Ali Khoynezhad, MD 1 , Carlos E. Donayre, MD 2 , Rodney A. White, MD 2

1. Current Methods and Results of Endovascular Treatment of Acute Complicated Type B Aortic Dissection in North America Ali Khoynezhad, MD1, Carlos E. Donayre, MD2, Rodney A. White, MD2 1Associate Professor of Surgery, Division of Cardiothoracic & Vascular Surgery, Creighton University Medical Center, Omaha, NE. 2Professor of Surgery, Division of Vascular & Endovascular Surgery, Harbor-UCLA Medical Center, Torrance, CA. Aortic Symposium 2010

2. Overview • introduction • equipment, IVUS • endovascular algorithm • approach for ruptured pts • approach for malperfused pts • review results in North America • reverse aortic remodeling

3. Introduction • definitions! • IRAD (n=82)1 • hospital mortality 29.3% • new neurologic deficit 23.3% • recent study (n=76)2: • hospital mortality 22.4% • spinal cord injury 6.6% • open repair associated with significant • morbidity and mortality • clinical challenge! • 1Trimarchi et al., Circulation 2006. 2Bozinovski et al., Ann Thorac Surg 2008

4. TEVAR-Equipment • imaging system • pressure injector • IVUS, TCD, pressure wire, MEP, CSF drain • nuts and bolts: needles, guide wires, dilators, • sheath, catheters, balloon, snares, coils, stents.

5. Procedural algorithm • dedicated team • IVUS-guided access to the TL • dx of exact location of entry tears • ruptures: coverage of entire DTA • malperfusions: coverage of • primary tear site and stagnation • of blood in false lumen • re-evaluate for branch-vessel • malperfusion

6. Endovascular technique: rupture • emergency TEVAR sets • permissive hypotension • CSF drainage and MEP if feasible • IVUS-guided access to the true lumen • coverage of entire DTA • hyperdynamic/hypertensive postop • same for patients with unrelenting • HTN/pain

7. Endovascular technique: malperfusion • more complicated! • LE < renal < mesenteric ischemia • differential-diagnosis: anatomic (static) vs. dynamic obstruction vs. both • procedural tools: • angiographic (scalloping vs. • floating viscera) • IVUS (benign vs. ischemic) • manometry • (simultaneous/pullback) False lumen

8. Cohort: 166 Patients • six publications with accurate patient cohort using standardized definitions: • Conrad (33), Freezor (33), Khoynezhad (38), • Szeto (35), Vedantham (11), Verhoye (16). • malperfusion on 83 (50%) • average follow-up: 20 months (6-38) • primary technical success: 156 (94%) • spinal cord injury: 15 (9%)

9. Survival • no intraoperative deaths • hospital mortality: 20 (12%) • 1y-survival 85% • treatment failure in follow-up: 41 (25%)

10. Reverse aortic remodeling • complete or • partial • thrombosis of • the false lumen • in 89 (79%) • survivors.

11. Preoperative 1-Year follow-up SMA Renals Neck

12. Conclusions • TEVAR for complicated acute type B aortic dissection is a technically challenging and complex endovascular procedure. • Using a clear algorithm, it has a relatively low morbidity and mortality in experienced hands, and it compares favorably to surgical outcomes. • favorable outcome in mid-term follow-up. • standard of care and therapy of choice in experienced centers. Aortic Symposium 2010