Department of Cardiothoracic & Vascular SurgeryMcGovern Medical School / The University of Texas Health Science Center at Houston

Acute UncomplicatedType B Aortic Dissection:Type B Aortic Dissection:The UT HoustonExperience

Ali Azizzadeh, MDProfessor & ChiefProfessor & ChiefProgram Director in Vascular Surgery

Department of Cardiothoracic and Vascular SurgeryMcGovern Medical SchoolThe University of Texas Science Center at HoustonThe University of Texas Science Center at HoustonMemorial Hermann Heart & Vascular Institute

Disclosures

Consultant

WL Gore WL Gore

Medtronic

Epidemiology

10-15 cases/100,000adults/yearadults/year

2/3 type A

1/3 type B 1/3 type B

Acute Type B

30% Cx 30% Cx

70% UnCx 70% UnCx

Male: Female 2-5:1

Classifications of Dissection:Stanford and DeBakeyStanford and DeBakey

Treatment of ATBAD

3° Referral Center

Multi-specialty team: Multi-specialty team: CT, Vasc Surg

Critical care

Consultants Consultants

Advanced imaging: CT, MR, IVUS, TEE CT, MR, IVUS, TEE

Hybrid OR’s

Monitoring MEP, SSEP

Full spectrum of Full spectrum ofopen/endovascularproceduresprocedures

Protocol

Admit CVICUCVC, arterial line, UOP

Admit CVICUCVC, arterial line, UOPCVC, arterial line, UOPCVC, arterial line, UOP

B -BlockerB -BlockerAnti-impulse Therapy

SBP<120, HR<60Control pain

Anti-impulse TherapySBP<120, HR<60

Control pain

B -Blocker

Ca+2 Blocker

Nitroglycerin

B -Blocker

Ca+2 Blocker

Nitroglycerin

Respiratory

DVT prevent

Nutrition

Respiratory

DVT prevent

NutritionControl painControl painNitroprussideNitroprusside

Nutrition

Mobilization

Nutrition

Mobilization

Reassessment

Blood pressure

Pain

Reassessment

Blood pressure

PainPainPain

Protocol

Percutaneous InterventionSurgical Intervention

Percutaneous InterventionSurgical Intervention

Rupture/ LeakRupture/ LeakRupture/ LeakMalperfusion (renal, visceral, peripheral)

Acute ExpansionRefractory Symptoms

Rupture/ LeakMalperfusion (renal, visceral, peripheral)

Acute ExpansionRefractory SymptomsRefractory SymptomsRefractory Symptoms

Acute Type B Aortic Dissection

2000 to 2014

1079 pts AD

532 ATBAD 532 ATBAD

60% Male

Mean age 60.6 ± 13.6 yrs Mean age 60.6 ± 13.6 yrs

Median age = 60.5 yrs

Range 16 –98 yrs Range 16 –98 yrs

Average Follow up: 3.7 yrs

Aortic Dissection

1079 DISSECTIONS

Aortic Dissection

535 532535TYPE A

532TYPE B

1079 DISSECTIONS

Aortic Dissection

294

535

294UNCOMPLICATED

535TYPE A

238COMPLICATED

1079 DISSECTIONS

COMPLICATED

Complicated ATBAD

Rupture

Malperfusion: Malperfusion:

Neurologic

Spinal Cord Spinal Cord

Visceral (Celiac, SMA)

Renal Renal

Lower Limb

Refractory Pain & HTN Refractory Pain & HTN

Goals of TEVAR for cATBAD

Seal off proximal entry tear

Alleviate malperfusion

Expand compressed true Expand compressed truelumen

Induce false lumen thrombosis Induce false lumen thrombosis

Prevent/treat rupture

TEVAR DON’TS

Oversize >10%

Balloon Angioplasty Balloon Angioplasty

Place distal device first

IVUS

Adjunct to CTA,angiogram and TEEangiogram and TEE

Wire placement intrue lumen

Assesses adequacyof treatment

Guide additional Guide additionaltherapy

Diagnose Diagnosecomplications

Mortality by Management Strategy

Total = 444Uncomplicated

C o m p l i c a t e d ( N = 1 7 3 )OR,

Total = 444Uncomplicated

N=271OR,

p-valueMedN=69

OpenN=52

TEVARN=37

Other CVN=15

Mortality5 13 6 5 3

* 8.8, 0.0001Mortality5

1.9%13

18.8%6

11.5%5

13.5%3

20%* 8.8, 0.0001

* Uncomplicated compared to complicated type b aortic dissection

Survival at 5 yrs forSurvival at 5 yrs foruATBAD was 76.6%

Uncomplicated ATBAD

Early intervention appears reasonable in following scenarios:

• Initial aortic diameter ≥ 4.0cm with patent false lumen• Initial aortic diameter ≥ 4.0cm with patent false lumen

• ≥ 22mm false lumen in proximal DTA

• Proximal entry tear size >10mm• Proximal entry tear size >10mm

• Recurrent/refractory pain or HTN

• Well-designed, prospective, randomized trial needed• Well-designed, prospective, randomized trial needed

Purpose

To determine which factors predisposepatients with uncomplicated acute type Bpatients with uncomplicated acute type B

aortic dissections to worse outcomes,including mortality and need for intervention.including mortality and need for intervention.

Acute Type B Aortic Dissections

PATIENTS WITH ACUTE TYPE B DISSECTION532532

294 238UNCOMPLICATED294 COMPLICATED238

Inadequate120

InadequateImaging120

Abdominal11

156

IMH / PAU7

WITH ADEQUATE IMAGING DATA ANALYSIS156

Methods Measurement: Measurement: TeraRecon(Foster City, CA) Multi-planar reconstruction Multi-planar reconstruction Double orthogonal oblique

measures

Proximal descending aorta FL Proximal descending aorta FLdiameter and area: level ofmain pulmonary artery

Maximum aortic diameter on Maximum aortic diameter onadmission

Measurements by specializedcardiovascular radiologistcardiovascular radiologist

Overall Survival: Max AorticDiameterDiameter

Overall Survival: False LumenDiameterDiameter

Overall Survival: Age

Intervention-free Survival:Max Aortic DiameterMax Aortic Diameter

Intervention-free Survival:False Lumen DiameterFalse Lumen Diameter

Intervention-free Survival:Max Aortic Diameter (Quartiles)Max Aortic Diameter (Quartiles)

Intervention Rates

Overall Intervention rate:

>44mm: 34.4%

≤44mm: 11.3%

(OR 4.12, p=0.02) (OR 4.12, p=0.02)

The 1,5,and 10 year intervention rates

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≤44 4.8 13.3 13.3

Intervention Rates

Intervention Rate (%)

Admission Aortic 1 5 10Admission AorticDiameter (mm)

1year

5years

10years

>44 18.8 29.5 50.3>44 18.8 29.5 50.3

≤44 4.8 13.3 13.3

Overall Intervention rate:

>44mm: 34.4% >44mm: 34.4%

≤44mm: 11.3%

(OR 4.12, p=0.02)

The 1,5,and 10 year intervention rates

Incidence of Risk Factors in AUTBAD

Risk FactorsRisk Factors

TAD >44mm / FLD >22 / Age >60

1 Risk Factor 44%1 Risk Factor 44%

2 Risk Factors 19%

3 Risk Factors 6%

Total 69%

Conclusions

Aortic diameter >44mm is a predictor ofmortality after adjustment for significantmortality after adjustment for significantrisk factors.

Age >60 years is a risk factor for mortality.

Decreased intervention-free survival in Decreased intervention-free survival inthose with FL>22mm and/or max aorticdiameter >44mm on admission.diameter >44mm on admission.

Patients with Aortic diameter >44mm,FL>22mm, and/or age>60 should beFL>22mm, and/or age>60 should beconsidered for TEVAR.

Department of Cardiothoracic & Vascular SurgeryMcGovern Medical School / The University of Texas Health Science Center at Houston

The Impact of Arch Involvement in AcuteType B Aortic Dissection

Hunter M. Ray, Kristofer M. Charlton-Ouw, Anthony L. Estrera,Charles C. Miller, Hazim J. Safi, Ali Azizzadeh

Type B Aortic Dissection

Charles C. Miller, Hazim J. Safi, Ali Azizzadeh

Department of Cardiothoracic and Vascular SurgeryMcGovern Medical School / The University of Texas Science Center at HoustonMemorial Hermann Heart & Vascular Institute

Department of Cardiothoracic & Vascular SurgeryMcGovern Medical School / The University of Texas Health Science Center at Houston

Ascending Aortic Size is a Predictor ofOutcomes in Patients with Uncomplicated

Hunter M. Ray, Joseph M. Besho, Jason Au, Kristofer M.Charlton-Ouw, Anthony L. Estrera, Charles C. Miller, Hazim J.

Outcomes in Patients with UncomplicatedAcute Type B Aortic Dissection

Charlton-Ouw, Anthony L. Estrera, Charles C. Miller, Hazim J.Safi, Ali Azizzadeh

Department of Cardiothoracic and Vascular SurgeryMcGovern Medical School / The University of Texas Science Center at HoustonMcGovern Medical School / The University of Texas Science Center at HoustonMemorial Hermann Heart & Vascular Institute

Thank You