TEVAR for Type B Aortic Dissection Nahar Alanezi Vascular Surgeon King Fahad Medical City
Aortic Dissection
ďƒ˜ The estimated worldwide incidence of
aortic dissection is widely quoted as 5-30 per million per year
J Clin Basic Cardiol 2000;3:151
The breakdown of type of dissection has been estimated as 60-75%Type A and 25-40% Type B J Hypertens 2004;22:11-19
Type B Aortic Dissection Acute : within 14 days of onset of
symptoms Chronic : beyond 14 days of onset of symptoms Sub- acute :a time frame in which the risk of complications is diminished and during which early intervention may be beneficial (15-90 days)
Acute Type B Aortic dissection ďƒ˜ Uncomplicated ďƒ˜ Complicated
25-40% Rupture Intractable pain Refractory Hypertension Visceral ischemia Spinal ischemia Limb ischemia
Sub acute and Chronic Type B Aortic Dissection Uncomplicated
Complication
Patients who survive the acute uncomplicated phase often suffer late complication New dissection with related complications Aneurysmal degeneration
IRAD : International Registry of Acute Aortic Dissection Frequently fatal Overall mortality 28% Complicated
32% Uncomplicated 11%
What is the optimal treatment strategy for patient with Type B Aortic Dissection ?
Type B Aortic Dissection Best Medical Therapy BMT Endovascular Surgery
Rationale ďƒ˜ Improving the natural history of the Type B
Aortic Dissection
The evidence
Randomized trials ……best evidence
Registries and personal series ……large amount of work ,generally confounded by independent scrutiny
From the first procedure, the subsequent use of TEVAR for this indication had grown without comprehensive evaluation of it’s benefit and risks Only one completed
randomized trial of
TEVAR vs. BMT NO Randomized trial of TEVAR vs. open repair
TEVAR for type B Aortic Dissection Cover the entry tear Prevent blood from
entering the proximal
dissection False lumen thrombosis Aortic remodeling In the setting of malperfusion :re establish flow in the true lumen allows the blood flow to enter the visceral vessels and often treat the malperfusion
Long term aim of TEVAR in type B aortic dissection to prevent: Early rupture of the dissection Progression of the dissection Late aneurysmal formation
BMT 140 patients with stable type B Aortic Dissection TEVAR+BMT J Thorac Cardiovasc Surg 2010;140:s101-8
Systematic evidence review Identification of evidence gaps in-depth
discussion in areas where evidence is contradictory Development of graft clinical practice recommendation unrestricted educational grants from Medtronic,Inc
183 Publications 3,928 patients treated with BMT 6,882 patients treated with open surgery 7,631 patients treated with TEVAR unrestricted educational grants from Medtronic,Inc
Complicated Acute Type B Aortic Dissection No RCT Number of small series have lent to the
collective experience Two large meta- analysis
Meta- analysis studies ďƒ˜ Outcome of endovascular treatment of
acute Type B Aortic dissection Parker JD,Golledge J Ann Thorac Surg.2008.Nov;86(5):1707-12
ďƒ˜ Endovascular stent graft placement with
type B aortic dissection: a meta-analysis in china Xiong et al J Thoracic Cardiovasc Surg.2009. Oct;138(4)865-72
Meta- analysis studies Two different patient population Excellent technical success Low complication rates High success rates of false lumen
thrombosis
TEVAR for Complicated Acute Type Aortic Dissection Feasible approach Available Data …support
the use of
TEVAR Adjunct procedure in malperfusion setting e.g. aortic fenestration /branch artery stent grafting
Uncomplicated Acute Type B Aortic Dissection ADSORB (Acute Dissection stent- graft or • • • •
Best Medical Treatment Trial) currently enrolling patients in Europe 270 patients Acute <2 weeks uncomplicated Primary endpoints: false lumen thrombosis, aortic rupture, aortic dilatation
Uncomplicated Type B Aortic Dissection INSTEAD(INvestigation of STEnt • • • •
graft in patients with type B Aortic Dissection) European randomized trial 140 patients Uncomplicated type Aortic Dissection 2-52 weeks Talent graft
Figure 3. A, Kaplanâ&#x20AC;&#x201C;Meier estimates of 2-year overall cumulative survival rate in both groups; P=0.15 by log-rank test.
Nienaber C A et al. Circulation 2009;120:2519-2528
Copyright Š American Heart Association
Cochrane Database
Uncomplicated type B aortic dissection Even with the comprehensive rationale
,the Benefit of TEVAR for uncomplicated type B aortic dissection is not yet proven yet Technical improvement are awaited More evidence is needed
Indication of TEVAR in chronic Type B Aortic Dissection Aortic diameter >5.5-6 cm Symptoms (size or ischemia related ) Growth rate >1 cm
/year
Summary ď&#x192;&#x2DC; Complication- specific approach instead of
endovascular surgery for all type B Aortic Dissection
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Thank you