Southern Association for Vascular Surgery 2007 Postgraduate Course San Juan, Puerto Rico

1. Southern Association for Vascular Surgery2007 Postgraduate CourseSan Juan, Puerto Rico Penetrating Ulcer and Aortic Dissection Peter H. Lin, MD Baylor College of Medicine Houston, TX

2. Presentation Outline • Thoracic Aortic Pathology • Aortic Dissection • Classification • Treatment Strategy • Medical • Stent-grafting • Fenestration

3. Acute Aortic Syndrome • Aortic dissection • Limited intimal tear with eccentric bulge • Intramural hematoma • Pre-dissection ? • Associated with penetrating ulcer • Penetrating ulcer • Traumatic transection

4. Hayter RG, Radiology 2006; 238:841-852

5. Suspected Acute Aortic SyndromeMDCT 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%) • 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

6. Diagnosis of Chest Pain in the ER. von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.

7. Presentation Outline • Thoracic Aortic Pathology • Aortic Dissection • Classification • Treatment Strategy • Medical • Stent-grafting • Fenestration

8. Acute Aortic Dissection • Most common aortic emergency • Incidence double that of ruptured abdominal aortic aneurysms • Without treatment, 36-72% of patients will die within 48 hours (one week mortality of up to 91% )

9. Aortic Dissection • 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 aortic regurgitation, tamponade, and focal neurological deficits • Majority of patients have no specific physical findings

10. Aortic Dissection: CXR Findings Klompas M. JAMA. 2002;287:2262-72.

11. 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.

12. Transesophageal Echocardiography of Aortic Dissection

13. Presentation Outline • Thoracic Aortic Pathology • Aortic Dissection • Classification • Treatment Strategy • Medical • Stent-grafting • Fenestration

15. Classification • Stanford Type A / DeBakey Type II

16. Classification • Stanford Type B / DeBakey III

17. Classification of Aortic Dissection • Classic with true and false lumens separated by intimal flap • Medial disruption with intramural hematoma or hemorrhage • Discrete/subtle aortic dissection bulge at tear site with no hematoma • Plaque rupture/penetrating aortic ulcer • Iatrogenic and traumatic dissection Task force on aortic dissection, European Society of Cardiology, Eur Heart J 2001;22: 1642-81

18. Class 1: Classic dissection

19. Aortic Dissection

20. Class 2: Intramural hematoma

21. Intramural Hematoma 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. 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 .

22. Intramural Hematoma

23. Class 3: Discrete/subtle dissection

24. Class 4: Penetrating ulcer

25. Class 4: Penetrating ulcer

26. Penetrating Ulcer

27. Class 5: Iatrogenic/traumatic

28. Presentation Outline • Thoracic Aortic Pathology • Aortic Dissection • Classification • Treatment Strategy • Medical • Stent-grafting • Fenestration

29. Initial Treatment of Type B Dissection • Initial treatment: hypotensive medication • Reserve intervention for 30-40% with: • Rupture • End-organ ischemia / malperfusion • Localized false aneurysm • Refractory hypertension • Continuing pain

30. Initial Medical Therapy • Pain control: opiates • Heart Rate control: Labetalol (bolus & maintenance) • Heart Rate < 70 • BP control: Nipride (Target SBP< 110, DBP<70) • Monitor hemodynamics, UOP, swan ganz catheter placement, pulses

31. Initial Treatment of Type B Dissection • Initial treatment: hypotensive medication • Reserve intervention for 30-40% with: • Rupture • End-organ ischemia / malperfusion • Localized false aneurysm • Refractory hypertension • Continuing pain

32. 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 into the true lumen • Combination of static and dynamic obstruction

33. MALPERFUSION MICHIGAN CLASSIFICATION

34. TREATING MALPERFUSION • DYNAMIC OBSTRUCTION • ENDOGRAFT ACROSS INTIMAL TEARS • FENESTRATION • STATIC OBSTRUCTION • STENTS FOR UNCOMPLICATED STENOSIS • WITH MECHANICAL THROMBECTOMY FOR STENOSIS COMPLICATED BY POST-OBSTRUCTIVE THROMBOSIS OF TRUE LUMEN OR EMBOLISM TO TRUE LUMEN

35. TX – Endografing vs. Fenetration

36. Tx – Stenting for uncomplicated stenosis

37. Endovascular Treatment • 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 • Should treat dynamic obstruction of branches • Can help with static obstruction of branches • Induction of aortic remodeling

38. Thoracic Stent-Grafting for Dissection

39. Thoracic Stent-Grafting for Dissection

40. Thoracic Stent-Grafting for PU

41. Thoracic Stent Grafts • TAG, WL Gore & Associates • Nitinol stent with polytetrafluoroethylene • Talent, Valiant, Medtronic AVE • Nitinol stent with polyester • TX-2, Cook Inc. • Stainless steel with polyester • Endofit, Endomed Inc. • Nitinol stent with polytetrafluoroethylene

42. Thoracic Stent-Graft

43. Zenith Thoracic Stent-Graft

44. Fenestrated Thoracic Endograft

46. Endovascular Treatment(Non-endograft option) • Static obstruction:uncovered stents in origin of branches • Dynamic obstruction: percutaneous fenestration of the intimal flap

47. WHAT FENESTRATION DOES • CREATES HOLE IN THE FLAP SEPARATING FALSE AND TRUE LUMEN • RAISES PRESSURE IN THE TRUE LUMEN • PROMOTES FLOW IN THE FALSE LUMEN

48. 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 • DOES NOT REDUCE LONG-TERM ANEURYSMAL DEGENERATION OF THE FALSE LUMEN

49. 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 (F/S) • tear in ascending aorta or arch • dissections with entry

50. FENESTRATIONCONTRAINDICATIONS • Sever aortic insufficiency • Leaking false lumen • Coronary artery dissection with MI or right heart failure