Risks for Retrograde Type-A Dissection After TEVAR

Frank R. Arko, III, MD

Chief, Vascular and Endovascular Surgery

Professor, Cardiovascular Surgery

Co-Director , Aortic Institute Sanger Heart and Vascular Institute

Charlotte, NC

Retrograde Type-A Dissection After TEVAR

TEVAR has shown to be an effective and durable repair option in the treatment of thoracic aortic pathology

Retrograde Type A dissection (RTAD) following TEVAR remains a highly lethal complication

Nearly two-thirds of the RTAD cases present within the first month

RTAD risk factors as described in literature are:

1. Hogendoorn W, Hunink MG, Schlosser FJ, Moll FL, Sumpio BE, Muhs BE. Endovascular vs: open repair of complicated acute type B aortic dissections. J Endovasc Ther 2014;21:503–14 2. Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP, Gore TAGI. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. Journal of Vascular Surgery

2008;47:912–8 3. Canaud L, Ozdemir BA, Patterson BO, et al: Retrograde aortic dissection after thoracic endovascular aortic repair. Ann Surg 2014;260(2):389–395

Device Oversizing (>20%)

Large Stent Graft Diameter

Proximal Landing Zone

Ascending Aortic Diameter (> 40mm)

Gender Ballooning/Iatrogenic

injury Smoking

Arch Angulation and STJ Dilation

Retrograde Type-A Timing

Intra–op – 20.9%

<30d – 50.0%

>30d – 29.1%

Range: 0 – 1825 days Canaud et al. Ann Surg 2014;00:1-7

Over 70% occur within the first 30-days

Delayed onset suggests disease progression

37% overall mortality

Pathology Treated

Patients treated for Aortic Dissection have the highest pooled rates of RTAD4

Acute TBAD had the highest associated rate for RTAD at 8.4%

Chronic TBAD associated rate for RTAD at 3%

The influence of acute dissection and aortic fragility on RTAD has been illustrated in other reports5

Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

Yanqing Chen, MD;* Simeng Zhang, MD;* Lei Liu, MD;* Qingsheng Lu, MD; Tianyi Zhang, MD; Zaiping Jing, MD

Hata M, Shiono M, Inoue T, Sezai A, Niino T, Negishi N, Sezai Y. Optimal treatment of type B acute aortic dissection: long-term medical follow-up results. Ann Thorac Surg. 2003;75:1781–1784

Landing Zone and RTAD

Landing Zone

RTAD (%)

OR (relative to zones 3/4)

0 6.8 5.7

1 2.4 1.9

2 4.1 3.3

3/4 1.3 1

RTAD rates vary significantly based on zone6

Significantly higher in Zones 0-2

7.5% during zone 0 total debranching7

Significant correlation between pathology, zone and repair complexity

Czerny M, Weigang E, Sodeck G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg. 2012;94:84–89

Canaud et al. Ann Surg 2014;00:1-7

Device Oversizing

Patients with RTAD had significantly

greater device oversizing8

• 22.0% vs. 10.3% (p<0.0001)

Each 1% oversizing above 9%

• Increase in OR of RTAD - 14% (p<0.0001)

Device Oversizing in TBAD resulted in a

higher RTAD rate - 24.4% vs 14.1%

Canaud et al. Ann Surg 2014;00:1-7

Ascending Arch Condition

Several arch characteristics for RTAD

• Enlarged aortic diameter >40mm (4.8% vs 0.9%; P =

.047)9

• Bicuspid valve

• Presence of angulated (>60°) “Gothic” arch type

• Abnormal aortic root morphology10 o Valsalva diameter >40mm (33% vs 15%, P ¼ .31) o Loss of STJ (> diameter of aortic root)

Williams JB, Andersen ND, Bhattacharya SD, et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg. 2012;55:1255-1262 Factors favoring retrograde aortic dissection after endovascular aortic arch repair Thomas Gandet, MD, Ludovic Canaud, MD, PhD, Baris Ata Ozdemir, MBBS, Vincent Ziza, MD, Roland Demaria, MD, PhD, Bernard Albat, MD, PhD, and Pierre Alric, MD, PhD; (J Thorac Cardiovasc Surg 2015;150:136-42)

Proximal Configuration

No significant differences between the proximal configuration of devices 2.8% Proximal Bare Stent (48/1724) VS 2.4% NBS, p=0.5895 (28/1159)

Zone placement and dynamic arch motion may also play a role

RTAD Experience at Carolinas Medical Center

Retrospective review of TBAD treated with TEVAR (2012 – 2017)

186 patients; Mean follow-up 569 days

Overall incidence of RTAD – 8.0% (15/186)

Number

Presentation (Days)

Percentage

1 Intra-Op 0.5%

5 1 – 30 2.6%

6 31 - 365 3.2%

3 366 - 569 1.6%

Demographics and Comorbidities

Variable; n (%)/ Mean (SD) RTAD (n-15) Non-RTAD (n-171) P-value

Male Sex 8 (46.7) 0.6

Age 61.5 (14.4) 0.9

Race 0.5

African-American 8 (53.3) 72 (42.1)

White 7 (46.7) 94 (55.0)

CAD 1 (6.7) 45 (26.3) 0.1

CKD/CRI 3 (20.0) 44 (25.7) 0.8

COPD 1 (6.7) 36 (21.1) 0.3

Diabetes 1 (6.7) 30 (17.5) 0.5

HLD 6 (40.0) 71 (41.5) 0.9

HTN 13 (86.7) 160 (93.6) 0.3

Smoking < 1yr 7 (46.7) 85 (49.7) 0.8

Marfans 1 (6.7) 5 (2.9) 0.4

Other Genetic/Connective Tissue 0 (0) 2 (1.2) 1.0

Previous Ascending/Arch Repair 2 (13.3) 11 (6.4) 0.3

Indication for Intervention

RTAD (n = 15) Non-RTAD (n = 171) P-value

Mesenteric Ischemia 2 (13.3) 8 (4.7) 0.2

Renal Ischemia 6 (40.0) 29 (17.0) 0.04

Lower Limb Ischemia 1 (6.7) 11 (6.4) 1.0

Spinal Ischemia 1 (6.7) 3 (1.8) 0.3

Aneurysm (> 6cm) 0 (0.0) 4 (2.3) 1.0

Rupture 1 (6.7) 6 (3.5) 0.5

High Risk: Refractory HTN 0 (0.0) 11 (6.4) 0.6

High Risk: Continued Pain 2 (13.3) 32 (18.7) 1.0

High Risk: Pain and HTN 1 (6.7) 23 (13.5) 0.7

Variable n(%) or Mean (SD) RTAD (n - 15)

Non-RTAD (n – 171)

Acute Complicated 8 (53.3) 50 (29.2)

Acute High Risk 3 (20.0) 69 (40.8)

Acute Uncomplicated

2 (13.3) 17 (9.9)

Chronic 2 (13.3) 35 (20.5)

Procedural Indication

Intervention Timing

Variable; n(%) or mean(SD) RTAD (n=15) No RTAD (n=171) p-value

Acute (less than two weeks) Presentation 10 (66.7) 94 (55.6) 0.4

Time to Intervention 0.4

Acute Early (<48 hours) 1 (6.7) 30 (17.5)

Acute Delayed (48 hrs-2 weeks) 9 (60) 64 (37.4)

Subacute (2-6 weeks) 1 (6.67) 19 (11.1)

Chronic 4 (26.7) 56 (32.8)

Unknown 0 (0) 2 (1.2)

Aorta Characteristics

Mean (SD); Frequency (%) RTAD (n=15) No-RTAD (n=171) P-value

Ascending Diameter 37.1 (4.9) 36.4 (4.3) 0.5

Ascending > 4cm 7 (46.7) 35 (21.5) 0.05

Arch Type 0.6

Type I 6 (40.00) 49 (28.99)

Type II 3 (20.00) 53 (31.36)

Type III 6 (40.00) 67 (39.64)

Bovine 5 (33.33) 49 (28.65) 0.8

Dissection proximal to LSA 5 (33.3) 26 (15.3) 0.1

Presence of IMH 10 (66.67) 65 (38.01) 0.03

IMH in Arch 3 (20.00) 12 (7.02) 0.1

Procedural Details

Variable; n(%) or mean(SD) RTAD (n=15) No RTAD (n=171) p-value

Proximal Landing Zone 0 - 2 14 (93.3) 109 (63.7) 0.02

Zone 0 1 (6.7) 2 (1.17)

Zone 1 4 (26.7) 8 (4.68)

Zone 2 9 (60.0) 99 (57.9)

Zone 3 1 (6.7) 44 (25.7)

Zone 4 - 5 0 (0.0) 18 (10.6)

Struts at most proximal attachment 11 (73.3) 124 (77.5) 0.7

Graft oversizing (based on CTA) 4.6 (6.1) 5.4 (6.9) 0.2

Diameter of most proximal graft 33.3 (3.3) 31.8 (4.1) 0.1

Length of most proximal graft 173.3 (25.8) 159.3 (35.1) 0.2

Number of stent grafts in thoracic aorta 1.8 (0.4) 1.7 (0.7) 0.2

Number of stents in visceral arteries 0.7 (1.0) 0.3 (0.8) 0.05

Had stents placed in visceral arteries 5 (33.3) 26 (15.2%) 0.1

Case Review

“Snorkel” repair of LSA and LCA with TEVAR in 2011

Routine follow-up (2 – year) with a Type A dissection and occlusion of LSA stent

Non-operative candidate for standard repair of ascending arch

Additional “snorkel” of innominate artery and placement of graft decided as treatment plan

Patient Presentation

Initial Angiogram

Type A Dissection

Device Placement

Final Angiogram

Minimizing Risks for RTAD

Careful patient presentation BEFORE determining treatment approach

Establish a systematic protocol to minimize threat of RTAD

Iatrogenic injury is REAL - minimize manipulation and wire/catheter movement

Size appropriately based on pathology and treatment zone

Use IVUS for all aortic procedures

Conclusions

The occurrence of RTAD after TEVAR remains relatively infrequent but devastating

Several risk factors influence risks for RTAD:

Pathology Anatomy, Procedural techniques Device selection Continued Cocaine Use

At risk patients for RTAD may require enhanced surveillance

Additional R & D and investigation must continue to further reduce the risk of

RTAD

Oversizing Treatment timing Acute Complicated TBAD Ischemia of Visceral/Renal

Arteries

Thank You Frank R. Arko, III, MD

Chief, Vascular and Endovascular Surgery

Professor, Cardiovascular Surgery

Co-Director , Aortic Institute Sanger Heart and Vascular Institute

Charlotte, NC