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
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
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.
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
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
Patient Demographics61 patients treated - Men 44 Women 17; Median age: 59.0±3.60 yrs
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
Complications• 3 patients suffered CVA: − 2 died within 30 days − 3rd died within 3 months
Reintervention by Late Aortic EventLate Aortic Event Freq. Reintervention RateAneurysm 7 71.4%Dissection Ext. 14 57.1%Type I Endoleak 7 57.1%Type II Endoleak 4 75%Type III Endoleak 1 100%
Cumulative Freedom From Reintervention 76% 68% 42%
Univariable Analysis of Freedom from Reintervention Factors Nonsmoker ► HR 0.23 p=.019 SC Ischemia HR 5.39 ► p=.017Small number of patients precluded multivariable analysis
Visceral Ischemia ComparisonsFreedom From Reintervention Cumulative Survival P=0.21
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
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.