CCS-CSCS-CSVS_2016

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CCS-CSCS-CSVS_2016
2016 CCS/CSCS/CSVS Joint Position Statement on Open and Endovascular
Thoracic Aortic Surgery
Jehangir Appoo
Multidisciplinary Thoracic Aortic Rounds
Foothills Medical Centre
January 29th, 2016
Multidisciplinary Thoracic Aortic Rounds
History
Feedback
Content
Format
Why 18mins ?
long enough to be serious and short enough to hold people’s attention
Why 18mins ?
long enough to be serious and short enough to hold people’s attention
Speakers have to think about what they want to say. What is the key point they want to
communicate?
a clarifying effect
brings discipline
Why 18mins ?
long enough to be serious and short enough to hold people’s attention
Speakers have to really think about what they want to say. What is the key point they want to
communicate?
a clarifying effect
brings discipline
“Cognitive Backlog”
act of listening can be as equally draining as thinking hard about a subject
“the more information we are asked to take in, the heavier and heavier it gets.
Eventually, we drop it all, failing to remember anything we've been told.”
CCS/CSCS/CSVS
Joint Position Statement on
Interventions for Thoracic Aortic Disease
Presented @ CCC Oct.2015 – Toronto
Canadian Journal of Cardiology, In Press
2014
Topics: Size thresholds, Genetics, Medical Therapy,
Diagnostic Imaging
Surgery and Endovascular Interventions not covered
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Process
• Proposal for Position Statement accepted
• Nationally Representative Primary Panel
– Cardiac & Vascular Surgery
• Focus on novel and emerging technical aspects of
thoracic aortic disease interventions
• Structured and focused literature review
–
–
–
–
Not “expert” consensus opinion
Primary literature
Existing systematic reviews when present
Creation of summary tables
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Process
GRADE criteria
– Quality of Evidence: Low, medium, or high
– Cohort studies, RCTs…
– Recommendations: graded as strong or weak
– Quality of evidence
– Balance btw desired and undesired effects
– Values and Preferences
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Process
• Voting by Primary Panel
• Review by International Secondary Panel
• Review by CCS Guidelines Committee
• Review by CCS, CSCS, and CSVS Executive
• *avoided use of “centres of expertise” term in Recommendation
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Primary Panel
Jehangir Appoo (Co-chair)
John Bozinovski
Michael Chu
Ismail El-Hamamsy
Tom L. Forbes
Michael Moon
Maral Ouzounian
Mark Peterson
Jacques Tittley
Munir Boodhwani (Co-chair)
www.ccs.ca
University of Calgary
University of British Columbia
Western University
University of Montreal
University of Toronto
University of Alberta
University of Toronto
University of Toronto
McMaster University
University of Ottawa
Interventions for Thoracic Aortic Disease
Guidelines
Secondary Panel
Joseph E. Bavaria
Francois Dagenais
Mark Farber
Chad Hughes
Thoralf Sundt
www.ccs.ca
University of Pennsylvania
Laval University
University of North Carolina
Duke University
Harvard University
Interventions for Thoracic Aortic Disease
Guidelines
Sections
1. Aortic valve preservation and repair
1. Aortic valve replacement in the young
2.
3.
4.
5.
6.
7.
8.
Perfusion techniques for aortic arch surgery
Total and Hybrid Arch repair
Extended repair for type A dissection
Total endovascular arch repair
Descending thoracic aortic aneurysms
Acute type B dissections
Chronic type B dissections
Document contains total of 20 Recommendations
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Highlights Today
1. Aortic valve preservation and repair
1. Aortic valve replacement in the young
2.
3.
4.
5.
6.
7.
8.
Perfusion techniques for aortic arch surgery
Contemporary total and hybrid arch repair
Extended repair for type A dissection
Total endovascular arch repair
Descending thoracic aortic aneurysms
Acute type B dissections
Chronic type B dissections
8 recommendations
Share some data behind recommendations
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Aortic Valve Preservation
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Free Margin Plication
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Reimplanation and BAV repair
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Meta-Analysis
Takkenberg Ann Thorac Surg 2015
N = 2,891 Patients
Total Follow-up Time: 11,274 pt-years
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Early Mortality
Pooled Estimate: 1.53% (0.90 – 2.3)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Endocardits
Pooled Estimate: 0.23%/pt-yr (0.08 – 0.44)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Thrombo-embolism
Pooled Estimate: 0.33%/pt-yr (0.2 – 0.4)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Late AV Reoperation
Pooled Estimate: 1.2%/pt-yr (0.6 – 2.0)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
PROACT Trial – Mechanical Valve
Outcome
Low INR
Regular INR
P-value
Neurologic Events
2.07%/pt-yr
1.46 %/pt-yr
0.38
All TE
2.67%/pt-yr
1.59 %/pt-yr
0.16
TE + Thrombosis
2.96%/pt-yr
1.85 %/pt-yr
0.17
Total Mortality
1.48%/pt-yr
1.46%/pt-yr
0.97
Total Bleeding
2.67%/pt-yr
6.62%/pt-yr
<0.001
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
A Word of Caution
JTCVS 2014
•
•
•
•
•
Prospective, multi-center, international
registry –ao root replacement in Marfans
Ao Valve Sparing vs. Replacement
316 pts – 76% AVS
Early Mortality 0.6%
Early (1-year) AI recurrence 7%
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
#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 and bicuspid aortic valves.
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
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.
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Considerations for Aortic Valve
Replacement inYoung Patients
with Aortic Dilatation
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Considerations for Aortic Valve Replacement
in Young Patients with Aortic Dilatation
• Aortic valve replacement is required if a
successful and durable valve-sparing/repair
operation can not be performed
• The ideal valve substitute remains elusive
• There is a paucity of data especially in patients
with associated aortic dilatation
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Considerations for Aortic Valve Replacement
in Young Patients with Aortic Dilatation
• Growing body of literature focusing on this
specific patient subset in the last 5-10 years
• Options
–
–
–
–
Mechanical
Tissue
Ross
Homograft
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Mean
Age
(years)
BAV
(%)
AS (%)
/
AI (%)
/
Mixed
AS-AI
(%)
Operativ
e
mortality
(%)
5-Year
Surviv
al (%)
10Year
Surviv
al (%)
15Year
Surviv
al (%)
5-Year
Freedom
from
reoperatio
n (%)
10-Year
Freedom
from
reoperatio
n (%)
15-Year
Freedom
from
reoperatio
n (%)
Study
Study Type
Study
Period
N
Mean
Followup
(years)
ElHamamsy
et al. (2010)2
RCT
19942001
216 pts
(108
Ross)
10.2
(2173
pt-yrs)
38
49%
28%
45%
27%
0.9%
97%
97%
95%**
96%
95%
94%
Sievers et
al. (2015)3
Multicenter
Ross
Registry
(prospective)
19902013
1779
8.3
(14,288
pt-yrs)
44.7
64.8
%
24%
22%
52%
1.1%
NA
NA
90%**
94.9%
91.1%
82.7%
David et al.
(2014)4
Single center
19902004
212
13.8*
34
71.7
%
0.4%
98.6%
97.5%
93.6%*
*
AG 98%
HG 100%
AG 97%
HG 98%
AG 93%
HG 96%
Mastrobuon
i et al.
(2015)5
Single center
19912014
306
10.6*
42
58.5
%
2.3%
NA
NA
88%**
NA
NA
75%
(AS 83%)
(AI 65%)
Skillington
et al. (2013)6
Single center
19922012
310
9.4
39.3
92%
0.3%
98%
98%
97%**
97%
94%
93%
Da Costa et
al. (2014)7
Single center
19952013
414
8.2
30.8
50%
2.7%
NA
NA
89.3%*
*
NA
NA
81%
Kalfa et al.
(2015)8
Single center
19902013
221
11.4*
41.5
76.5
%
81%
0%
19%
0.9%
NA
92%
90.5%
NA
95%
88%
Andreas et
al. (2014)9
Single center
19912011
246
10*
29
75%
29%
40%
31%
1.6%
96%
94%
91%**
95%
88%
81%
www.ccs.ca
50%
36%
13%
68%
31%
0%
46%
32%
22%
29%
39%
31%
Interventions for Thoracic Aortic Disease
Guidelines
Considerations for Aortic Valve Replacement
in Young Patients with Aortic Dilatation
#3 We recommend that the Ross procedure be
considered as an alternative for prosthetic valve
replacement in young adults with bicuspid or
tricuspid aortic valve stenosis and aortic dilatation.
(Strong recommendation, Medium Quality Evidence)
Values and Preferences: The Ross procedure is most appropriate in patients with
high levels of physical activity, those contemplating pregnancy and patients with small
aortic annuli at risk of patient-prosthesis mismatch. Patients with aortic regurgitation
and a dilated annulus may be at higher risk of a late operation. This recommendation
elicited varied opinions from the expert panel, but was ultimately approved by the
majority of panel members following extensive review of the available literature.
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
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
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Case Example: 46y.o male flown in from OSH
Hemodynamic shock
Abdomen tender
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Intima intussuscepted
through arch
Interventions for Thoracic Aortic Disease
Guidelines
Case Example: 46y.o male flown in from OSH
Compromised visceral flow
Renal infarct/malperfusion
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Case Example: 46y.o male flown in from OSH
Both legs:
Cold
Mottled
Pulseless
Paralyzed
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Interventions for Thoracic Aortic Disease
Guidelines
46y.o male
Will visceral, renal, & peripheral malperfusion be resolve?
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
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
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Standard hemiarch
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Interventions for Thoracic Aortic Disease
Guidelines
Extended Arch
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Interventions for Thoracic Aortic Disease
Guidelines
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
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Extending the Distal Repair
• What does the literature tell us?
• Randomized controlled trials?
– No RCT comparing extent of distal repair in acute type A
dissection exist
– Unlikely for one to be forthcoming
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
The Primary Intimal Tear
DOES A STANDARD HEMIARCH ADDRESS ALL
PRIMARY INTIMAL TEARS
•Not all
– “Only 60 % of patients with acute type A dissections arose
from solitary primary intimal tears in the ascending aorta”
– Lansman et al. Ann Thorac Surg 1999; 67: 1975-1980
– Those not in the ascending aorta are not addressed by
hemiarch procedures
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Interventions for Thoracic Aortic Disease
Guidelines
Extending the Distal Repair
RESECTION OF THE PRIMARY INTIMAL TEAR
Does it decrease the need for reoperation?
• Failure to resect the intimal tear was independent
determinant for late re-operation in these studies
– Moon et al. Ann Thorac Surg 2001; 71:1244-1250
• In 95 survivors of ATAD repair
– Kazui et al. Ann Thorac Surg 2002; 74: S1844-1847
• In 113 survivors of ATAD repair
– Zeirer et al. Ann Thorac Surg 2007; 84: 479-487
• Odds ratio 4.0 (168 survivors of ATAD repair)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Extending the Distal Repair
PATENCY OF THE FALSE LUMEN
Does it increase risk of death
• YES
survival
– Halstead et al. J Thorac Cardiovasc Surg 2007; 133:127-135
• 179 patients with type A dissections (DeBakey I)
• Patency of the false lumen was a predictor of death after
discharge
– Sagaguchi et al. ICVTS 2007; 6: 204-208
• 52 patients
months
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Interventions for Thoracic Aortic Disease
Guidelines
Extending the Distal Repair
PATENCY OF THE FALSE LUMEN
Does it increase risk of death
• NO
– Kimura et al. J Thorac Cardiovasc Surg 2008; 136:1160-1166
• 193 patients with type A (DeBakey I) dissections
• 124 patent false lumen; 69 thrombosed
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Interventions for Thoracic Aortic Disease
Guidelines
Extending the Distal Repair
PATENCY OF THE FALSE LUMEN
Does it increase risk of reoperation
• YES
– Sagaguchi et al. ICVTS 2007; 6: 204-208
• NO
– Kimura et al. J Thorac Cardiovasc Surg
2008; 136:1160-1166
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Extending the Distal Repair
Malperfusion
Patients with malperfusion have an increased mortality
Mortality increases depending on number of organ
systems involved
None
One
Two
Three
12.6%
21.3%
30.9%
43.4%
GERAADA REGISTRY, JACC 2015; 65(24)
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Interventions for Thoracic Aortic Disease
Guidelines
Review of Publications for Extended Distal Repair for Acute Type A Dissection
www.ccs.ca
Author
(Reference)
Year
Type of repair
Yun et al.10
Kazui et al.11
Takahara et
al.12
Ohtsubo et
al.13
Watanuki et
al.14
Kim et al.15
Mizuno et al.16
Tsagakis et
al.17
Ma et al.18
Katayama et
al.19
Roselli et al.20
Pan et al.21
Chen et al.22
Preventza et
al.23
Vallabhajosyul
a et al.24
Diethrich et
al.25
Marullo et al.26
Kent et al.27
Chang et al.28
1991 Total Arch
2000 Total Arch
2002 Total Arch
Permanent
Stroke (%)
7
70
37
30-day / inhospital mortality
(%)
29
16
8.1
N/A
2.9
0
Permane
nt SCI
(%)
N/A
1.4
0
2002 Total Arch
24
33.3
12.5
N/A
2007 Total Arch
54
3.7
5.6
0
2011 Total Arch
2002 FET & Total arch
2010 FET & Total arch
44
9
68
13.4
11.1
13
15.9
11.1
10
2.3
22.2
1
2013 FET & Total Arch
2015 FET & Total Arch
398
120
7.8
6
2.5
3
2.5
2
2013
2013
2014
2014
17
27
122
25
0
0
4.93
12
0
0
0
12
0
0
0
0
2014 FET & Hemi Arch
62
14
8
1
2005 Arch Debranching
1
0
0
0
2010 Arch Debranching
2012 Arch Debranching
2013 Arch Debranching
15
1
21
4.2
0
4.8
0
0
0
0
0
0
FET & Hemiarch
FET & Hemiarch
FET & Hemi Arch
FET & Hemi Arch
N
Interventions for Thoracic Aortic Disease
Guidelines
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
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
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)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
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.
b.
c.
d.
Distal malperfusion
Concomitant descending thoracic aortic aneurysm
Young patients
Patients with connective tissue disorders
(Weak recommendation, Low Quality Evidence)
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Since 2008, known that in complicated acute Type B Dissection,
Endovascular Rx is first line of therapy.
Management of Acute Uncomplicated Type B is not as clear
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
“Uncomplicated” Type B - ? misnomer
Admission mortality < 10%
5 year mortality substantially higher in some publications
51 y.o male
Admission
acute Type B
www.ccs.ca
6 months
Interventions for Thoracic Aortic Disease
Guidelines
2 years post
Type B
Uncomplicated Type B
Medical Management Alone vs. TEVAR & Medical management
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
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Predictors of Growth:
Initial aortic diameter > 4cm
False Lumen > 22mm
Large proximal entry tear >1.0cm
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
#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.
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
#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.
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
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
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines
Highlights Today
1. Aortic valve preservation and repair
1. Aortic valve replacement in the young
2.
3.
4.
5.
6.
7.
8.
Perfusion techniques for aortic arch surgery
Total and hybrid arch repair
Extended repair for type A dissection
Total endovascular arch repair
Descending thoracic aortic aneurysms
Acute type B dissections
Chronic type B dissections
www.ccs.ca
Interventions for Thoracic Aortic Disease
Guidelines

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