Azienda Ospedaliera “S. Maria” - Terni

Dipartimento Cardio Toraco Vascolare

Dr. Fiore Ferilli

Dissezione B post A e dissezione B

primaria: analogie e differenze

Dr. Paolo Ottavi

ACUTE TYPE DISSECTION

cardiac surgery vascular surgery

INCIDENCE EXCEEDING THAT OF RUPTURED ABDOMINAL AORTIC ANEURYSMS

MGH - ATKINS MD, J VASC SURG 2006:43(2 Supl.):A30-A43

ACUTE DISSECTION

intent to treat:

1.SURVIVAL

2.Prevent aortic disease

evolution

TREATMENT STRATEGY

The objective of IRAD was to assess the etiology, mode of presentation, clinical features,

management and outcomes of patients with acute aortic dissection

550 patients with TBD

250 (45.5%) complicated

300 (54.5%) uncomplicated

Dissecazione

acuta B

complicata

TEVAR-Open

Surgery d’urgenza

Dissezione acuta non complicata

Assenza di predictors

Best Medical Therapy

sorveglianza radiologica

INSTEAD XL trial

10mm

High RiskPrimary entry tear > 10 mm

Primary entry tear location (inner curve)

Total aortic diameter (> 40 mm)

False lumen diameter (> 22 mm)

Partial false lumen thrombosis

Shape (forma circolare vs ellittica VL)

Morfologia della dissezione (lineare vs spiraliforme)

PRE-EMPTIVE TEVAR

….ma le dissezioni sono una eterogeneità di manifestazioni clinico-anatomiche

The safety success of aortic

dissection

surgery depends upon

complete resection of the

primary intimal tear with

attempted obliteration of

the

false lumen

Ascending aorta and emi-arch replacement

Ascending aorta and emi-arch replacement

Ascending aorta and arch replacement

Ascending aorta replacement and aortic archdebranching

HYBRID SURGICAL APPROACHAscending aorta, arch replacement and endoposthesis (Frozen Elephant Trunk)

Ascending aorta, arch replacement and endoposthesis (Home Made Frozen Elephant Trunk)

247 pts remaining type B after type A

112 pts primary type B aortic dissection

Median follow-up 23 months

a patent primary entry tear in patients after surgery for acute

type A aortic dissection

predictor for intervention duringfollow-up

Case report 154 aa, pregressa dissezione A (EVITA)

Dolore ingravescente, anemizzazione ATBD

C-TAG 34-200 (diametro 31.5 oversizing 9%)

Estensione distale TAG GORE 37-200mm.

Rifornimento retrogrado del falso lume. Monitoraggio pressione liquorale, TEE

CONTROLLO: PERSISTENZA RIFORNIMENTO FALSO LUME

EMBOLIZZAZIONE FALSO LUME: Coils e colla (glubran)

pre-TEVAR

CT 75 mesi

24% di reinterventi (1 mese e 6 anni)

Median time: 9 mesi

DISSEZIONI B POST A

Fondamentale un follow-up ANGIO-TAC con primo esame entro 1- 3 mesi poi ogni anno

63 mm

Nel 2014 sostituzione aorta ascendente

Entry tear in arco

Evoluzione aneurismatica (42 vs 63 mm in 3 anni 6-8 mm anno)

PROGETTO:

«KICK OFF»

Richiamare tutti i pazienti sottoposti negli ultimi 5 anni ad intervento per dissezione A con programmazione di un esame angio-TC