aortic dissection GP

1. AORTIC DISSECTION
Dicky A.Wartono ,drSpBTKV(K) FIHA FICA
National Cardiac & Vascular Centre, Harapan Kita
Jakarta 2019

2.  Operating CV Surgeon/Consultant
– Harapan Kita National CV Centre
– Pondok Indah Group
– Siloam Health Care Group
 Lecturer
– Dept of (CVT) surgery Indonesia University
– Dept of Cardiology, Indonesia University
– Medical Faculty Matranatha Christian Univst

3.  Medical Consultant
– Cardiac & Vascular surgery
– Aortic Intervention/Surgery
– Heart Failure & Circulatory Assist Device
 Research/Training Advisor
– Abbot / St Jude Medical
 Speaker Bureau of Cryolife & Haemonetics

4. Nothing to declare

7. Definition
 Aortic dissection is an aortic wall disease.
 Intimal layer separates from the medial layer and this
separation continues in general to the distal of the
Aorta.

9. tear in the inner layer of the aortic
wall, followed either by an aortic
rupture in the case of adventitial
disruption or which allows blood to
enter into the wall of the aorta ,
creating a new passage for blood,
known as the “false lumen.”

12.  The most catastrophic disease of the aorta
 5-10 patients/ 1 milion per year
 Incidence is 0.2-0.8 % in autopsy series
 M/F: 2.5-3
 Most frequently seen 5.-6. decade of age.

13. Mortality
 First 24-48 hours 20-50%
– Increases 1% every passing hour
 First 2 weeks 75%
 First 3 months 90%

15. Patogenesis
 1. Primary intimal tear theory
– Proxymal dissections 95-100%
– Distal dissections 90-95%
 2. Occurence of intramural hematoma
theory
– Vasovasorum rupture
– Rupture of penetrating atherosclerotic ulcers

16. Intimal tear
 Intimal layer separates
and it results in 2 lumens:
True lumen and False
lumen.
60-70% Ascending aorta
10-20% Arcus aorta
25% Descending aorta

17. Ethiology
 Hypertension
 Medial degenerative disease
 Genetic diseases
 Congenital heart and vascular diseases
 Atherosclerosis
 Inflammatory aortic diseases
 Travmatic injuries
 Iatrogenic injuries
 Drug abuse
 Pregnancy

18. Classifications
 Clinical classification
 Topografical classification
– De Bakey
– Stanford
– Svensson

19. Clinical Classification
 Acute: 0-14 days
 Subacute: 14 days- 2 months
 Chronic: After 2 months

20. Topografical Classification

21. Rupture
 Rupture is the most frequent cause of death
and usually occurs at the site of intimal tear.
 Type A dissection Intrapericardial
 Dissection of arcus aorta Intramediastinal
 Type B dissection Left pleura

23. Organ malperfusion
 Serebral ischemia
 Spinal ischemia
 Renal ischemia
 Visceral ischemia
 Lower extremity ischemia
 Cardiac ischemia

24. Clinical Findings
 Pain
 Serebrovascular accidents (Syncope, stroke)
 CHF
 Acute aortic valve insufficiency
 Hypovolemia
 Cardiac tamponade
 Malperfusion signs

27. Pain in Acute Type A Dissection

28. Pain in Acute Type B Dissection

34. Under diagnostic
• Most common , most lethal aortic emergency
– Among life-threatening causes of chest pain, AD has the
highest mortality — an estimated 1-2% per hour for the
first 48 hours.
–
• Still a formidable diagnostic challenge in ED - As many
as 65% AD missed in initial exam.
Freedman DL. Aortic dissection: Be suspicious or the autopsy will make diagnosis.
• ED Legal Letter 2000; 11:105-116.
• Diagnostic delays of >24 hrs in 39 % patients. (31 %
proximal AD, 53 % distal AD )
Viljanen T. Diagnostic difficulties in aortic dissection.
• Ann Chir Gynaecol 1986;75:328

39. Treatment
 Surgical treatment
 Medical treatment
 Endovascular treatment
 Hybrid treatment

41. Treatment-Aim
 Stabilize the dissection
 Avoid the rupture
 Avoid organ ischemia
 Systolic BP 100-110 mmHg
 Mean BP 60-75 mmHg
 Urine output and neurologic status
should be monitorized

42. Surgical Treatment
 Acute Type A Emergent surgical treatment
 Acute Type B Endovascular or medical
treatment (surgery for rupture, intractable
sympoms or organ ischemia)
 Chronic Type A Elective surgical treatment
 Chronic Type B Surgery for aneurysmatic
aorta, organ ischemia.

43. Medical Therapy
 Reduces propagation tendency
– BP lowering: SBP 100-120
 Rule out significant AR
 Watch for oliguria
 HR lowering: ≤ 60 bpm
Decreasing LV contraction velocity
 Decreasing Aortic wall shear stress

44. Beta blockers DOC – but cautious of significant AR
• IV Labetalol
• IV Esmolol
Additional drugs +/-
• IV Verapamil/Diltiazem
IV Enalapril
IV Nitroprusside
Vasodilators always with background rate control
Avoid Hydralazine – increase shear stress
•PAIN CONTROL
Opioids: Morphine

45. Surgery For Type A Ao Dissection

50. Surgery For Type B Ao Dissection

53. ENDOVASCULAR THERAPY
Advantages
• Less Invasive – No thoracotomy/No CPB
• Less painful
• Less morbidity – No aortic clamp – Less stroke
•– Less intercostal artery coverage – Less paraplegia
• Shorter hospitalization
• Feasible in high surgical risk pts
• Feasible in hemodynamically unstable pts – less blood loss
Disadvantages
• Suitable anatomy is pre-requisite Contrast related toxicity
Higher cost
More secondary interventions
Lifelong follow-up req

57. Highlights Today
1. Aortic valve preservation and repair
1. Aortic valve replacement in the young
2. Perfusion techniques for aortic arch
surgery
3. Contemporary total and hybrid arch
repair
4. Extended repair for type A
dissection
5. Total endovascular arch repair
6. Descending thoracic aortic
aneurysms
7. Acute type B dissections
8. Chronic type B dissections

59. Recommendation
#1 We recommend aortic root and ascending
aortic aneurysms in patients with normally
functioning or mildly regurgitant trileaflet aortic
valves be treated with valve sparing
operations whenever feasible
Strong recommendation Medium quality evidence
Values and Preferences: A composite valve and root replacement may
be preferred in emergency settings, in elderly patients, those with
multiple co-morbidities, poor left ventricular function, or with poor quality
cusp tissue. A reimplantation approach to valve sparing root
replacement may be preferred in those with connective tissue diseases

60. Recommendation
#2 We suggest aortic root and ascending aortic
aneurysms in patients with moderate or greater
insufficiency with or without bicuspid aortic valves
be considered for valve sparing root replacement
with or without cusp repair.
Weak recommendation Medium quality
evidence
Values and Preferences: A number of important considerations should guide
this decision including surgeon experience, patient age and preference, quality
of cusp tissue, and the ability to perform these procedures with similar mortality
and morbidity as composite valve and root replacement procedures.

61.  41 year-old female with 8 children
 ECG: Paroxysmal AF
 Entubated
 Diagnosis: Acute Stanford type A Aortic
Dissection
 Hypertension
Case Report

62. Extended Repair Type A
Dissection
Goals of Surgery
Acute Valvular Insufficiency
Ascending aortic rupture
Coronary Ischemia
But Dissection is a diffuse
process involving other
organ systems

63. Extending the Distal Repair
THE PROBLEM
How much distal aorta should, or must, be repaired
in an acute type A aortic dissection
Surgical principles
– Resect dissected aorta
– Resect primary intimal tear
– Re-establish flow downstream, preferably in true lumen
– Obliterate the false lumen
Basic techniques
– Open distal anastomosis
– Period of circulatory arrest
– Hypothermia
– cerebral perfusion during distal aortic repair

64. Standard hemiarch

65. Extended Arch

66. Extending the Distal Repair
 Is it necessary?
 Potential risks
– Longer and more technically challenging
operation
 Potential benefits
– Seal distal tears
– Better likelihood of obliterating false lumen
– Prevention of complications
 Malperfusion
 Aortic dilation
 Re-intervention
 Death

67. Summary – Extended
Distal Repair
1. Organ malperfusion portends to poorer
outcomes
2. The primary intimal tear is not amenable to
resection in many acute type A dissections
3. Resection of the primary intimal tear is likely to
decrease reoperation rates
4. Obliteration of the false lumen may increase
survival & decrease risk of reoperation
5. Extended surgery can be done with similar
morbidity and mortality risk

68. RECOMMENDATIONS
 #4 We recommend an extended distal arch repair
technique be considered for patients who present
with acute Type A dissection and one of the
following
a. Primary intimal entry tear in the arch or descending aorta
b. Significant aneurysmal disease of the arch
(Strong recommendation, Low Quality Evidence)

69. RECOMMENDATIONS
 #5 We suggest that it is reasonable to consider
an extended distal arch repair technique for
patients who present with acute Type A
dissection and one of the following:
a. Distal malperfusion
b. Concomitant descending thoracic aortic aneurysm
c. Young patients
d. Patients with connective tissue disorders
(Weak recommendation, Low Quality Evidence)

70. Admission
acute Type B
6 months 2 years post
Type B
51 y.o male
“Uncomplicated” Type B - ? misnomer
Admission mortality < 10%
5 year mortality substantially higher in some publications

71. Instead XL
Circ Cardiovasc Int 2013
RCT -140 pts OMT vs.
OMT + TEVAR
Improved aortic
remodelling & aorta
specific survival in TEVAR
group at 5 years
ADSORB
European J Vasc
Endovasc Surg 2014
RCT 61 pts OMT vs. OMT
+ TEVAR
Improved aortic
remodeling at 1 year
IRAD
Ann Cardiothorac Surg
2014
Retrospective review of
registry patients
Improved aorta related
survival at 5years
Uncomplicated Type B
Medical Management Alone vs. TEVAR & Medical management

72. Predictors of Growth:
Initial aortic diameter > 4cm
False Lumen > 22mm
Large proximal entry tear >1.0cm

73. ‘COMPLICATED’ TYPE B
30-42% of TBAAD
 Persistent or recurrent pain
 Uncontrolled HTN despite full medication
 Early aortic expansion
 Malperfusion
 Signs of rupture (haemothorax, increasing
periaortic/mediastinal haematoma)
 Retrograde dissection into the aortic arch
 If anatomy suitable – Endovascular preferred over surgery
 No randomized trial – but long term registries show lower
mortality than surgical series

74. UNCOMPLICATED TYPE B AD
• Apart from best medical Mx – endovascular
Mx has been tried
• Rationale – To promote Aortic positive
remodeling – thinking it would improve
survival
• Compared in 3 randomised trials - Remains
a controversy

75. #7 We recommend that patients with uncomplicated
acute type B aortic dissections be managed with
hypertension and pain control and radiologic
surveillance.
(Strong Recommendation, Medium quality evidence)
Values and Preferences: If patients remains
“uncomplicated” early follow up imaging at 48-72 hrs
and 1-4 weeks is recommended to detect early signs
of aneurysm expansion and radiologic malperfusion.

76. #8 We suggest that endovascular repair be considered for
patients with uncomplicated type B aortic dissections to
improve aorta-specific endpoints
(Weak recommendation, Low quality evidence)
Values and Preferences: The Instead XL trial which
randomized patients in the delayed phase (2-52 weeks)
showed decreased aorta specific 5-year mortality and
improved aortic remodelling. The ADSORB trial which
randomized patients in the acute phase (< 2 weeks)
showed improvement in aortic remodelling at one year.

77. Summary:
Evolution in open and endovascular aortic surgery
Improved patient outcomes
Rapid change – thus, little high quality evidence
to make strong recommendations
New Recommendations:
1.Valve Repair….with caution in regurgitant valves…
2.Extended arch at time of Type A….distal tears, aneurysm
– strong recommendation
3.Asymptomatic Type B Dissections….consider early
TEVAR – weak recommendation

78. TERIMA KASIH