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