DEBATE: Surgical Treatment for Chronic Type B Aortic ...

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Darren B. Schneider, MD

Associate Professor of Surgery

Chief, Vascular and Endovascular Surgery 03.08.2019

DEBATE: Surgical Treatment for Chronic Type B Aortic DissectionEndo approach is the preferred option

Disclosures

W.L. Gore - research funding; consulting; medical

advisory board

Cook - research funding

Medtronic - medical advisory board

Endologix - research funding

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Ronald Stoney, MD

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Thoracoabdominal Aortic Aneurysm

“Pillsbury” Incision

Pillsbury Crescent Rolls

“Dr. Pillsbury”

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Largest Open TAAA Experience

Aftab J Thorac Cardiovasc Surg 2015Cosselli J Thorac Cardiovasc Surg 2016

➢ Lack of a Learning curve:

▪ No improvement in outcomes

from 1st to 3rd decades

➢ Poor Outcomes in patients ≥ 80 yrs:

▪ 26% Mortality

▪ 62% for extent II TAAA

3309 TAAA repairs over 3

decades

➢ Median age 67 yrs

Open TAAA Repair:

Real World Outcomes

California Office of Statewide

Health Planning and Development

(OSHPD) patient discharge

database from 1995 to 2010

N = 1188

➢ Mortality 23.9%

➢ Outcomes were not better at

high volume centers

Weiss Vasc and Endovasc Surg 2014

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TBAD: Progression to Chronic Phase

• Mortality 25% within 3 years

• False lumen growth averages 3mm-12mm/year

• 50% of patients rupture or require repair within 4 years

Conrad et al. J Vasc Surg 2011Pujara et al. J Thorac Cardiovasc Surg 2012Fattori et al. JACC 2013Durham Jvasc Surg 2015

• Low 30-D Mortality:➢ INSTEAD 2.8%➢ STABLE 5%➢ ADSORB 0%

• Increased FL Thrombosis

• Favorable remodeling:

TEVAR for Acute Type B Dissection

Nienaber Circ 2009Lombardi J Vasc Surg 2012Brunkwall Eur J Vasc and Endovasc Surg 2014

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Famularo et al. J Vasc Surg 2017

Systematic review of TEVAR for TBAD

After treatment of acute TBAD» Thoracic aortic growth in 8%-63%

» Abdominal aortic growth 8%-47%

TEVAR for TBAD does not prevent late aneurysmal

degeneration

Should we TEVAR be used for uncomplicated TBAD?

TBAD: Endovascular Repair

Natural history of TEVAR after the treatment of

TBAD becoming more clear.

Aneurysmal progression is an expected outcome

in 20 - 30% of patients treated.

Higher in patients treated in acute phase

➢ Mitigation of persistent false lumen flow in these pt’s

is paramount for aneurysm regression

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Complete FL thrombosis is achieved in only 40% of patients after TEVAR (Cheng J Am Coll Card)

FL patency is independently associated with worse survival (Li Am Heart Assoc 2016)

Presence of distal reentry tears may increase the occurrence of late events and prevent remodeling (Zhu J

Vasc Surg 2017)

Proximal and distal stent grafting can improve TL perfusion, but does not affect FL patency (Canaud Ann

Cardiothorac Surg 2014)

Partial FL thrombosis may lead to faster aneurysmal degeneration (Tsai J Thorac Cardiovasc Surg 2014)

It’s All About the False Lumen

Open surgery

TEVAR +/- FL embolization» Coils, plugs

» “Candy Plug”, “Knickerbocker” (Tilo Kolbel)

“Stabilise” technique

Hybrid» Debranching + TEVAR

F/B-EVAR

Treat Options – Post-dissection

Aneurysms

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False Lumen Occlusion – “Candy Plug”

Rohlffs et al. J Endovasc Ther 2017

Dissection Bare Stent - PETTICOAT

Lombardi et al. J Vasc Surg 2012

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Dissection Bare Stent - PETTICOAT

Bertoglio et al 2016

Melissano et al. J Vasc Surg 2018

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Melissano et al. J Vasc Surg 2018

Endo vs. Open for Chronic TBAD,

A Meta-Analysis

39 studies: 10 OS, 25 ER, 4 comparative

> 2000 patients

Boufi et al. Ann Thoracic Surg, in press

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Endo vs. Open for Chronic TBAD,

A Meta-Analysis

Boufi et al. Ann Thoracic Surg, in press

ENDO(N=1271)

OSR(N=1079)

Age 59.0 yrs 58.1 yrs

deBakey IIIb 79.6% 81.5%

Urgent/emergent 4.7% 14.4%

TAA repair - 63.2%

DTA repair Almost all TEVAR 36.8%

Endo vs. Open for Chronic TBAD,

A Meta-Analysis

Boufi et al. Ann Thoracic Surg, in press

ENDO(N=1271)

OSR(N=1079)

30-d mortality 2% 9.3%

Stroke 2.7% 4.5%

SCI 2.2% 5%

Dialysis 0% 5.2%

Pulm complications 4% 24.9%

Early Outcomes

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Endo vs. Open for Chronic TBAD,

A Meta-Analysis

Boufi et al. Ann Thoracic Surg, in press

ENDO(N=1271)

OSR(N=1079)

1-year survival 91% 84%

3-year survival 91% 79.9%

Reintervention 20.2% 11.8%

Late rupture 3% 1.2%75% Endo

85% Surgical

Late Outcomes

Comparative studies (N=4) meta-analysis:

↓ early mortality for ER (OR: 4.13, 95% CI: 1.10 – 15.4)

↓ stroke for ER (OR:4.33, 95% CI: 1.02-18.35)

↓ SCI for ER (OR: 3.3, 95% CI: 0.97 – 11.25)

↑reintervention rate for ER (OR: 0.34, 95%CI: 0.16 – 0.69)

Similar mid-term survival (OR: 1.19, 95% CI:0.42 - 3.32)

Endo vs. Open for Chronic TBAD,

A Meta-Analysis

Boufi et al. Ann Thoracic Surg, in press

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FEVAR and BEVAR for Post-Dissection Aneurysms

Patient Specific

Cook platform• Any design with

fenestrations ±

branches

Off-the-Shelf

Cook t-Branch®

Gore TAMBE®

Jotec

Medtronic

Post-dissection aneurysms, N=71

F/B-EVAR

95.8% technical success

5.6% 30-d mortality

70% 3-year survival

52.6% 3-year freedom from reintervention

Oikonomou et al. Eur J Vasc Endovasc Surg 2019

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GSO: consulting and research grants from Cook Medical, WL Gore and GE Healthcare; all fees and grants paid to Mayo Clinic

No other disclosures

Outcomes of endovascular repair of post-dissection and degenerative thoracoabdominal aortic aneurysms using fenestrated-branched stent-grafts

Emanuel R. Tenorio, Gustavo S. Oderich, Mark A. Farber, Darren B. Schneider, Carlos H. Timaran, Andres Schanzer, Adam W. Beck and Matthew P. Sweet

On Behalf of the United States Fenestrated and Branched Research Consortium Investigators

DisclosuresERT: none; GSO: consulting and research grants from Cook and WL Gore paid to Mayo Clinic; MAF: consulting and research grants from Cook, WL Gore, Endologix and Medtronic; DBS: consulting and research grants from Cook, WL Gore, Endologix and Medtronic; CHT:consulting and research grants from Cook; AS: consulting and research grants from Cook; AWB: none; MPS: none

Fenestrated Branched Research Consortium Clinical Sites

Surgical Associatesof Palm Beach CountryAnthony Lee

Mayo ClinicGustavo Oderich

University ofNorth CarolinaMark A. Farber

Weill Cornell MedicineNewYork-PresbyterianDarren B. Schneider

University ofMassachusettsAndres Schanzer

University of WashingtonMatthew Sweet

University of CaliforniaSan FranciscoTim Chuter

Universityof AlabamaAdam W. Beck

Mass GeneralHospitalMatt Eagleton

University of TexasSouth WesternCarlos H. Timaran

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Patients

50 (21%)post-dissection

240 patients with Extent I to III TAAAs

190 (79%)degenerative

30-day results

Overalln = 240

Post-dissectionTAAAsn = 50

Degenerative TAAAs

n = 190P

value

Percent

30-day mortality 3 2 3 .79

Any MAE 26 24 26 .73

EBL >1L 15 14 15 .82

Acute kidney injury 8 10 7 .53

Paraplegia 6 2 7 .19

Respiratory failure 3 2 4 .55

Bowel ischemia 1 0 2 .37

Major stroke 1 0 1 .47

Myocardial infarction 0.4 0 1 .61

3% 30-day mortality

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0

50

100

0 1 2

Follow-up (years)

DegenerativePost-dissection

Surv

ival

(%

)

At risk (no.)

190 83 40

50 26 15

P=.13

89 ± 5(79 – 100)

80 ± 4(74 – 86)

84 ± 7(70 – 99)

72 ± 4(64 – 82)

Degenerative – mean follow 13.4±12 monthsvs

Post-dissection – mean follow up 14.7±11 months

Patient survival

At risk (no.)

190 83 39

50 26 15

0

50

100

0 1 2

94 ± 2(90 – 99)

Follow-up (years)

Free

do

m fr

om

Ao

rtic

-Rel

ated

Mo

rtal

ity

(%)

P=.93

98 ± 2(94 – 100)

96 ± 2(93 – 99)

98 ± 2(94 – 100)

No conversion

Patient survival

DegenerativePost-dissection

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Reintervention

All (n=240) <30 days (n=240) > 30 days (n=234)

Percent

Aortic 25 5 21

Branch kinking/stenosis/thrombosis 5 1 4

Iliac artery thrombosis/stenosis 1 1 0

Endoleak 19 3 16

Type IC 4 1 3

Type IB 3 1 2

Type II 3 1 2

Type IIIA 2 0 2

Type IIIC 5 1 4

Combined 4 0.4 3

Branch perforation 0.4 0 0.4

Type B aortic dissection 0.4 0 0.4

68 patients (28%) had re-interventions

Conclusions

Endovascular repair, especially F/B-EVAR, is the better option for treatment of post-dissection aneurysms in many patients

False lumen thrombosis is the key

Careful planning and execution is essential

Outcomes are promising» FL thrombosis

» Favorable remodeling

» Freedom from aneurysm rupture

Reinterventions are common for both OSR and ER, but for ER most are endovascular

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VASCULAR AND ENDOVASCULAR SURGERY

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