Vascular

Peter Lin, MD

Southern Association for Vascular Surgery

2007 Postgraduate CourseSan Juan, Puerto Rico

Penetrating Ulcer and Aortic Dissection

Peter H. Lin, MD

Baylor College of Medicine

Houston, TX

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Vascular

“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Presentation Outline

• Thoracic Aortic Pathology

• Aortic Dissection

• Classification

• Treatment Strategy

• Medical

• Stent-grafting

• Fenestration

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Vascular

“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Acute Aortic Syndrome

•Aortic dissection

• Limited intimal tear with eccentric bulge

•Intramural hematoma

• Pre-dissection ?

• Associated with penetrating ulcer

•Penetrating ulcer

•Traumatic transection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Hayter RG, Radiology 2006; 238:841-852

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Suspected Acute Aortic SyndromeMDCT in 373 Emergency Evaluation

•N=365 patients; men: 56%; women: 44%

•Mean age: 61 years (range 21 to 96); men: 61; women: 69

•67 cases (18%) positive for acute aortic disorders (n=112)

• 23 (34%) acute aortic dissections; A=13 (19%), B=10 (15%)

• 14 (21%) acute aortic IMH; A=1 (2%), B=13 (19%)

• 20 (30%) acute penetrating ulcer; A=3 (5%), B=17 (25%)

• 44 (67%) new or enlarging aortic aneurysms

• 11 (17%) acute aortic ruptures

•Overall hospital mortality: 6% (4/67); A=2; B=2; 3/4 ruptured

Hayter RG, Radiology 2006; 238:841-852

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Diagnosis of Chest Pain in the ER.

0% 5% 10% 15% 20% 25%

Percentage

Aortic dissection

No clear diagnosis

Cardiac arrhythmia

Vasovagal

Pulmonary disease

Neuro-radicular pain

Acute coronary syndromes

ED Diagnosis

von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Presentation Outline

• Thoracic Aortic Pathology

• Aortic Dissection

• Classification

• Treatment Strategy

• Medical

• Stent-grafting

• Fenestration

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Acute Aortic Dissection

• Most common aortic emergency

• Incidence double that of ruptured

abdominal aortic aneurysms

• Without treatment, 36-72% of patients

will die within 48 hours (one week

mortality of up to 91% )

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Aortic Dissection

• Classic presentation includes acute-onset, severe chest/back pain described as “tearing” or “ripping”

• Atypical presentations are common

• 15% of patients report NO pain

• Supportive findings include pulse deficit, new aortic regurgitation, tamponade, and focal neurological deficits

• Majority of patients have no specific physical findings

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Aortic Dissection: CXR Findings

0 10 20 30 40 50 60 70 80

Sensitivity (%)

Displaced intimalcalcification

Pleural effusion

Wide mediastinum

Abnormal aortic contour

Ch

est

X-R

ay F

ind

ing

s

Klompas M. JAMA. 2002;287:2262-72.

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Abnormal CXR finding – a 1-cm separation between the intimal calcification and the adventitial outline of the descending aorta (the “calcium sign”), consistent with aortic dissection.

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Transesophageal Echocardiography of Aortic Dissection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Presentation Outline

• Thoracic Aortic Pathology

• Aortic Dissection

• Classification

• Treatment Strategy

• Medical

• Stent-grafting

• Fenestration

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

•Stanford Type A / DeBakey Type II

Classification

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

•Stanford Type B / DeBakey III

Classification

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Classification of Aortic Dissection

1. Classic with true and false lumens separated by intimal flap

2. Medial disruption with intramural hematoma or hemorrhage

3. Discrete/subtle aortic dissection bulge at tear site with no hematoma

4. Plaque rupture/penetrating aortic ulcer

5. Iatrogenic and traumatic dissection

Task force on aortic dissection, European Society of Cardiology, Eur Heart J 2001;22: 1642-81

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Class 1: Classic dissection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Aortic Dissection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Class 2: Intramural hematoma

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

   Intramural Hematoma

In contrast to typical aortic dissection, in which there is an intimal tear, IMH is caused by a spontaneous hemorrhage of the vasa vasorum of the medial layer, which weakens the media without an intimal tear.

Clinical manifestations and the risk factors in IMH are similar to those in typical aortic dissection. IMH accounts for approximately 13% of the prevalence of acute aortic dissection .

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Intramural Hematoma

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Class 3: Discrete/subtle dissection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Class 4: Penetrating ulcer

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Class 4: Penetrating ulcer

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Penetrating Ulcer

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Class 5: Iatrogenic/traumatic

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Presentation Outline

• Thoracic Aortic Pathology

• Aortic Dissection

• Classification

• Treatment Strategy

• Medical

• Stent-grafting

• Fenestration

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Initial Treatment of Type B Dissection

•Initial treatment: hypotensive medication

•Reserve intervention for 30-40% with:

• Rupture

• End-organ ischemia / malperfusion

• Localized false aneurysm

• Refractory hypertension

• Continuing pain

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Initial Medical Therapy

• Pain control: opiates

• Heart Rate control: Labetalol (bolus & maintenance)

• Heart Rate < 70

• BP control: Nipride (Target SBP< 110, DBP<70)

• Monitor hemodynamics, UOP, swan ganz catheter placement, pulses

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Initial Treatment of Type B Dissection

•Initial treatment: hypotensive medication

•Reserve intervention for 30-40% with:

• Rupture

• End-organ ischemia / malperfusion

• Localized false aneurysm

• Refractory hypertension

• Continuing pain

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Mechanisms Involved in Aortic Dissection Type B

•Primary tear: usually close to the aortic isthmus

•End-organ ischemia:

• Static obstruction from extension of dissection into side branches

• Dynamic obstruction from the intimal flap bowing into the true lumen

• Combination of static and dynamic obstruction

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

MALPERFUSION MICHIGAN CLASSIFICATION

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

TREATING MALPERFUSION

• DYNAMIC OBSTRUCTION

• ENDOGRAFT ACROSS INTIMAL TEARS

• FENESTRATION

• STATIC OBSTRUCTION

• STENTS FOR UNCOMPLICATED STENOSIS

• WITH MECHANICAL THROMBECTOMY FOR STENOSIS COMPLICATED BY POST-OBSTRUCTIVE THROMBOSIS OF TRUE LUMEN OR EMBOLISM TO TRUE LUMEN

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

TX – Endografing vs. Fenetration

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Tx – Stenting for uncomplicated stenosis

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Endovascular Treatment

• Decreases pressure in false lumen by obliterating flow

• Causes thrombosis of the false lumen which is associated with good long term outcome

• Should treat dynamic obstruction of branches

• Can help with static obstruction of branches

• Induction of aortic remodeling

•Primary tear: cover with stent graft

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Thoracic Stent-Grafting for Dissection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Thoracic Stent-Grafting for Dissection

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Thoracic Stent-Grafting for PU

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Thoracic Stent Grafts

•TAG, WL Gore & Associates

• Nitinol stent with polytetrafluoroethylene

•Talent, Valiant, Medtronic AVE

• Nitinol stent with polyester

•TX-2, Cook Inc.

• Stainless steel with polyester

•Endofit, Endomed Inc.

• Nitinol stent with polytetrafluoroethylene

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Thoracic Stent-Graft

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Zenith Thoracic Stent-Graft

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Fenestrated Thoracic Endograft

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Endovascular Treatment(Non-endograft option)

•Static obstruction: uncovered stents in origin

of branches

•Dynamic obstruction: percutaneous fenestration of

the intimal flap

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

WHAT FENESTRATION DOES

• CREATES HOLE IN THE FLAP SEPARATING FALSE

AND TRUE LUMEN

• RAISES PRESSURE IN THE TRUE LUMEN

• PROMOTES FLOW IN THE FALSE LUMEN

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

WHAT FENESTRATION DOES NOT DO

•DOES NOT REDUCE PRESSURE IN THE FALSE LUMEN

• DOES NOT “DECOMPRESS” THE FALSE LUMEN

• DOES NOT MODIFY THE RISK OF ACUTE AORTIC RUPTURE IN

TYPE A DISSECTIONS

• DOES NOT REDUCE LONG-TERM ANEURYSMAL DEGENERATION

OF THE FALSE LUMEN

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Fenestration & stents = Rx for malperfusion

• Static obstruction (S)

• Aortic obstruction due to thrombosing false lumen (F/S)

• Dissection presenting with paraplegia

• Dynamic obstruction when entry tear is unsuitable for

endografts (F/S)

• tear in ascending aorta or arch

• dissections with entry

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

FENESTRATIONCONTRAINDICATIONS

• Sever aortic insufficiency

• Leaking false lumen

• Coronary artery dissection with MI or right heart failure

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Eggebrecht et al, Heart 2003: 89: 973

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

•A 61 y/o male with acute

type B thoracic dissection.

•Despite of maximal medical

therapy, he developed right

leg arterial occlusion.

•Endovascular fenestration

was performed

Eggebrecht et al, Heart 2003: 89: 973

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

•Endovascular fenestration

was performed.

•Right groin access and

intimal flap was punctured at

the aortic bifurcation using a

Brockenborough needle into

the false lumen. PTA was

performed to enlarge the

intimal fenestrated site

Eggebrecht et al, Heart 2003: 89: 973

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

•Although balloon PTA has

reestablished the flow to the

right leg, the flow remained

impaired.

•A 14 stent was placed from

the aorta into the right

common iliac artery.

•His right leg perfusion was

restored.Eggebrecht et al, Heart 2003: 89: 973

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

•Uncomplicated type B aortic dissection should be treated with medical therapy

•Symptomatic type B aortic dissection refractory to medical intervention should undergo repair

• Open surgical repair – physiologically suitable patients

• Aortic stent-graft – to cover entry site

• Stent – to treat static obstruction

• Fenestration – to treat dynamic obstruction

CONCLUSIONS

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Endovascular Treatment Principles

yes no

fenestration

prolonged malperfusion?

A Bsurgical medical

Suitable entry tear?

endograft

yes no

dissection type?

residual malperfusion?

no yes

Goals: Treatment of malperfusion and thrombosis of false lumen

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“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD

Be Prepared and Know Your Tools