncomplicated type b dissection - ali azizzadeh, …€¦ · high risk uncomplicated type...
TRANSCRIPT
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High Risk Uncomplicated Type B Dissection
Ali Azizzadeh, MD, FACS
Director, Vascular Surgery Vice Chair, Department of Surgery Associate Director, Heart Institute Cedars-Sinai Medical Center Los Angeles, CA
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Treatment of ATBAD
3° Referral Center
Multi-specialty team:
CT, Vasc Surg
Critical care
Consultants
Advanced imaging:
CT, MR, IVUS, TEE
Hybrid OR’s
Monitoring MEP, SSEP
Full spectrum of
open/endovascular procedures
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Admit CVICU
CVC, arterial line, UOP
Anti-impulse Therapy
SBP<120, HR<60
Control pain
B-Blocker
Ca+2 Blocker
Nitroglycerin
Nitroprusside
Respiratory
DVT prevent
Nutrition
Mobilization
Reassessment
Blood pressure
Pain
Protocol
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Percutaneous Intervention
Surgical Intervention
Rupture/ Leak
Malperfusion (renal, visceral, peripheral)
Acute Expansion
Refractory Symptoms
Protocol
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Acute Type B Aortic Dissection
2000 to 2014
1079 pts AD
532 ATBAD
60% Male
Mean age 60.6 ± 13.6 yrs
Median age = 60.5 yrs
Range 16 – 98 yrs
Average Follow up: 3.7 yrs
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Aortic Dissection
1079 DISSECTIONS
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Aortic Dissection
1079 DISSECTIONS
535 TYPE A
532 TYPE B
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Aortic Dissection
1079 DISSECTIONS
535 TYPE A
294 UNCOMPLICATED
238 COMPLICATED
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Acute Type B Aortic Dissections
PATIENTS WITH ACUTE TYPE B DISSECTION 532
UNCOMPLICATED 294 COMPLICATED 238
WITH ADEQUATE IMAGING DATA ANALYSIS 156
Inadequate Imaging 120
Abdominal 11
IMH / PAU 7
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Methods Measurement:
TeraRecon(Foster City, CA)
Multi-planar reconstruction
Double orthogonal oblique measures
Proximal descending aorta FL diameter and area: level of main pulmonary artery
Maximum aortic diameter on admission
Measurements by specialized cardiovascular radiologist
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Overall Survival: Max Aortic
Diameter
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Overall Survival: Age
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Intervention-free Survival:
Max Aortic Diameter
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Intervention-free Survival:
False Lumen Diameter
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Intervention-free Survival:
Max Aortic Diameter (Quartiles)
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Intervention Rates
Overall Intervention rate:
>44mm: 34.4%
≤44mm: 11.3%
(OR 4.12, p=0.02)
Intervention Rate (%)
Admission Aortic Diameter (mm)
1 year
5 years
10 years
>44 18.8 29.5 50.3
≤44 4.8 13.3 13.3
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Incidence of Risk Factors in
AUTBAD
Risk Factors
TAD >44mm / FLD >22 / Age >60
1 Risk Factor 44%
2 Risk Factors 19%
3 Risk Factors 6%
Total 69%
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Conclusions
Aortic diameter >44mm is a predictor of mortality
after adjustment for significant risk factors.
Age >60 years is a risk factor for mortality.
Decreased intervention-free survival in those with
FL>22mm and/or max aortic diameter >44mm
on admission.
Patients with Aortic diameter >44mm, FL>22mm,
and/or age>60 should be considered for TEVAR.
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Cohort
6/2000 to 1/2015
294 uATBAD
245 any available CT
131 CTA available for review
60% male
53% caucasian
Mean age 60.9 ±13.4 years
Median follow up: 6.9 years
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Methods
Contrast enhanced CT
imaging
TeraRecon(Foster City, CA)
Multi-planar reconstruction
Measurements by
cardiovascular radiologist
Max ascending diameter
Max ascending area
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Proximal Aortic Intervention as predicted by Max Ascending Aortic
Area
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Proximal Aortic Intervention as predicted by Max
Ascending Aortic Diameter
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Proximal Aortic Interventions
24 pts total aortic interventions on f/u
6 pts proximal aortic intervention
5: Type A dissection Repair
1: Ascending/ Arch Aneurysm Repair
Need for proximal aortic intervention
predicted by
Max asc area >12.1cm2 (p<0.03)
Max asc diameter >40.8mm (p=0.03)
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Stratified Analysis: Intervention-
free Survival
Max Ascending Aortic Diameter > 40.8mm (HR
2.01, p=0.04)
Max Ascending Aortic Area >12.1cm2 (HR 1.99,
p=0.04)
Controlled for:
Max Aortic Diameter along aorta >44mm (HR 3,
p<0.01)
Syncope on admission (HR 26, p<0.01)
Pleural effusion on admission (HR 3, p<0.01)
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Conclusion uATBAD patients w/ max asc area >12.1 cm2
and/ or max asc diameter >40.8mm on admission are at high risk of subsequent arch/proximal progression
Ascending aortic size (diameter and area) predicts decreased intervention-free survival in uATBAD
Max aortic diameter >44mm predicts increased mortality
Patients with these high-risk characteristics may benefit from closer follow-up or earlier intervention with TEVAR
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Thank You