High Risk Uncomplicated Type B Dissection - Ali Azizzadeh, …€¦ · High Risk Uncomplicated Type...
Transcript of High Risk Uncomplicated Type B Dissection - Ali Azizzadeh, …€¦ · High Risk Uncomplicated Type...
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
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
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
Percutaneous Intervention
Surgical Intervention
Rupture/ Leak
Malperfusion (renal, visceral, peripheral)
Acute Expansion
Refractory Symptoms
Protocol
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
Aortic Dissection
1079 DISSECTIONS
Aortic Dissection
1079 DISSECTIONS
535 TYPE A
532 TYPE B
Aortic Dissection
1079 DISSECTIONS
535 TYPE A
294 UNCOMPLICATED
238 COMPLICATED
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
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
Overall Survival: Max Aortic
Diameter
Overall Survival: Age
Intervention-free Survival:
Max Aortic Diameter
Intervention-free Survival:
False Lumen Diameter
Intervention-free Survival:
Max Aortic Diameter (Quartiles)
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
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%
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.
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
Methods
Contrast enhanced CT
imaging
TeraRecon(Foster City, CA)
Multi-planar reconstruction
Measurements by
cardiovascular radiologist
Max ascending diameter
Max ascending area
Proximal Aortic Intervention as predicted by Max Ascending Aortic
Area
Proximal Aortic Intervention as predicted by Max
Ascending Aortic Diameter
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)
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)
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
Thank You