Progress in Management of Visceral Ischemia from Type B Dissections

1. Progress in Management of Visceral Ischemia
from Type B Dissections
Colin P. Ryan, Tara Mastracci MD, Lina Vargas MD,
Sunita Srivastava MD, Mathew Eagleton MD,
Rebecca Kelso MD, Sean Lyden MD, Daniel Clair MD, and
Timur P. Sarac MD
Department of Vascular Surgery
Cleveland Clinic Foundation

2. Disclosures
• Colin P. Ryan: Nothing to disclose
• Tara M. Mastracci: Cook, Speaker’s bureau
• Matthew J. Eagleton: Cook, Speaker’s bureau
• Sunita Srivastava: Nothing to disclose
• Rebecca Kelso: Nothing to disclose
• Sean Lyden: Medtronic, Consulting fees/other remuneration
• Daniel G. Clair: Endologix, Consulting fees/other
remuneration
• Timur P. Sarac: AAA patents, Ownership/Partnership

3. Introduction
• Ischemia-complicated acute type B dissection (icABAD) is
associated with mortality ranging from 43-50% of cases, despite
advances in treatment.
• TEVAR has emerged as the preferred treatment of malperfusion
due to lower morbidity and mortality when compared to open
surgery for emergent cases.
• Identifying the contributing factors to mortality will help to select
patients for type of repair.

4. Objective
• The purpose of this study is to evaluate our results of type B
dissection complicated by ischemia and specifically:
– to determine factors associated with mortality and
reintervention
– to evaluate the efficacy of TEVAR
– to evaluate visceral ischemia versus other branch vessel
compromise

5. Methods
• Retrospective review of all dissections complicated by
malperfusion and treated with TEVAR from 1999 to 2011.
• Exclusion criteria:
• Type A dissection
• Open aortic graft replacement
• Traumatic dissection
• TEVAR/Open repair at outside hospital prior to transfer
• Branch vessel stenting without TEVAR
• Outcomes measures analyzed included:
 Mortality: 30-day/in-hospital and cumulative survival
 Complications
 Freedom from reintervention
 Univariable analysis w/ Cox proportional hazards

6. Patient Demographics
61 patients treated - Men 44 Women 17; Median age: 59.0±3.60 yrs

7. Ischemic Vascular Bed
100
90
73.8
80
62.3 60.7
70
Percentage
60
50
40
30
20
11.5
10
0

8. False Lumen Status
Post-op
Mean follow-up time: 37.1±30.4 months
False Lumen Status Frequency (%)
Partial Thrombosis: 8 (13.1%)
Peri-stent Thrombosis: 25 (40.9%)
Patent Distal False Lumen
Complete Thrombosis 8 (13.1%)

9. Procedure Demographics
• Proximal Landing Zone:
– 39.3% Distal to LSA
– 60.7% Proximal to LSA
• Time to treatment:
– 36 patients < 24 hours
– 25 patients > 24 hours
• Mean # stents deployed: 1.62
– 99 aortic stents in 61 patients

10. Procedure Demographics (cont.)

11. Cumulative Survival
• 30 day/in hospital mortality: 21.3% (13 patients)
71%
60% 56%

12. Univariable Analysis of
Cumulative Survival Factors
► Male HR 0.42 p=.040
► Quit Smoking HR 0.31 p=.047
LSA Occlusion
► HR 2.97 p=.034
• Small number of patients precluded multivariable analysis

13. Complications
• 3 patients suffered CVA:
− 2 died within 30 days
− 3rd died within 3 months

14. Reintervention by Late Aortic Event
Late Aortic Event Freq. Reintervention Rate
Aneurysm 7 71.4%
Dissection Ext. 14 57.1%
Type I Endoleak 7 57.1%
Type II Endoleak 4 75%
Type III Endoleak 1 100%

15. Cumulative Freedom From Reintervention
76%
68%
42%

16. Univariable Analysis of
Freedom from Reintervention Factors
Nonsmoker
► HR 0.23 p=.019
SC Ischemia HR 5.39
► p=.017
Small number of patients precluded multivariable analysis

17. Visceral Ischemia Comparisons
Freedom From Reintervention Cumulative Survival
P=0.21

18. Limitations
• Despite 12 years of data, number of patients was too small for
reliable multivariable analyses.
• Non-randomized, single center, retrospective study precludes
drawing conclusions about TEVAR vs. other therapies for
icABAD

19. Conclusions
• TEVAR for emergent cases of ischemia-complicated acute type
B dissection demonstrated an acceptable 30-day mortality rate.
• The mortality rates from TEVAR for icABAD are superior to
reported open repair rates with regard to 30-day mortality and
long term survival.
• Women and tobacco users are at greater risk of cumulative
mortality during 5 year follow-up.
• Stent graft coverage of the LSA was associated with decreased
survival at 1, 3, and 5 years.
• Spinal cord ischemia and tobacco use were associated with
increased risk of aortic reintervention during follow-up.
• The increasing need for reintervention over time indicates that
better devices are needed.