Transcript Slide 1

Southern Association for Vascular Surgery
Vascular
2007 Postgraduate Course
San Juan, Puerto Rico
Penetrating Ulcer and Aortic
Dissection
Peter H. Lin, MD
Baylor College of Medicine
Houston, TX
Peter Lin, MD
Presentation Outline
Vascular
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
VASCULAR
• Medical
• Stent-grafting
• Fenestration
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
Acute Aortic Syndrome
•Aortic dissection
• Limited intimal tear with eccentric bulge
•Intramural hematoma
• Pre-dissection ?
• Associated with penetrating ulcer
VASCULAR
•Penetrating ulcer
•Traumatic transection
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
VASCULAR
Hayter RG, Radiology 2006; 238:841-852
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Suspected Acute Aortic Syndrome
Vascular
MDCT 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%)
• VASCULAR
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
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Diagnosis of Chest Pain in the ER.
Vascular
Acute coronary syndromes
Neuro-radicular pain
Pulmonary disease
ED Diagnosis
Vasovagal
Cardiac arrhythmia
VASCULAR No clear diagnosis
Aortic dissection
0%
5%
10%
15%
20%
25%
Percentage
von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Presentation Outline
Vascular
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
VASCULAR
• Medical
• Stent-grafting
• Fenestration
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Acute Aortic Dissection
Vascular
•
Most common aortic emergency
•
Incidence double that of ruptured
abdominal aortic aneurysms
•
Without treatment, 36-72% of patients
VASCULAR
will die within 48 hours (one week
mortality of up to 91% )
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Aortic Dissection
Vascular
• 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
VASCULAR
aortic
regurgitation, tamponade, and focal
neurological deficits
• Majority of patients have no specific physical
findings
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Aortic Dissection: CXR Findings
Vascular
Chest X-Ray Findings
Abnormal aortic contour
Wide mediastinum
Pleural effusion
VASCULAR
Displaced intimal
calcification
0
10
20
30
40
50
60
70
80
Sensitivity (%)
Peter Lin, MD
Klompas M. JAMA. 2002;287:2262-72.
“Penetrating
Ulcer and Aortic Dissection”
Vascular
VASCULAR
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.
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
Transesophageal Echocardiography
of Aortic Dissection
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Presentation Outline
Vascular
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
VASCULAR
• Medical
• Stent-grafting
• Fenestration
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Classification
Vascular
•Stanford Type A / DeBakey Type II
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Classification
Vascular
•Stanford Type B / DeBakey III
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Classification of Aortic Dissection
Vascular
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
VASCULARrupture/penetrating aortic ulcer
4. Plaque
5. Iatrogenic and traumatic dissection
Task force on aortic dissection, European Society of
Cardiology, Eur Heart J 2001;22: 1642-81
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Class 1: Classic dissection
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Aortic Dissection
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Class 2: Intramural hematoma
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Intramural Hematoma
Vascular
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.
VASCULAR
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 .
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Intramural Hematoma
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Class 3: Discrete/subtle dissection
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
Class 4: Penetrating ulcer
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Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Class 4: Penetrating ulcer
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Penetrating Ulcer
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Class 5: Iatrogenic/traumatic
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Presentation Outline
Vascular
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
VASCULAR
• Medical
• Stent-grafting
• Fenestration
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
Initial Treatment of Type B
Dissection
•Initial treatment: hypotensive medication
•Reserve intervention for 30-40% with:
• Rupture
• End-organ ischemia / malperfusion
•VASCULAR
Localized false aneurysm
• Refractory hypertension
• Continuing pain
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Initial Medical Therapy
Vascular
• Pain control: opiates
• Heart Rate control: Labetalol (bolus &
maintenance)
• Heart Rate < 70
• BP control: Nipride (Target SBP< 110,
DBP<70)
VASCULAR
• Monitor hemodynamics, UOP, swan ganz
catheter placement, pulses
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
Initial Treatment of Type B
Dissection
•Initial treatment: hypotensive medication
•Reserve intervention for 30-40% with:
• Rupture
• End-organ ischemia / malperfusion
•VASCULAR
Localized false aneurysm
• Refractory hypertension
• Continuing pain
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
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
VASCULAR
into the true lumen
• Combination of static and dynamic obstruction
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
MALPERFUSION
MICHIGAN CLASSIFICATION
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
TREATING MALPERFUSION
Vascular
• DYNAMIC OBSTRUCTION
• ENDOGRAFT ACROSS INTIMAL TEARS
• FENESTRATION
• STATIC OBSTRUCTION
• STENTS FOR UNCOMPLICATED STENOSIS
• WITH MECHANICAL THROMBECTOMY FOR STENOSIS
VASCULAR
COMPLICATED BY POST-OBSTRUCTIVE THROMBOSIS
OF TRUE LUMEN OR EMBOLISM TO TRUE LUMEN
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
TX – Endografing vs. Fenetration
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Tx – Stenting for uncomplicated stenosis
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Endovascular Treatment
Vascular
•Primary tear: cover with stent graft
• Decreases pressure in false lumen by
obliterating flow
• Causes thrombosis of the false lumen
which is associated with good long
term outcome
VASCULAR
• Should
treat dynamic obstruction of
branches
• Can help with static obstruction of
branches
• Induction of aortic remodeling
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Thoracic Stent-Grafting for Dissection
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Thoracic Stent-Grafting for Dissection
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Thoracic Stent-Grafting for PU
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Thoracic Stent Grafts
Vascular
•TAG, WL Gore & Associates
• Nitinol stent with polytetrafluoroethylene
•Talent, Valiant, Medtronic AVE
• Nitinol stent with polyester
•TX-2, Cook Inc.
• VASCULAR
Stainless steel with polyester
•Endofit, Endomed Inc.
• Nitinol stent with polytetrafluoroethylene
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Thoracic Stent-Graft
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Zenith Thoracic Stent-Graft
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Fenestrated Thoracic Endograft
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Endovascular Treatment
Vascular
(Non-endograft option)
•Static obstruction:
uncovered stents in origin
of branches
•Dynamic obstruction:
VASCULAR
percutaneous fenestration of
the intimal flap
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
WHAT FENESTRATION DOES
Vascular
• CREATES HOLE IN THE FLAP SEPARATING FALSE AND
TRUE LUMEN
• RAISES PRESSURE IN THE TRUE LUMEN
VASCULAR
• PROMOTES FLOW IN THE FALSE LUMEN
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
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
VASCULAR
• DOES NOT REDUCE LONG-TERM ANEURYSMAL DEGENERATION
OF THE FALSE LUMEN
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
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
VASCULAR (F/S)
•
tear in ascending aorta or arch
•
dissections with entry
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
FENESTRATION
CONTRAINDICATIONS
• Sever aortic insufficiency
• Leaking false lumen
• Coronary artery dissection with MI or right
heart
failure
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
VASCULAR
Eggebrecht et al, Heart 2003: 89: 973
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
•A 61 y/o male with acute
type B thoracic dissection.
•Despite of maximal medical
therapy, he developed right
leg arterial occlusion.
•Endovascular fenestration
wasVASCULAR
performed
Eggebrecht et al, Heart 2003: 89: 973
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
•Endovascular fenestration
was performed.
•Right groin access and
intimal flap was punctured at
the aortic bifurcation using a
Brockenborough needle into
the VASCULAR
false lumen. PTA was
performed to enlarge the
intimal fenestrated site
Eggebrecht et al, Heart 2003: 89: 973
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
•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.
VASCULAR
•His right leg perfusion was
restored.
Eggebrecht et al, Heart 2003: 89: 973
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
CONCLUSIONS
•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
VASCULAR
• Fenestration – to treat dynamic obstruction
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”
Vascular
Endovascular Treatment Principles
Goals: Treatment of malperfusion and thrombosis of
false lumen
Suitable entry tear?
yes
endograft
no
prolonged malperfusion?
VASCULAR
residual malperfusion?
no
yes
yes
fenestration
no
dissection type?
A
surgical
Peter Lin, MD
B
medical
“Penetrating Ulcer and Aortic Dissection”
Be Prepared and Know Your Tools
Vascular
VASCULAR
Peter Lin, MD
“Penetrating Ulcer and Aortic Dissection”