Aortic Diseases

Aortic Diseases
Geneviève Derumeaux, FESC
Henri Mondor Hospital, APHP
Créteil
France
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
2014 ESC Guidelines on
the Diagnosis & Treatment of
AORTIC DISEASES
Chairpersons: Raimund Erbel (Germany) & Victor Aboyans (France)
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Acute aortic syndrome
Aortic aneurysm
Genetic aortic diseases
Congenital diseases like aortic coarctation
Atherosclerotic lesions
Aortitis and aortic tumors
2014 version
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European Heart Journal
(2014):doi:10.1093/eurheartj/ehu281
Acute Aortic Syndromes (AAS)
Ï Acute aortic dissection (AAD)
Ï Intramural hematoma (IMH)
Ï Penetrating aortic ulcer (PAU)
Ï Aortic pseudoaneurysm
Ï (Contained) rupture of aortic aneurysm
Ï Traumatic aortic injury
1. Diagnosis challenging
2. Untreated may be rapidly deadly
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Class 1: Classic AD
Class 2: Intramural haematoma (IMH)
Classification of Acute Aortic Syndromes (AAS)
According to Pathophysiology
Class
3: Subtle or discrete AD
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with bulging of the aortic wall
European
Heart Journal
Class 4:
Penetrating
aortic(2014):doi:10.1093/eurheartj/ehu281
ulcer (PAU) Class 5: Iatrogenic/traumatic AD
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical Presentations and Complications of AAD
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Laboratory Testing in Suspected AD
D –Dimers
• Should always be considered along with the pretest clinical probability
• Immediately very high in AAD
• May be negative in IMH and PAU
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Clinical Probability Score of AAS
Risk score 0-3 according to the number of positive categories (1 point per column)
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
2014 ESC Guidelines on the Diagnosis and
Treatment of Aortic Diseases
Breakthrough due to Imaging followed by new Treatment Options
Landmarks for Imaging the Aorta
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
2014 ESC Guidelines on the Diagnosis and
Treatment of Aortic Diseases
- Imaging Techniques -
For work up usually more than one technique is used
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
2014 ESC Guidelines on the Diagnosis and
Treatment of Aortic Diseases
- Recommendations for Imaging -
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Decision-Making in Patients with Suspected AD
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Recommendations for Diagnostic Work-Up in AAS
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Recommendations for Diagnostic Work-Up in AAS
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Treatment of Acute Type-A AD
Ï Untreated 50% mortality within 48 hours, 90% at 1 month.
Ï Urgent surgery treatment of choice
→ 25% perioperative mortality, 18% neurologic complications
→ age increases the perioperative morbidity and mortality but
age per se not an exclusion criterion for surgery.
→ controversial for patients with major neurologic deficit or
coma; prognosis poorer but recovery possible if time from
symptom onset to surgery <5 hours.
Ï Mesenteric malperfusion
→ surgical/hybrid approach, fenestration of the intimal flap.
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Treatment of Complicated Type-B AD
Ï
Ï
Ï
Persisting/recurrent pain, uncontrolled
TEAVAR in Type-B AD
HTN on full medication, early aortic
expansion, malperfusion, signs of
rupture (haemothorax, periaortic and
mediastinal hematoma↑)
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
Nienaber CA et al. Circ Cardiovasc Interv. 2013;6:407-16
Surgery reserved for patients not
candidate for TEVAR
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Treatment of Uncomplicated Type-B AD
Ï Medical therapy to control
pain and blood pressure
Ï Repetitive imaging (MRI/CT)
Ï TEVAR → INSTEAD (XL) trials
• 140 pts, randomized TEVAR + OMT
vs OMT alone
• At 2 y TEVAR better aortic remodeling
but no difference in mortality
• Retrospective analysis of extended FU at 5y
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Progression plus aorta-related
adverse events (deaths, conversion,
ancillary interventions)
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
INSTEAD-XL Trial: TEVAR vs. Medical
Management in Stable Type-B AD
11.1% versus 19.3%
All-cause mortality
6.9% versus 19.3%
Aorta-specific mortality
Nienaber CA et al. Circ Cardiovasc Interv. 2013;6:407-416
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Treatment of Type A/B Acute Aortic Dissection
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
TEVAR for Acute Aortic Syndromes
Indications for TEVAR
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
TEVAR for Acute Aortic Syndromes
Indications for TEVAR
Recommendation for management of intramural haematoma(IMH)
(TAI)
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
2014 ESC Guidelines on the Diagnosis and
Treatment of Aortic Diseases
(Thoracic) Endovascular Aortic Repair (T)EVAR
((T)EVAR
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Follow-up after thoracic aortic intervention (1)
Ï Clinical and imaging are both necessary to limit and
detect complications, not only at the operated site but
also the remaining aorta.
Ï After TEVAR or surgical thoracic aortic repair, first F-U
should be performed at 1 month to exclude the presence
of early complications. Surveillance should be repeated.
Ï Follow-up includes risk factors control. Blood pressure
should be monitored closely, as >50% of cases may
have resistant hypertension.
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Follow-up after thoracic aortic intervention (2)
Ï If, after TEVAR for TAA, patients show a stable course
without evidence of endoleak over 24 months, it may be
safe to extend imaging intervals to every 2 years;
however, clinical follow-up of the patient´s symptom
status and accompanying medical therapy should be
maintained at yearly intervals.
Ï Patients with TEVAR for AD should receive yearly
imaging, since the FL of the abdominal aorta is usually
patent and prone to disease progression.
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Follow-up
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Intramural Hematoma (IMH)
Ï Hematoma develops in the media of the aortic wall in the
absence of a false lumen or intimal tear.
Ï Diagnosis: circular or crescentic thickening >5 mm of the
aortic wall in the absence of detectable blood flow.
Ï 10-25% of AAS
– 30% ascending aorta
Type-A IMH
– 10% arch
– 60-70% descending TA (Type-B IMH)
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Intramural Hematoma (IMH)
Ï Diagnosis → CT/MRI
– Unenhanced acquisition + contrast-enhanced aquisition
in CT → sensitivity 96%
Ï Type-A IMH
– In-hospital mortality similar to type-A AD
– 30-40% evolve into AD
Ï Type-B IMH
– In-hospital mortality similar to type-B AD
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Predictors of IMH Complications
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Management of Intramural Hematoma (IMH)
Complicated IMH → recurrent pain, IMH expasion, periaortic hemantoma, tears
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Penetrating Aortic Ulcer (PAU)
Ï Ulceration of an atherosclerotic plaque penetrating through
the internal elastic lamina into the media.
Ï 2-7% of all AAS.
Ï Propagation → IMH, pseudoaneurysm, aortic rupture, AD.
Ï Natural history: progressive TAA.
Ï Most commonly located in the middle and lower distal
thoracic aorta (type-B PAU).
Ï Elderly patients, smokers, HTN, associated CAD, COPD, AAA
Ï Diagnosis → unenehanced/contrast enhanced CT
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Management of Penetrating Aortic Ulcer (PAU)
Complicated PAU → Refractory pain or signs of contained rupture (rapidly
growing ulcer, periaortic hematoma, pleural effusion)
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Conclusions Acute Thoracic Aortic Syndromes (1)
Ï Potentially deadly but at the same time treatable conditions to be
considered in the differential diagnosis of acute chest pain.
Ï 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.
Ï TTE: initial imaging investigation, frequently complemented by
TOE/CT/MRI.
Ï Type-A AD → urgent surgery.
Ï Type-B AD
→ complicated →TEVAR
→ uncomplicated →TEVAR to be considered.
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European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
Conclusions Acute Thoracic Aortic Syndromes (2)
Ï IMH
– Type-A → surgery recommended
– Type-B → OMT; if complicated TEVAR should be considered
Ï PAU
– Type-A → surgery should be considered
– Type-B → OMT; if complicated TEVAR should be considered
Ï (Contained) rupture of TAA and traumatic aortic injury
– If anatomy favorable and expertise available
→ TEVAR preferred over surgery
www.escardio.org/guidelines
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281
2014 ESC Guidelines on the Diagnosis and
Treatment of Aortic Diseases
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Summary
Holistic view on the aortic disease
Close cooperation of many experts for
diagnosis and treatment
Create Aortic clinics and Aorta Teams
Imaging by TTE/TOE, CT and MRI
corner stones search for land marks
Medical therapy follows disease aetiology
Endovascular treatment breakthrough
Surgery provides new technology
www.escardio.org/guidelines
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

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