Chapters Transcript Video Acute Aortic Syndrome Thank you. Dr DiMasi thank everyone for allowing me to present on the subject. So acute aortic syndromes, it's a constellation of life threatening allergic diseases that are usually similar in presentation in the form of chest pain and back pain. They may start as one entity and evolved to another one. But they all do have distinct demographic pathologic clinical and survival characteristics. So the three acute aortic syndromes we're talking about is acute aortic dissection, intramural hematoma and penetrating aortic ulcer. We'll talk about each of them. Hopefully cover the big points that we need to cover acute aortic dissection. This is the communist type of acute aortic syndrome. It's about 90% of the patients belong to this category incidences 300,000 person years, two thirds of the patients are males. It starts as an internal terror and then dissection and separation of the layers of the Award tech wall. The false lumen usually has a higher pressure than the true loom and that creates most of the complications down the road. The usual classification historically was either the Becky or the stanford classification. However, recently the SVS sts did a more detailed classification which didn't only include the anatomy of the the disease but also the acuteness and presence or absence of complications. So it divides it into Type A. Or type B based on where the tear and the antenna is. If the tear is in zone zero as we see it here and red. That's a Type A. Anything else is Type B. There is also a description of where the proximal and distal extent of the dissection. and to give us more an atomic detail than just the old usual classification rule, Type B versus A. So, for example, if we say A. B 19, that means it's a tear inside somewhere in the anthem. A. Beyond zone zero. And approximate extent of the dissection is up to zone one which is between the nominate artery and the left common carotid, Then the distal is in the water that is zone nine. The other parts of the classification includes the acuity of the classification. Is it an uncomplicated patient, complicated or uncomplicated with high risk features? And this third group is the very important category that was kind of invented in this type of classification compared to the past where we classified patients are uncomplicated or complicated alone. Then about the timing, it's classified into hyper acute, the 1st 24 hours of the presentation acute, which is the first two weeks, sub acute, up to three months and then it becomes a chronic disease acute. Type Type A dissection is the more common type of dissection, including two thirds of the cases. It has a very high mortality quoted to about 1% per hour. And it's one of the very few surgical emergencies where cardiac surgeons operate at night. Different levels of repairs are based on the pathology and all required ascending award tech repair. Some of them will need root replacement, coronary implantation or awarded valve replacement. These are the different surgical options. They are all open surgery, there is no endovascular option for this category as of yet. And the description of all the different ones are beyond this presentation. Now, acute type B dissection. Again, it's because of the tear is somewhere not in zone zero. About one third of all dissections are belong to this category. And there has been major change in the management of this type of dissection because of the introduction of ivar. So as we said, there is uncomplicated dissection and this is the more common presentation of type B, including 2/3 of the cases. The treatment is always medical therapy for those cases in the ICU where they get admitted to the ICU. We give them I've medications to control, impulse control, blood pressure control and pain control. We get a cat scan once they present cat scan when they are discharged and a cat scan whenever there is a change that might show us that there is an acute complication developing and then after they discharged they all get medical therapy for life. And this was the classic treatment for all patients of uncomplicated type B aortic dissection. Now the complicated aortic dissection is a surgical emergency. What's a complicated Tybee? Tybee that's complicated by rupture or impending rupture of the aorta or clinical and organ perfusion due to obstruction of one of the branch vessels. Whether that's the mezzanine Zurich the renal or the lower extremity treatment as I said, is an emergency surgical intervention. And this is how you can get obstruction of the branch vessel either by static or dynamic obstruction and then on follow up of the classic treatment of uncomplicated patients. The international registry of aortic dissection have looked at all of these patients long term and it found out that a war tech remodeling I. E. Healing on optimum medical therapy is unlikely and less than half of the patients are supposed to be on optimal medical therapy are not getting the optimal medical therapy. And over half of those patients long term are going to develop late vortec aneurysm degeneration which is very difficult to treat. So what that excited the vascular community is to try to treat all of the uncomplicated Type B dissections so that we don't get those long term complications and problems. And that created the instant trial which is a randomized trial which took all of uncomplicated type a acute aortic dissection. I'm sorry, acute dissection to treat it either by optimal medical therapy alone or opt in medical therapy plus tip bar. And they found that after two years there is no survival benefit for routine tiv are compared to optimal medical therapy. But there was better remodeling of the award to the healing of the award to in the group. They extended the follow up for five years which is the instead excel trial. And that showed again the five year all cause mortality was not statistically different between the two groups. However, the award to specific mortality was significant. So maybe if we follow these patients even more, we can start seeing a difference. So because the optimal medical therapy alone is having those problems with late complications and treating all patients up front is not making a difference. Maybe the treatment should be somewhere in the middle. It's not medical therapy alone or it's not surgical therapy alone. Maybe there is a group where they have high risk features that can anticipate those patients are going to be the ones who are going to get complications in the future. And those patients we treat them bite ivar and then those will do better. And that is what's ongoing right now in the vascular community, looking at which group should get that treatment early on to prevent the late complications. And that is the uncomplicated patient with high risk features that was created in the new classification. The high risk criteria for aortic dissection is a moving target. It's still, we don't know all of the factors, but those are the factors that currently known to be associated with long term problems with the water. And about over half of the patients belong to this category. And the uncomplicated group that tells us the problem is actually bigger than what we expect. So where does optimal medical therapy stay? It's opt in medical therapy is for everyone whether that's a cute just presenting now or can be the only modality for patients with uncomplicated or dissection with low risk features or as a bridge to get them to the sub acute stage to get them treated if they have uncomplicated presentation with high risk features that the group we talked about or post operative for anyone who got the surgical therapy. So what's the surgical management? Surgical management is all the time for emergency cases. What's emergency? Is that patients who are complicated or dissection the ones who ruptured or map of fusion or after cooling the patient with high risk features to get them at war to prevent long term complications. Or for chronic aortic dissection, aneurysms, degeneration down the road. And mind you, the treatment of those patients is extremely difficult. So what's the surgical treatment currently for T. B. Aortic dissection? The primary treatment is to bar and the whole idea of the T. Bar is to seal or cover the area of the proximal tear, redirect the flow into the true lumen and then that will allow the government to expand on the false lumen from both. Now we have to cover all of the administration's down in the award to and usually that means we have to cover down to the celiac artery and we should not oversize those graphs and we should not balloon them because there is a high risk of rupture of the septum and then you can create retrograde aortic dissection or a new dissection. We use ivy's a lot of times and the highest complication rate is in the hyper acute and acute phase. That's why if we are going to use a T. Bar, it's better than after two weeks of the presentation where the patients are sub acute. The risk of those complications of the treatment is lower, but at the same time we get the benefit of the procedure. Now we are alone is successful about 80% of the time. 10-20%. We need to do something else. Like if you have a branch vessel that's occluded and putting the bar doesn't completely revascularization. We need to do a stent with or without administration of the septum and that will help to get out of the emergency. Now we can. Another problem is if you have a rupture and if you have rupture you can have continued bleeding from the water even though you seal the proximal tear, then you need to seal distantly in the false loom and that's where we put a plug and try to avoid any retrograde flow from the true looming distantly. That will cause continued bleeding. Sometimes you put the T. Bar and the true looming doesn't really fully expand because the pressure and the false lumen was pretty high. Then we have a bare metal stent that we can extend beyond the T. Bar portion and that will help to kind of expand the true lumen, maintaining the flow through the branches and we can actually stent through that stent into the branches if there is a branch compromise. So what's the outcome of acute dissection? 30% are complicated. 10% have 30 day mortality of all comers. Of the complicated 1 60% have mortality within 30 days. The overall survival is 90% in one and two years. For those who can survive to get out of the hospital and the presentation, the 10 year survival is very variable depending on how the award to behaves and that is very variable between the patients, failure of positive remodeling is associated with long term complications, mainly big aneurysm degeneration, usually in a very bad area of the water and that affects long term survival. So how about I match which is intramural hematoma. That's another disease where there is a hematoma within the world of the water that doesn't communicate with the true lumen patients are usually older. The presentation is the same as acute aortic dissection. They have kind of a similar outcome. And for those patients, the treatment is essentially the same optimal medical therapy. Cat scan and presentation. Cat scan at discharge and following up how that intramural hematoma is going. The treatment is bite ivar if needed, only for acute ruptures or impending ruptures or patients with big aneurysms in the presence of a big hematoma or presence of mild confusion. All of these are usually not that common. However more of the cases of treatment using tiv are are delayed Tiv are because of intractable pain or uncontrolled hypertension with medications and changes in the un repeated cat scan where the hematoma evolves to get worse and thicker. It was found that eight millim thickness of the hematoma is an independent risk factor for failure of medical therapy and most of these patients will need to work down the road. So the treatment with the T bar is the same like dissection. We don't oversize, we try to land in normal healthy award a beyond both ends of the under graft and we do not balloon That segment, Penetrating aortic ulcer is defined as an ulcer like projection in the medial lining of the artery originating at the site of a soft plaque. Again, 21% need immediate repair and 22% need delayed repair. The penetrating ulcer treatment is for reserved for symptomatic patients where there is a rupture or a large penetrating ulcer and they are treated by far along the same lines of acute aortic syndromes. In general. For asymptomatic patients, usually those patients behave in a very benign fashion. They don't progress that much and usually following the upward cat scan is reasonable. So in summary acute award tech syndrome is a group of closely related acute award pathologies. They have distinct morbidity and mortality rates management is currently evolving has significantly changed and will continue to change its treatment paradigm. Thank you very much Published December 7, 2022 Created by Related Presenters Hosam F. El Sayed, M.D. SurgerySurgery - Vascular View full profile
BROADCASTMED