Prediction of Aortic Growth in Uncomplicated TBAD

Prediction of Aortic Growth in
Uncomplicated TBAD
Frans L. Moll
Uncomplicated type B aortic dissection
• 45-55% of TBAD presents uncomplicated
• 1-10% in-hospital mortality
Tsai et al.EJVES 2006
Best medical treatment
• Medical treatment first option
• Mortality best medical treatment 6.4%
(vs. TEVAR 10.2% vs. Open surgery 17.%)
Cao et al. Circ 2010
Fattori et al. JACC 2013
Uncomplicated TBAD: long-term outcome
• Long term prognosis
 Survival rates 48% to 82% after 5 years
• Large percentage of mortality aortarelated
 Aortic rupture or extension of the
dissection
Trimarchi et al. Circ 2006
Estrera et al. ATS 2007
TEVAR in uncomplicated TBAD
• Remains debated
5-yr mortality
TEVAR
15,5 %
Medical
29,0 %
Disadvantages of TEVAR in TBAD
• TEVAR in TBAD has been associated
with severe complications:
• Endoleaks
• Retrograde Type A dissection
• Conversion to open surgery
• Up to 30% of patients require
reintervention
• 50% have excellent results with OMT alone
• Costs
Parker et al. ATS 2008
Walker et al. JTCVS 2010
Question
• May
Which
needs
to be stented
and which
patient can
wepatient
improve
the outcome
of individual
uncomplicated
benefit
from medical
therapy
alone?
type
B dissection
patients
based
on predictors of aortic
growth ?
Predictors of aortic growth
• The role of partial lumen thrombosis
Patent
Partial
Thrombosis
Complete
Thrombosis
P- Value
Initial aortic
diameter
32.0 ± 6.9
38.0 ± 12.0
35.2 ± 8.4
<.001
Final aortic
diameter
34.7 ± 7.7
43.1 ± 14.4
39.3 ± 12.2
<.001
Mean growth
2.10 ± 5.56
4.25 ± 10.18
1.51 ± 5.65
.069
Trimarchi et al. JTCVS 2012
Predictors of aortic growth
• Number of entry tears
8.00
Mean Aortic Growth Rate (mm/year)
6.00
4.00
2.00
0.00
-2.00
0
1
2
3
4
Number of entry tears
Error Bars: 95% CI
Tolenaar et al. ATS 2012
Predictors of aortic growth
• Size of entry tears and location
Evangelista et al. Circ 2012
Predictors of aortic growth
• Inital aortic diameter
Jonker et al. ATS 2012
Predictors of aortic growth
• Saccular formation
Tolenaar et al. JVS 2013
Predictors of aortic growth
• Circular shaped treu lumen
• False lumen located on outer curvature
Tolenaar et al. JVS 2013
Predictors of aortic growth
Van Bogerijen et al. JVS 2014
Conclusion
• Recent years, several predictors of aortic growth in TBAD
have been identified
• These findings can help to stratify which patients may
benefit from early intervention
Future perspectives
• Dynamic imaging
• Fluid dynamics
Discussion
When do we have identified enough risk factors to start
The proper multicenter randomized trial in the most efficient
module