Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

AAS 3 dec 2018

From ESC GL 2014

  • Login to see the comments

AAS 3 dec 2018

  1. 1. MANAGEMENT IN ACUTE AORTIC SYNDROME : WHEN IS TEVAR NEED? F2 Parach Sirisriro 3rd Dec 2018
  2. 2. REFERENCE Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 81, 3183-3221.e Textbook Journal - Members, A. T. F., et al. (2014). "2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS)." European heart journal 35(43): 3033-3073. - Erbel, R., et al. (2015). "Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases." European heart journal 36(41): 2779-2779. JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026 - Choe, C. H. and R. R. Arya (2017). Management of Acute Aortic Syndromes. Evidence-Based Critical Care, Springer: 163-170. - Wells, C. M. and K. Subramaniam (2011). Acute aortic syndrome. Anesthesia and Perioperative Care for Aortic Surgery, Springer: 17-36.
  3. 3. REFERENCE • Hiratzka, L. F., et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease." Journal of the American College of Cardiology 55(14): e27-e129. • Group, J. J. W. (2013). "Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection (JCS 2011)." Circulation Journal 77(3): 789-828. • Mussa, F. F., et al. (2016). "Acute aortic dissection and intramural hematoma: a systematic review." Jama 316(7): 754-763. • Rozado, J., et al. (2017). "Comparing American, European and Asian practice guidelines for aortic diseases." Journal of thoracic disease 9(Suppl 6): S551. Song, C., et al. (2016). "The new indication of TEVAR for uncomplicated type B aortic dissection." Medicine 95(25).
  4. 4. OUTLINE Definition Pathology and Classification Clinical presentation and complication Treatment Indication for TEVAR Conclusion
  5. 5. DEFINITION • Acute aortic syndromes : - Emergency conditions with similar clinical characteristics involving the aorta. - Breakdown of the intima and media. - Result in IMH, PAU, or in separation of aortic wall layers,leading to AD or even thoracic aortic rupture European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  6. 6. PATHOLOGY
  7. 7. PATHOLOGY OF ACUTE AORTIC SYNDROME
  8. 8. PROGRESSION OF ONE TYPE OF ACUTE AORTIC SYNDROME TO ANOTHER TYPE Classical dissection Intramural hematoma Acute Aortic Synrdrome Aortic ulcer European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  9. 9. AORTIC DISSECTION
  10. 10. PATHOPHYSIOLOGY Static dissection Dynamic dissection European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  11. 11. AORTIC DISSECTION CLASSIFICATION DEBAKEY AND STANFORD CLASSIFICATIONS JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026
  12. 12. TEMPORAL CLASSIFICATION JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026
  13. 13. RISK FACTORS FOR DISSECTION European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  14. 14. RISK FACTORS FOR DISSECTION European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  15. 15. INTRAMURAL HEMATOMA (IMH)
  16. 16. EVOLUTION OF INTRAMURAL HEMATOMA
  17. 17. ● Diagnosis: circular or crescentic thickening >5 mm of the aortic wall in the absence of detectable blood flow. ● 10-25% of AAS – 30% ascending aorta – 10% arch – 60-70% descending TA (Type B) INTRAMURAL HEMATOMA (IMH) Type A
  18. 18. ● Diagnosis → CT/MRI – Unenhanced acquisition + contrast-enhanced acquisition in CT → sensitivity 96% ● Type-A IMH – In-hospital mortality similar to type-A AD – 30-40% evolve into AD ● Type-B IMH – In-hospital mortality similar to type-B AD INTRAMURAL HEMATOMA (IMH) JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026
  19. 19. PREDICTOR OF IMH COMLICATION European Heart Journal (2014):doi:10.1093/eurheartj/ehu2
  20. 20. PENETRATING AORTIC ULCER
  21. 21. PENETRATING AORTIC ULCER
  22. 22. • ● Ulceration of an atherosclerotic plaque penetrating through the internal elastic lamina into the media. ● 2-7% of all AAS. ● Most commonly located in the middle and lower distal thoracic aorta (type-B PAU). ● Elderly patients, smokers, HTN, associated CAD, COPD, AAA ● Diagnosis → unenhanced/contrast enhanced CT PENETRATING AORTIC ULCER JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026
  23. 23. Clinical presentation and complication
  24. 24. • Main symptoms Present in Both type A and B • Almost present in Type A Main clinical presentations and complications of patient with acute aortic dissection −
  25. 25. Main clinical presentations and complications of patient with Acute aortic syndrome Intramural hematoma Chest or back pain, tamponade High blood pressure , rarely any malperfusion Penetrating ulcer Painless or low intensity pain Pain located in back or abdomen High blood pressure, collapse with perforation Traumatic dissection or rupture Deceleration trauma, severe pain, pulse differential, syncope, Exsangunation, tamponade Stable at low blood pressure , rapid pulse prior to exsanguination JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026
  26. 26. 2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases - Imaging Techniques -
  27. 27. Diagnostic value of various imaging modalities of acute aortic syndrome European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  28. 28. Management and indication for TEVAR
  29. 29. DIAGNOSIS AND MANAGEMENT ALGORITHM FOR ACUTE AORTIC DISSECTION. ACS, ACUTE CORONARY SYNDROME
  30. 30. CLINICAL DATA USEFUL TO ASSESS THE A PRIORI PROBABILITY OF ACUTE AORTIC SYNDROME European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  31. 31. RECOMMENDATIONS FOR DIAGNOSTIC WORK-UP IN AAS European Heart Journal (2014):doi:10.1093/eurheartj/ehu28
  32. 32. DIAGNOSIS AND MANAGEMENT ALGORITHM FOR ACUTE AORTIC SYNDROME
  33. 33. European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
  34. 34. COMPLICATED TYPE-B AD - Persisting/recurrent pain - uncontrolled HTN on full medication, - Early aortic expansion, malperfusion, - signs of rupture (haemothorax, periaortic and mediastinal hematoma↑) European Heart Journal (2014):doi:10.1093/eurheartj/ehu28
  35. 35. TEVAR FOR COMPLICATED TYPE-B AD Thoracic endovascular aortic repair (TEVAR) treatment of choice →closure of the primary entry tear → decompression and thrombosis of the false lumen → malperfusion (if present) may resolve → aortic remodeling and stabilization ** Surgery reserved for patients not candidate for TEVAR European Heart Journal (2014):doi:10.1093/eurheartj/ehu28
  36. 36. Management of Intramural Hematoma (IMH)
  37. 37. Management of Penetrating aortic ulcer (PAU) Complicated PAU → Refractory pain or signs of contained rupture (rapidly growing ulcer, periaortic hematoma, pleural effusion)
  38. 38. Management of (contained) rupture the thoracic aortic aneurysm
  39. 39. Management of traumatic aortic injury
  40. 40. OUTCOME OF TREATMENT ACUTE AORTIC SYNDROME JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026
  41. 41. COMPARING AMERICAN, ASIA AND EUROPE GUILDELINE FOR ARTIC DISEASE
  42. 42. COMPARING AMERICAN, ASIA AND EUROPE GUILDELINE FOR ARTIC DISEASE
  43. 43. Conclusion
  44. 44. CONCLUSIONS ACUTE THORACIC AORTIC SYNDROMES ● Potentially deadly but at the same time treatable conditions to be considered in the differential diagnosis of acute chest pain. ● Decision making in suspected AAS should be based on the a priori probability based on a clinical score and according to the score results it should include biomarkers (D-dimers) and imaging. ● TTE: initial imaging investigation, frequently complemented by TOE/CT/MRI. ● Type-A AD → urgent surgery. ● Type-B AD → complicated →TEVAR → uncomplicated →TEVAR to be considered.
  45. 45. CONCLUSIONS ACUTE THORACIC AORTIC SYNDROMES (2) • ● IMH – Type-A → surgery recommended – Type-B → OMT; if complicated TEVAR should be considered ● PAU – Type-A → surgery should be considered – Type-B → OMT; if complicated TEVAR should be considered ● (Contained) rupture of TAA and traumatic aortic injury – If anatomy favorable and expertise available → TEVAR preferred over surgery
  46. 46. THANK YOU

×