Early outcomes of acute retrograde dissection in the ... · Foeke JH Nauta, MD, PhD Resident Cardiothoracic Surgery, Academic Medical Center, Amsterdam. Disclosure 2 Speaker name:

Early outcomes of acute retrograde dissection in the

aortic arch and the ascending aorta

– data from IRAD

Foeke JH Nauta, MD, PhDResident Cardiothoracic Surgery, Academic Medical Center, Amsterdam

Disclosure

2

Speaker name: Foeke JH Nauta

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interest

Acute Retrograde Dissection - IRAD

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Background

• Management of acute aortic dissection (AD) is predominantly based on the Debakey and Stanford classifications:

http://www.med.umich.edu/cvc/research/mcorrp/mcorirad.htm


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1Hiratzka, AHA Guidelines 2010 2Erbel, ESC Guidelines 2014

Acute open surgery1,2 Endovascular/Medical1,2

• Management of acute aortic dissection (AD) is predominantly based on the Debakey and Stanford classifications:

Background



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Retrograde Type A AD

Background



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Spontaneous or post-TEVAR

Background



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Background

• Presentations and outcomes may differ from classic type A dissection



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Background


• However, guidelines recommend urgent surgical repair for both entities,associated with high mortality (17-25%)3,4

3Kim, et al. Circulation 20144Trimarchi, et al. JTCVS 2005



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Background



3Kim, et al. Circulation 20144Trimarchi, et al. JTCVS 2005



• Could these patients benefit from a less invasive approach?



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Background

N = 49 patientsCirculation 2014



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Background

Circulation 2014

Selected patients may benefit from medical therapy alone

N = 49 patients



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Semin Thorac Cardiovasc Surg 2017



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Methods42 active sites



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• All patients with a known entry tear between 1996 – 2015: N = 1433

Results



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Results


7%



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Results




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Results – demographics



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SURG patients showed widest ascending

aortic diameters, P=0.04



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Results – clinical presentation



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Results – false lumen patency



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Results – early outcomes

No significant difference in mortality



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Results – early outcomes

No significant difference in mortality or complications between treatment groups



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Results – management per zone

SURG71.8%

P


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MED 72.7%ENDO 86.4%

P


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Results – mortality per zone

Mortality 18.6% N=43



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P=0.14

Mortality 8.6%N=58



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P=0.14

A trend of favorable mortality in patients with retrograde extension till zone 1

Mortality 8.6%N=58



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Results – outcomes compared to type B and A

Retro AD Type B AD P-value

Early mortality 12.9% 11.5% P=0.72



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Retro AD Type A AD P-value






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Retro AD Type A AD P-value




Retro AD Type B AD Type A AD P-value

Major neurological complications

7.1% 8.4% 19.1% P


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Type B:N = 337

Retrograde arch extension:N = 67



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Type B:N = 337


No difference in management



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Type B:N = 337


No difference in management: 1/3 endovascular approach



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Type B:N = 337


No difference in mortality: ~ 10%



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• Retrograde AD is not rare in dissection patients: 7%

Conclusions



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• Retrograde AD limited to the arch tends to do better than extension into the ascending. We suggest to define them as: Retro-Arch and Retro-Asc dissections

Conclusions



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• Retrograde AD limited to the arch tends to do better than extension into the ascending. We suggest to define them as: Retro-Arch and Retro-Asc dissections

• A subset of retrograde AD patients may be managed less invasively, particularly those with: - extension limited to the arch- no tamponade- no ascending aneurysm or aortic regurgitation- thrombosed false lumen

Conclusions



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TEVAR case

Tear in descending,

thrombosis in ascending



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TEVAR case

Tear in descending,

thrombosis in ascending

2 mo f/u:thrombosis in

descending



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Thank you



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Results – outcomes compared to type B and A AD

Variable Retro AD Type A AD Type B AD P value

N (%) 101 (7.0) 977 (68.2) 355 (24.8)


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Results – predictors of death



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Results – outcomes compared to type B and A ADpresentation

Variable Retro AD Type A AD Type B AD P value

Major neurologic deficit

(coma, CVA, SCI, %)

5 (5.2) 73 (8.3) 13 (4.0) .02

Limb ischemia (%) 8 (7.9) 98 (11.4) 25 (7.6) .11

Syncope (%) 4 (4.2) 148 (16.5) 9 (2.6)

Figure Legends

Fig. 1. Type B dissection versus type B dissection with retrograde arch extension. (A) Type B dissection

with an entry tear in descending aorta and antegrade dissection distally. (B) Type B dissection with

retrograde arch extension; entry tear in the descending aorta and retrograde extension of hematoma into the

aortic arch.

Fig. 3. Kaplan Meier survival curves in acute type B dissection patients with and without RAE during a

5-year follow-up. RAE = retrograde arch extension.

No difference in 5-year survival

Retrograde Extension of Type B Dissection in Arch

No difference in 5-year survival

Retrograde Extension of Type B Dissection in Arch

Figure Legends

Fig. 1. Type B dissection versus type B dissection with retrograde arch extension. (A) Type B dissection

with an entry tear in descending aorta and antegrade dissection distally. (B) Type B dissection with

retrograde arch extension; entry tear in the descending aorta and retrograde extension of hematoma into the

aortic arch.

Acute Retrograde Type A Dissection

N = 27 patients

Circulation 2003

Retrograde AD with thrombosed false lumen

Retrograde AD with non-thrombosed false lumen

Type A ADP=0.024

Background


Acute Retrograde Type A Dissection

N = 27 patients

Circulation 2003

Retrograde AD with thrombosed false lumen

Retrograde AD with non-thrombosed false lumen

Type A ADP=0.024

Medically

Background

Surgery



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MED/ENDO

SURG71.8%



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MED/ENDO

MED 72.7%ENDO 86.4%

Documents

Early outcomes of acute retrograde dissection in the ... · Foeke JH Nauta, MD, PhD Resident Cardiothoracic Surgery, Academic Medical Center, Amsterdam. Disclosure 2 Speaker name: