7. Basic Epidemiology of Dissection
• 4:1 male to female
• 60-75% are Stanford Type A
– Peak between 50-60 years
• 25% are Stanford Type B
– Peak between 60-70 years
• Hypertension in >70%
8. Basic Epidemiology of Dissection
• Other factors:
– Cystic Medial Necrosis (Marfan’s, E-D synd)
– Pregnancy
– Cocaine
– Bicuspid valve
– Aortic coarctation
– Syndromes - Turner’s, Noonan’s, etc
– Chronobiologic patterns
• Early am
• Winter vs. Summer
10. Complications of Dissection
• Type A
– Death from coronary malperfusion,
tamponade, rupture
– Stroke and distal malperfusion
• Type B
– Rupture
– Malperfusion - visceral, spinal, extremity
– Aneurysm
11. Intervention
• Complicated or Failure of Medical Therapy
• What is Complicated? (Failure of Medical)
– Rupture
– Aneurysmal false lumen or expansion
– Malperfusion
– Persistent pain
– Untreatable hypertension
15. Open Repair
• Advocated by some for all cases of
complicated Type B dissection requiring
intervention
• Role of open repair in the Endo era is
further blurred
16. Endovascular Repair
• Currently accepted as a viable treatment
option in selected cases of complicated
Type B aortic dissection
• What is Complicated? (Failure of Medical)
– Rupture
– Aneurysmal false lumen or expansion
– Malperfusion
– Persistent pain
– Untreatable hypertension
21. Endovascular Repair
• At RVH:
–Approx 170 TEVAR
–23% indication is either:
• Acute complicated type B dissection
• IMH with ulcer
22. Endovascular Repair
• Goals
– Cover entry tear of the dissection
– Expansion of compressed true lumen
– Induce false lumen thrombosis
– Allow remodeling of aorta
– Potentially prevent aneurysm development
– Without the morbidity of open repair
23. Endovascular Repair
• Concept of inducing true lumen expansion
and false lumen thrombosis is a valid one:
– Reduces morbidity/mortality of malperfusion
– Lowering the risk of false lumen enlargement
• aneurysm
24.
25.
26.
27.
28. Endovascular Repair
• In the real world:
• True lumen expansion and false lumen
thrombosis in complicated Type B dissection
can be achieved
35. Procedural issues to be considered
• Define your indication
• Review the CT images
• ‘Best guess’ for location of primary tear
• Determine appropriate vessel diameters
– Guiding graft selection
36. Procedural issues to be considered
• Deployment Access Vessel
– Best femoral/iliac for delivery
– Assure true lumen graft deployment
• Femoral access with true lumen imaging
• Brachial access
• TEE confirmation
37. Procedural issues to be considered
• Imaging
– Quality
– Flush catheter access and position
– Contrast delivery
– Image Intensifier angulation
46. What procedural issues should be
considered?
• Graft oversizing (? less)
• ? Limited use of ballooning
• Stent graft specific deployment steps
–Understand your grafts
• Strengths and Weaknesses
49. Have to be familiar with the grafts you will use
– What they are capable of doing
– How they will perform in routine cases
– What they will do when you ask it to do something
• Within the IFU
• Outside the IFU
72. Endovascular Repair
• What are we still unsure about?
– The use and utility of uncovered dissection stents
– The use of TEVAR for ‘uncomplicated’ dissection
• Predictors where treatment is reasonable?
– What is the best device?
75. Endovascular Repair
• What are we still unsure about?
– The use and utility of uncovered dissection stents
– The use of TEVAR for ‘uncomplicated’ dissection
• Predictors where treatment is reasonable?
– What is the best device?
76.
77.
78.
79. • Randomized Trial
• Acute Dissection <2 weeks
• BMT vs. TEVAR
• Primary End-Point
– False-lumen thrombosis at 1 year
– Aortic dilatation at 1 year
– Aortic rupture at 1 year
• Expect to enroll 250-260 patients
ADSORB
80. Endovascular Repair
• What are we still unsure about?
– The use and utility of uncovered dissection stents
– The use of TEVAR for ‘uncomplicated’ dissection
• Predictors where treatment is reasonable?
– What is the best device?