THORAKALA AORTASJUKDOMAR

Matias Hannuksela 26.10.2012 Hjärtcentrum,  Norrlands   Universitetssjukhus  

DISPOSITION

•   •   •   •   AORTAS ANATOMI / HISTOLOGI AORTADISSEKTION –   TYP A –   TYP B TRAUMATISK AORTASKADA HANDLÄGGNING PÅ HEMORTEN

HISTOLOGI

•   AORTAVÄGGEN BESTÅR AV TRE LAGER –   INTIMA •   Endotelceller •   Basalmembran –   MEDIA •   Lamina elastica interna •   •   Elastiska fibrer och glatta muskelceller Lamina elastic externa –   •   Elastiska fibrerna cirkulärt, SMC longitudinellt orienterade ADVENTITIA •   Lager av collagen, vasa vasorum and nerver

Hjärtcentrum, Norrlands Universitetssjukhus

THORAKALA ANEURYSM Hjärtcentrum, Norrlands Universitetssjukhus

THORAKALA ANEURYSM

•   •   •   Sällan några symtom –   Ev obehag i bröstet, heshet, andningspåverkan, sväljningssvårigheter Elektiv operation när –   –   Ascendens 50-55 mm Descendens 60mm Tidigare om ärftlig form av dissektioner, Marfans syndrom eller annan bindvävssjukdom

THORAKALA ANEURYSM

AORTADISSEKTION Hjärtcentrum, Norrlands Universitetssjukhus

AORTADISSEKTION Hjärtcentrum, Norrlands Universitetssjukhus

INCIDENS EPIDEMIOLOGI

•   •   •   Förhållande typ A : typ B 2:1 Medelålder 65 år, 70% män Ca 600 fall per år i Sverige •   20% av alla dissektioner ärftliga

SYMTOM

•   •   •   •   •   •   Stark bröst- / ryggsmärta 85-90% –   Ev migrerande (ca 25%) Hypertension 70% Pulsdeficit 21% Neurologi 3-15% Hypotension / Chock 3% Övriga symtom beroende vilket organsystem som drabbas

KOMPLIKATIONER TILL DISSEKTION

•   •   •   KARDIELLA –   Hjärtinfarkt –   –   Aortainsufficiens Tamponad NEUROLOGISKA –   Stroke –   Pareser, sensibilitetsbortfall KÄRLKOMPLIKATIONER –   Försämrad perfusion till bukviscera / extremiteter –   –   Buksmärtor Compartment-syndrom

UNDERSÖKNINGSMETODER

•   •   •   •   Thorax rtg TTE CT (MR - ffa kontroller efteråt)

BEHANDLING

•   TYP A DISSEKTIONER –   Akut operation •   TYP B DISSEKTIONER –   –   Konservativ behandling Operation om •   hotande ruptur (periaortalt hematom, mediastinalt blod, hemothorax) •   organmalperfusion •   smärta som ej svarar på analgetika / sedativa

BEHANDLING – TYP A

•   Operation –   –   proximala delen av ascendens byts mot ett dacrongraft viktigit att identifiera entry –   –   klaffbyte om dissektionen når ned till roten, strukturella fel på klaffen eller vid anulus dissektionen blir kvar i (distala) arcus och descendens

OP- RESULTAT

1997-2007 30-dagars mortalitet Aorta-aneurysm icke brustet <70 år >=70 år Totalt 2,1% 6,3% 3,2% n 253 Aorta-aneurysm brustet Aorta-dissektion Totalt 17,6% 20,4% 9,4% 33,3% 59,3% 23,5% 24,1% 27,9% 12,8% 29 140 422 Hans  Pe9er  Ildgruben,  Hjärtcentrum,  Norrlands  Universitetssjukhus  

TYP A – HANDLÄGGNING PÅ HEMORTEN

•   •   •   •   Snabbt omhändertagande och snabb transport ! Dokumentera status inkl neurologi Bra monitorering, aggressiv behandling av bltr, möjlighet till snabb vätsketillförsel, intubationsberedskap BLTR-sänkning (mål syst <120) 1)   2)   3)   analgetika / anxiolytika betablockad / labetalol vasodilaterare

TYP A – HANDLÄGGNING PÅ HEMORTEN

•   •   Kanylering / monitorering –   Minst två grova PVK (2.0) –   –   A-kat helst bilateralt i radialis CVK och PA-introducer (eller högflödes-CVK) i v jug int dx –   PA-introducern till för att kunna ge volym snabbt –   –   A-kat i a femoralis sin om tid finns Temp-KAD Prover –   Rutin + blödningsstatus, levergallstatus, Trop

BEHANDLING – TYP B

Medikamentell beh – 73 % Kirurgisk beh – 15 % Pc intervention – 12 % - Clinical Profiles and Outcome of Acute Type B Aortic Dissection (IRAD) Suzuki et al – Circ 2003;108;312-317 Hjärtcentrum,  Norrlands   Universitetssjukhus  

PROGNOS – TYP B short-term

•   •   •   Sammanlagd sjukhusmortalitet 13% Medikamentell behandling –   Sjukhusmortalitet 10% Kirurgisk behandling –   Sjukhusmortalitet 32% –   Clinical Profiles and Outcome of Acute Type B Aortic Dissection (IRAD) Suzuki et al – Circ 2003;108;312-317 Hjärtcentrum,  Norrlands   Universitetssjukhus  

Överlevnad KIR BEH MED BEH

PROGNOS – TYP B long-term

6 MÅN 1 ÅR 75-93 90-100 75-90 90-99 5 ÅR 68-75 76-99 Hjärtcentrum,  Norrlands   Universitetssjukhus  

PROGNOSTISKA FAKTORER – TYP B

•   •   Prediktorer för sjukhusmortalitet –   Hypotension/chock –   –   Engagemang av från aorta avgående kärl Avsaknad av bröst/ryggsmärta Prediktorer för framtida händelser –   Aortadiameter >40 mm –   Flöde i falskt lumen Hjärtcentrum,  Norrlands   Universitetssjukhus  

PROGNOSTISKA FAKTORER – TYP B

•   •   Övrigt –   Ökning av diametern med > 4-5 mm/år –   Betablockad minskar risken för framtida händelser –   Pat >70 år med komplikationer (hypotension, malperfusion) har sämre prognos än yngre med kompl, likvärdig prognos utan komplikationer QoL (2-12 år efter dissektion) –   I stort sett likvärdig med ålders- och könmatchad population Hjärtcentrum,  Norrlands  

UPPFÖLJNING TYP A OCH TYP B

•   •   Noggrann blodtryckskontroll (<135/80) CT / MR 1-3-6-12 mån, därefter årligen –   –   –   –   Expansion av aorta? Aneurysmbildning? Tecken till läckage? Malperfusion? Hjärtcentrum,  Norrlands   Universitetssjukhus  

MEDIKAMENTELL BEHANDLING TYP B akutskede

Mål: Smärtfri patient Bltr första dagarna 100-120 syst därefter <135/80 resten av livet 1)   2)   3)   4)   5)   Analgetika / anxiolytika Betablockad Vasodilaterare (Nitroprussid, Nitroglycerin) Ca-blockerare, ACE-hämmare, diuretika, alfa blockad Övriga blodtryckssänkande lm (perifera vasodilaterare – hydralazin, minoxidil) Hjärtcentrum,  Norrlands   Universitetssjukhus  

MEDIKAMENTELL BEHANDLING TYP B efter utskrivning

•   •   •   •   Bltr <135/80 Livslång betablockad I regel kan antihypertensiv behandling trappas ned med tiden Statiner ? ATII-blockerare? Hjärtcentrum,  Norrlands   Universitetssjukhus  

TRAUMATISK AORTARUPTUR

•   •   A descendens fixerad av ligamentum arteriosum, a subclavia sin, vertebralis artärer Skada i regel strax distalt om a subclavias avgång

TRAUMATISK AORTARUPTUR

•   •   •   •   •   Fallolycka, olycka med motorfordon Nästvanligaste dödsorsaken i smb med trauma (skallskada vanligast) <25% av TAR når sjukhus 50% av de som kommer in dör inom 24 timmar Samtidig –   –   –   Skallskada 31% Bukskada 29% Bäckenskada 15%

THORAKALA AORTARUPTUR – initial handläggning

•   •   •   •   •   •   ATLS Bedöm ev andra skador Monitorering / behandling som vid typ A dissektioner Kontakt alltid med thx kirurg Transport till Umeå – hemklinik beroende på övriga skador Stentas i regel, TEVAR (Traumatic EndoVascular Aortic Repair)

THORAKAL AORTARUPTUR

•   •   •   •   Öppen kirugi vs stent Consensus stent i första hand Rekommendation inom <24h om andra skador under kontroll Bättre prognos med fördröjd (2-3 dygn) åtgärd av aortarupturen om andra allvarliga skador

SOCIETY FOR VASCULAR SURGERY ® DOCUMENTS

Endovascular repair of traumatic thoracic aortic injury: Clinical practice guidelines of the Society for Vascular Surgery

W. Anthony Lee, MD, a Jon S. Matsumura, MD, b Roy K. Greenberg, MD, e Ali Azizzadeh, MD, f R. Scott Mitchell, MD, c Mark A. Farber, MD, Mohammad Hassan Murad, MD, MPH, g

and

d Ronald M. Fairman, MD, h

Boca Raton, Fla; Madison, Wisc; Palo Alto, Calif; Chapel Hill, NC; Cleveland, Ohio; Houston, Tex; Rochester, Minn; and Philadelphia, Pa

The Society for Vascular Surgery tions. The systematic review included 7768 patients from 139 studies. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair, and nonoperative management (9%, 19%, and 46%, respectively,

P

JOURNAL OF VASCULAR SURGERY Volume 53, Number 1

< Table II.

® pursued development of clinical practice guidelines for the management of traumatic .01). Based on the overall very low quality of evidence, the committee suggests that endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, graft, and systemic infections compared with open repair or nonoperative management (Grade 2, Level C). The committee was also surveyed on a variety of issues that were not specifically addressed by the meta-analysis. On these select matters, the majority opinions of the

Summary of guidelines for thoracic endovascular aortic repair (

cases. ( J Vasc Surg 2011;53:187-92.)

TEVAR Lee et al

189

) in traumatic thoracic aortic injuries

Grade of recommendation 1—strong 2—weak Quality of evidence A—high B—moderate C—low or very low

Blunt traumatic thoracic aortic injury is associated with a high mortality rate, and has been implicated as the second most common cause of death in trauma patients, behind

Guideline

Cardiothoracic Surgery, Stanford University, Palo Alto; c Division of Vascular Surgery, University of North Carolina, Chapel Hill; d Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland; Choice of treatment e b Department of Division of Vascular Sur f a Divi Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester; and Division of Vascular Surgery, University of Pennsylvania, Philadelphia.

g h Competition of interest: Dr Lee received research support and consultation fees Timing of repair We suggest urgent ( Gore. Dr Mitchell has no conflict of interest disclosures. Dr Farber received consultant fees from W. L. Gore, Medtronic, Cook, Aptus Endosystems, and Management of minimal aortic injury Type of repair in the young patient Christine E. Lynn Heart and Vascular Institute, 670 Glades Road, Suite Management of left Independent peer-review and oversight has been provided by members of subclavian artery (chair), Enrico Ascher, MD, Jack L. Cronenwett, MD, R. Clement Systemic heparinization 0741-5214/$36.00

Copyright © 2011 by the Society for Vascular Surgery.

doi:10.1016/j.jvs.2010.08.027

Choice of anesthesia Femoral access technique ).

artery.

only to intracranial hemorrhage.

that less than 25% of patients with such an injury live to be evaluated in a hospital, 3 1,2 It has been estimated and of those who do, up to 50% will die within 24 hours.

4 50% to 70% of cases, 4 Given the location of injury in

Consensus

cardiopulmonary bypass and significant blood loss, which can negatively impact the pulmonary, cardiac, and neuro logic status of the patient. Historically, open repair of traumatic aortic injuries has been associated with a 28% mortality rate hospital discharge.

idly evolving therapy in the treatment of a variety of tho racic aortic pathologies. TEVAR involves placing an endo I injuries.

5 and a 16% paraplegia rate.

!

6 There has been 7 Thoracic endovascular aortic repair (TEVAR) is a rap the potential for a durable aortic repair while avoiding the morbidity of a thoracotomy, aortic cross clamping, and cardiopulmonary bypass. Nevertheless, stroke, spinal cord ischemia, and other complications that are associated with open repair can also occur with TEVAR.

Although there is no device currently commercially available with an on-label indication for repair of trau matic thoracic aortic transections, these are increasingly being treated off-label using endovascular devices. At the time of this manuscript, there were at least two ongoing investigator device exemption (IDE) pivotal clinical trials in We suggest general anesthesia.

We suggest open femoral exposure.

187

2 2 2 2 2 2 2 2 2 C C C C C C C C C venting death is paramount in this setting, the committee recommends endovascular repair.

CONSENSUS OF OPINION ON SELECT ISSUES

Endovascular repair of traumatic thoracic aortic injuries poses several unresolved or controversial issues whose sup porting evidence lacks sufficient clarity in the literature due to cohort heterogeneity, size, and length of follow-up.

Nevertheless, the committee sought to arrive at some con sensus on a select number of these issues to offer guidance in actual clinical practice. To this end, a series of questions were used to survey the opinions of each committee mem ber. Published evidence is provided in support of the ma jority and minority opinions when available. Using the GRADE system, all of the following opinions should be regarded as Grade 2, Level C statements ( Table II ).

Issue 1: Timing of TEVAR in a stable patient.

The committee suggests urgent ( !

24 hours) repair barring other serious concomitant nonaortic injuries, or repair im mediately after other injuries have been treated, but at the latest prior to hospital discharge.

those managed nonoperatively.

aging.

9 10,11

(periadventitial defect or hematoma).

This is consistent with the available evidence in which mortality was 46% in While most did not favor discharge without repair, depending on the severity of the injury (see below), minority opinion was expressed that expectant management was appropriate with follow-up im-

Issue 2: Management of “minimal aortic injury”

Intimal or periad ventitial defects or hematomas are not infrequently seen on computed tomography (CT) scan. A classification scheme for grading the severity of aortic injury has been proposed: type I (intimal tear), type II (intramural hematoma), type III (pseudoaneurysm), and type IV (rupture) 12 ( Fig ). The committee suggests expectant management with serial im aging for type I injuries, while types II to IV should be repaired. This is based on early evidence that most type I injuries heal spontaneously.

open.

12 Decision to intervene and its timing should be guided by progression of the initial radio graphic abnormality and/or symptoms.

Issue 3: Choice of repair in the young—TEVAR vs

There was near unanimity of opinion that anatomic suitability is important for TEVAR but age should not be a factor in deciding the type of repair. The risks of death and spinal cord ischemia are significantly lower in all age groups after endovascular repair compared with open surgery, repair should be considered.

FDA-approved thoracic endografts.

which can lead to endoleak and endograft collapse.

even death from acute aortic occlusion.

16 16 13-15 and these early benefits outweigh the concerns of potential late complications. However, in surgically fit patients with poor anatomy for endovascular repair, conventional open

Issue 4: Suitability and the unmet needs of current

With the availabil ity of three commercially available devices, there was con siderable divergence of opinion about the “best” device for use in traumatic thoracic aortic injury. There was a consen sus, however, that arch conformation represented the sin gle greatest unmet need given the curvature of the thoracic aorta at the location of the injury. Inability to conform to this curvature can result in malapposition of the endograft, The aortic diameters are relatively smaller in the younger subset of trauma patients. Currently, available thoracic endograft sizes mostly reflect the larger aortic diameters that would be typically encountered in an older cohort with degenerative aneurysms. Excessive oversizing may result in attachment site endoleak, device infolding, endograft collapse, and Endograft col lapse represents a failure of the therapy and a marker of unsuitable anatomy, and open surgical conversion should be considered. No consensus could be reached regarding optimal oversizing for these cases, and opinions were equally divided among minimal to no oversizing, 5% to 10% oversizing, and standard oversizing per manufacturer’s rec ommendations. Historically, abdominal endograft compo-