Vascular
Peter Lin, MD
Southern Association for Vascular Surgery
2007 Postgraduate CourseSan Juan, Puerto Rico
Penetrating Ulcer and Aortic Dissection
Peter H. Lin, MD
Baylor College of Medicine
Houston, TX
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Presentation Outline
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
• Medical
• Stent-grafting
• Fenestration
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Acute Aortic Syndrome
•Aortic dissection
• Limited intimal tear with eccentric bulge
•Intramural hematoma
• Pre-dissection ?
• Associated with penetrating ulcer
•Penetrating ulcer
•Traumatic transection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Hayter RG, Radiology 2006; 238:841-852
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Suspected Acute Aortic SyndromeMDCT in 373 Emergency Evaluation
•N=365 patients; men: 56%; women: 44%
•Mean age: 61 years (range 21 to 96); men: 61; women: 69
•67 cases (18%) positive for acute aortic disorders (n=112)
• 23 (34%) acute aortic dissections; A=13 (19%), B=10 (15%)
• 14 (21%) acute aortic IMH; A=1 (2%), B=13 (19%)
• 20 (30%) acute penetrating ulcer; A=3 (5%), B=17 (25%)
• 44 (67%) new or enlarging aortic aneurysms
• 11 (17%) acute aortic ruptures
•Overall hospital mortality: 6% (4/67); A=2; B=2; 3/4 ruptured
Hayter RG, Radiology 2006; 238:841-852
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Diagnosis of Chest Pain in the ER.
0% 5% 10% 15% 20% 25%
Percentage
Aortic dissection
No clear diagnosis
Cardiac arrhythmia
Vasovagal
Pulmonary disease
Neuro-radicular pain
Acute coronary syndromes
ED Diagnosis
von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Presentation Outline
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
• Medical
• Stent-grafting
• Fenestration
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Acute Aortic Dissection
• Most common aortic emergency
• Incidence double that of ruptured
abdominal aortic aneurysms
• Without treatment, 36-72% of patients
will die within 48 hours (one week
mortality of up to 91% )
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Aortic Dissection
• Classic presentation includes acute-onset, severe chest/back pain described as “tearing” or “ripping”
• Atypical presentations are common
• 15% of patients report NO pain
• Supportive findings include pulse deficit, new aortic regurgitation, tamponade, and focal neurological deficits
• Majority of patients have no specific physical findings
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Aortic Dissection: CXR Findings
0 10 20 30 40 50 60 70 80
Sensitivity (%)
Displaced intimalcalcification
Pleural effusion
Wide mediastinum
Abnormal aortic contour
Ch
est
X-R
ay F
ind
ing
s
Klompas M. JAMA. 2002;287:2262-72.
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Abnormal CXR finding – a 1-cm separation between the intimal calcification and the adventitial outline of the descending aorta (the “calcium sign”), consistent with aortic dissection.
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Transesophageal Echocardiography of Aortic Dissection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Presentation Outline
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
• Medical
• Stent-grafting
• Fenestration
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
•Stanford Type A / DeBakey Type II
Classification
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
•Stanford Type B / DeBakey III
Classification
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Classification of Aortic Dissection
1. Classic with true and false lumens separated by intimal flap
2. Medial disruption with intramural hematoma or hemorrhage
3. Discrete/subtle aortic dissection bulge at tear site with no hematoma
4. Plaque rupture/penetrating aortic ulcer
5. Iatrogenic and traumatic dissection
Task force on aortic dissection, European Society of Cardiology, Eur Heart J 2001;22: 1642-81
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Class 1: Classic dissection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Aortic Dissection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Class 2: Intramural hematoma
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Intramural Hematoma
In contrast to typical aortic dissection, in which there is an intimal tear, IMH is caused by a spontaneous hemorrhage of the vasa vasorum of the medial layer, which weakens the media without an intimal tear.
Clinical manifestations and the risk factors in IMH are similar to those in typical aortic dissection. IMH accounts for approximately 13% of the prevalence of acute aortic dissection .
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Intramural Hematoma
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Class 3: Discrete/subtle dissection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Class 4: Penetrating ulcer
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Class 4: Penetrating ulcer
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Penetrating Ulcer
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Class 5: Iatrogenic/traumatic
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Presentation Outline
• Thoracic Aortic Pathology
• Aortic Dissection
• Classification
• Treatment Strategy
• Medical
• Stent-grafting
• Fenestration
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Initial Treatment of Type B Dissection
•Initial treatment: hypotensive medication
•Reserve intervention for 30-40% with:
• Rupture
• End-organ ischemia / malperfusion
• Localized false aneurysm
• Refractory hypertension
• Continuing pain
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Initial Medical Therapy
• Pain control: opiates
• Heart Rate control: Labetalol (bolus & maintenance)
• Heart Rate < 70
• BP control: Nipride (Target SBP< 110, DBP<70)
• Monitor hemodynamics, UOP, swan ganz catheter placement, pulses
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Initial Treatment of Type B Dissection
•Initial treatment: hypotensive medication
•Reserve intervention for 30-40% with:
• Rupture
• End-organ ischemia / malperfusion
• Localized false aneurysm
• Refractory hypertension
• Continuing pain
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Mechanisms Involved in Aortic Dissection Type B
•Primary tear: usually close to the aortic isthmus
•End-organ ischemia:
• Static obstruction from extension of dissection into side branches
• Dynamic obstruction from the intimal flap bowing into the true lumen
• Combination of static and dynamic obstruction
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
MALPERFUSION MICHIGAN CLASSIFICATION
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
TREATING MALPERFUSION
• DYNAMIC OBSTRUCTION
• ENDOGRAFT ACROSS INTIMAL TEARS
• FENESTRATION
• STATIC OBSTRUCTION
• STENTS FOR UNCOMPLICATED STENOSIS
• WITH MECHANICAL THROMBECTOMY FOR STENOSIS COMPLICATED BY POST-OBSTRUCTIVE THROMBOSIS OF TRUE LUMEN OR EMBOLISM TO TRUE LUMEN
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
TX – Endografing vs. Fenetration
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Tx – Stenting for uncomplicated stenosis
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Endovascular Treatment
• Decreases pressure in false lumen by obliterating flow
• Causes thrombosis of the false lumen which is associated with good long term outcome
• Should treat dynamic obstruction of branches
• Can help with static obstruction of branches
• Induction of aortic remodeling
•Primary tear: cover with stent graft
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Thoracic Stent-Grafting for Dissection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Thoracic Stent-Grafting for Dissection
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Thoracic Stent-Grafting for PU
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Thoracic Stent Grafts
•TAG, WL Gore & Associates
• Nitinol stent with polytetrafluoroethylene
•Talent, Valiant, Medtronic AVE
• Nitinol stent with polyester
•TX-2, Cook Inc.
• Stainless steel with polyester
•Endofit, Endomed Inc.
• Nitinol stent with polytetrafluoroethylene
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Thoracic Stent-Graft
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Zenith Thoracic Stent-Graft
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Fenestrated Thoracic Endograft
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Endovascular Treatment(Non-endograft option)
•Static obstruction: uncovered stents in origin
of branches
•Dynamic obstruction: percutaneous fenestration of
the intimal flap
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
WHAT FENESTRATION DOES
• CREATES HOLE IN THE FLAP SEPARATING FALSE
AND TRUE LUMEN
• RAISES PRESSURE IN THE TRUE LUMEN
• PROMOTES FLOW IN THE FALSE LUMEN
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
WHAT FENESTRATION DOES NOT DO
•DOES NOT REDUCE PRESSURE IN THE FALSE LUMEN
• DOES NOT “DECOMPRESS” THE FALSE LUMEN
• DOES NOT MODIFY THE RISK OF ACUTE AORTIC RUPTURE IN
TYPE A DISSECTIONS
• DOES NOT REDUCE LONG-TERM ANEURYSMAL DEGENERATION
OF THE FALSE LUMEN
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Fenestration & stents = Rx for malperfusion
• Static obstruction (S)
• Aortic obstruction due to thrombosing false lumen (F/S)
• Dissection presenting with paraplegia
• Dynamic obstruction when entry tear is unsuitable for
endografts (F/S)
• tear in ascending aorta or arch
• dissections with entry
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
FENESTRATIONCONTRAINDICATIONS
• Sever aortic insufficiency
• Leaking false lumen
• Coronary artery dissection with MI or right heart failure
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Eggebrecht et al, Heart 2003: 89: 973
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
•A 61 y/o male with acute
type B thoracic dissection.
•Despite of maximal medical
therapy, he developed right
leg arterial occlusion.
•Endovascular fenestration
was performed
Eggebrecht et al, Heart 2003: 89: 973
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
•Endovascular fenestration
was performed.
•Right groin access and
intimal flap was punctured at
the aortic bifurcation using a
Brockenborough needle into
the false lumen. PTA was
performed to enlarge the
intimal fenestrated site
Eggebrecht et al, Heart 2003: 89: 973
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
•Although balloon PTA has
reestablished the flow to the
right leg, the flow remained
impaired.
•A 14 stent was placed from
the aorta into the right
common iliac artery.
•His right leg perfusion was
restored.Eggebrecht et al, Heart 2003: 89: 973
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
•Uncomplicated type B aortic dissection should be treated with medical therapy
•Symptomatic type B aortic dissection refractory to medical intervention should undergo repair
• Open surgical repair – physiologically suitable patients
• Aortic stent-graft – to cover entry site
• Stent – to treat static obstruction
• Fenestration – to treat dynamic obstruction
CONCLUSIONS
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Endovascular Treatment Principles
yes no
fenestration
prolonged malperfusion?
A Bsurgical medical
Suitable entry tear?
endograft
yes no
dissection type?
residual malperfusion?
no yes
Goals: Treatment of malperfusion and thrombosis of false lumen
VASCULAR
Vascular
“Penetrating Ulcer and Aortic Dissection”Peter Lin, MD
Be Prepared and Know Your Tools