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IF11. Clinical Features and Natural Course of Isolated Spontaneous Abdominal Aortic Dissection (ISAAD)
JOURNAL OF VASCULAR SURGERY June Supplement 2016
42S Abstracts
patients were symptomatic. Early efficacy was assessed with a thrombus score based on venography. Latest and 2-year follow-up included popliteal and iliofemoral patency assessed with duplex ultrasound or venography, and PTS was assessed with the Villalta scale. Lysis was successful (ie, >50%) in 78 cases of entirelimb DVT. CDT was performed by accessing the ipsilateral small saphenous vein, posterior tibial vein, and popliteal join point (27 via incision, 61 via puncture guided by ultrasound or fluoroscopy). Of 16 total bleeding complications, none were classified as major, and 11 were related to the site of incision in the small saphenous or posterior tibial vein, causing lower leg numbness. Poor wound healing occurred in one case. At the latest follow-up, the patency was 87.09% (54 of 62). During the 24-month follow-up, the patency 80.43% (37 of 46) and the PTS rate was 32.61% (15 of 46). Further, the time between symptom onset and lysis was inversely correlated with the Villalta score (P < .05). Conclusions: Timely CDT after DVT symptom onset reduces the incidence of PTS. BTK access is an appropriate selection to entire-limb DVT, with safety and efficacy. Author Disclosures: G. Liu: Nothing to disclose.
IF11 IF11. Clinical Features and Natural Course of Isolated Spontaneous Abdominal Aortic Dissection (ISAAD) Ji-Hee Kang, MD, Seon-Hee Heo, MD, Shin-Young Woo, MS, Yang-Jin Park, PhD, Duk-Kyung Kim, PhD, Young-Wook Kim, PhD. Samsung Medical Center, Seoul, Republic of Korea Objectives: Aortic dissections (ADs) often affect the thoracic aorta, garnering much attention from cardiologists and aortic surgeons. Isolated spontaneous abdominal AD (ISAAD) can be defined as an AD confined to the abdominal aorta not attributed to traumatic or iatrogenic etiology. Contrary to thoracic AD, ISAAD is rare and has been not well known in its etiology, natural course, or an optimal management so far. We attempted to see the clinical features and natural course of ISAAD. Methods: To detect ISAAD, we searched the patient database of a single institution with key words of “aortic dissection” or “dissection” and “aorta” within the interpretation text of the computed tomography (CT) images performed from 2003 to 2015. Diagnosis of ISAAD was made by reconfirming a typical finding of “double-lumen sign” on axial views of contrastenhanced CT scans. Abdominal ADs that extended from the distal thoracic aorta or were secondary to traumatic or iatrogenic cause were excluded from the study. We retrospectively reviewed demographic and clinical features, coexisting disease, aorta-related events, and morphologic changes on CT images during the followup period.
Table I. Demographic, clinical and morphologic characteristics of 210 patients with isolated spontaneous abdominal aortic dissection (ISAAD) Characteristic Age, year Gender, male Symptomatic Coexisting disease or risk factor Hypertension Renal cyst Diabetes mellitus Abdominal aortic aneurysm Chrome renal failure Coronary heart disease Current or former smoker Chronic obstructive pulmonary disease Vasculitisa Connective tissue diseaseb Computed tomography findings Affected aorta Supraceliac aorta Paravisceral aorta Infrarenal aorta Degree of aortic wall calcification None <25% of aortic circumference 25%-50% of aortic circumference 50% of aortic circumference Length of aortic dissection, mm Location of dissection entry 12 to 3 o’clock direction 3 to 6 o’clock direction 6 to 9 o’clock direction 9 to 12 o’clock direction Extension of aortic dissection Celiac artery Superior mesenteric artery Renal artery Inferior mesenteric artery Iliac artery
No. (%) or median (range) (N ¼ 210) 69.3 (30-93) 155 (73.8) 27 (12.9) 132 84 51 30 5 50 83 16 5 4
(62.9) (40) (24.3) (14.3) (2.4) (23.8) (39.5) (7.6) (2.4) (1.9)
17 (8.1) 11 (5.2) 182 (86.7) 67 112 23 8 17.5 51 50 53 59
(31.9) (53.3) (11.0) (3.8) (2-290) (24.2) (23.8) (25.2) (28.1)
0 2 (0.9) 1 (0.5) 0 24 (11.4)
a
Vasculitis includes 4 patients with Takayasu arteritis and 1 with Kawasaki disease. b Connective tissue disease includes 2 patients with Marfan syndrome and 2 patients with Ehlers-Danlos syndrome.
Results: During the study period of 12 years, 1958 patients with AD were detected on the primary screening. Among them, 210 ISAAD patients (median age, 69.3 years; range, 30-93 years; male, 73.8%) were enrolled for the analysis excluding trauma or iatrogenic cause (n ¼ 6). Demographic, clinical and morphologic features of ISAAD are summarized in Table I. As shown in the Table, ISAAD often affects the infrarenal aorta (86.7%) and rarely extends to the visceral branch (1.4%). During the follow-up period of 40 months (median, 1-158 months), there were progression of AD in 7%, false lumen enlargement in 8.5%, and aortic rupture in 1.4%. The two aortic ruptures occurred in patients with Ehlers-Danlos syndrome. Five (2.4%) elective abdominal aortic aneurysm (AAA) repairs (1 open repair and 4 EVARs) were performed due to large AAA size indicated for treatment at the initial presentation. There was no aorta-related death other than the 2 aortic rupture patients. The follow-up results are summarized in Table II.
JOURNAL OF VASCULAR SURGERY Volume 63, Number 6S
Abstracts 43S
Conclusions: On the follow-up examinations of CT scan, ISAAD showed progression of AD; expansion of false lumen or visceral artery involvement is uncommon. Aortic rupture occurred only in patients with connective tissue disease. Therefore, ISAAD can be observed with the same treatment criteria with other AAA patients unless it causes symptom or underlying cause is connective tissue disease. Table II. Follow-up results of 142 patients with isolated spontaneous abdominal aortic dissection (ISAAD) Results Duration of follow-up, months Age, year Male gender Progression of dissection Prograde Retrograde No progress Remodeling False lumen diameter Enlarged Thrombosis (total) No change Aortic rupturea Aorta-related deatha
No. (%) or median (range) 40.3 (1-158) 67.5 (30-90) 105 (73 .9) 4 6 130 2
(2.8) (4.2) (91.5) (1.4)
12 4 121 2 2
(8.5) (2.8) (85.2) (1.4) (1.4)
a
Two aortic ruptures developed in patients with Ehlers-Danlos syndrome, and both patients died.
Author Disclosures: S. Heo: Nothing to disclose; J. Kang: Nothing to disclose; D. Kim: Nothing to disclose; Y. Kim: Nothing to disclose; Y. Park: Nothing to disclose; S. Woo: Nothing to disclose.
IF12. IF12 Anatomic Feasibility of Next-Generation Stent Grafts to Treat Type A Aortic Dissection in the Japanese Population Naoki Fujimura, MD, PhD1, Shinji Kawaguchi, MD2, Hideaki Obara, MD, PhD3, Akihiro Yoshitake, MD, PhD2, Masanori Inoue, MD, PhD2, Satoshi Otsubo, MD, PhD1, Yuko Kitagawa, MD, PhD2, Hideyuki Shimizu, MD, PhD2. 1Saiseikai Central Hospital, Minatoku-ku, Tokyo, Japan; 2Keio University School of Medicine, Shinjuku, Tokyo, Japan; 3Keio University School of Medicine, Shinjuku, Tokyo, Jersey Objectives: The purpose of this study is to analyze the anatomical characteristics of type A aortic dissection (TAAD) in the Japanese population and evaluate the feasibility of two next-generation stent grafts dedicated to the ascending/arch aortic lesion. Methods: Consecutive patients receiving surgical treatment for TAAD at two institutions from 2007 to 2015 in Japan were reviewed. Patients with high-quality preoperative computed tomography (CT) angiograms adequate for the analysis using three-dimensional (3D) workstation were included and analyzed. The anatomical feasibility of two next generation stent grafts,
Zenith Ascend and Zenith A-branch (both Cook Medical, Inc, Bloomington, Ind), were evaluated using the instructions for use (IFU) proposed by the manufacturer. Results: Of 172 TAAD patients, 41 patients were excluded due to inadequate preoperative CT scans, leaving 131 patients (62.6% male; mean age, 63.3 6 14.5; mean height, 162.8 6 10.2 cm) for the analysis. Dissection was present at sinotubular junction (STJ) in 107 patients (81.7%) and mean diameter at STJ was 39.4 6 6.0 cm. Location of the entry tear (ET) was the STJ in 32 patients, ascending aorta in 47 patients, aortic arch in 30 patients, and descending aorta in 21 patients. Mean length from STJ to innominate artery (IA) and STJ to ET was 81.9 6 12.5 cm and 59.5 6 52.7 cm, respectively. Mean diameter for IA, left common carotid artery (CCA), and left subclavian artery (SCA) was 15.2 6 2.8 cm, 8.5 6 1.6 cm, and 10.3 6 1.6 cm, respectively. Mean angle (clock position) for IA, left CCA, and left SCA was 10.3 6 13.3 , e8.8 6 12.5 , and e3.3 6 13.4 , respectively. Mean aortic radius was 31.9 6 7.0 cm. IFU proposed for Zenith Ascend was ET at ascending aorta, aortic diameter of 24 to 40 mm at the landing zone, proximal neck length >10 mm (STJ-ET), distal neck length >10 mm (ETIA), STJ-IA distance >65 mm and aortic radius > 40 mm. IFU proposed for Zenith A-branch was aortic diameter of 24 to 38 mm at the landing zone, neck length >20 mm, STJ-IA distance >59 mm, branch vessels diameter of 8 to 20 mm, branch length >36 mm, and ICA-left CCA angle <45 . When we applied these IFUs, none of the patients were within IFU for Zenith Ascend and only 18 patients (13.7%) were within IFU for Zenith A-branch. Primary mode of failure for Zenith Ascend was aortic radius (16 of 131 [12.2%]) and proximal neck diameter (31 of 131 [23.7%]) for Zenith Abranch. Conclusions: Expansion of proximal aortic diameter, small aortic radius, and ET at the STJ level still precludes most of Japanese TAAD patients from endovascular treatment even in the next-generation stent grafts. Author Disclosures: N. Fujimura: Cook Medical: other financial or material support; M. Inoue: Nothing to disclose; S. Kawaguchi: Nothing to disclose; Y. Kitagawa: Nothing to disclose; H. Obara: Nothing to disclose; S. Otsubo: Nothing to disclose; H. Shimizu: Nothing to disclose; A. Yoshitake: Nothing to disclose.
IF13. IF13 Outcomes of the Candy-Plug Technique to Achieve Thrombosis of Thoracic False-Lumen Postdissection Aneurysms Nikolaos Tsilimparis, MD, PhD, Fiona Rohlffs, MD, Franziska Heidemann, MD, E. Sebastian Debus, MD, PhD, Tilo Kölbel, MD, PhD. University Heart Center Hamburg, Hamburg, Germany
42S Abstracts
patients were symptomatic. Early efficacy was assessed with a thrombus score based on venography. Latest and 2-year follow-up included popliteal and iliofemoral patency assessed with duplex ultrasound or venography, and PTS was assessed with the Villalta scale. Lysis was successful (ie, >50%) in 78 cases of entirelimb DVT. CDT was performed by accessing the ipsilateral small saphenous vein, posterior tibial vein, and popliteal join point (27 via incision, 61 via puncture guided by ultrasound or fluoroscopy). Of 16 total bleeding complications, none were classified as major, and 11 were related to the site of incision in the small saphenous or posterior tibial vein, causing lower leg numbness. Poor wound healing occurred in one case. At the latest follow-up, the patency was 87.09% (54 of 62). During the 24-month follow-up, the patency 80.43% (37 of 46) and the PTS rate was 32.61% (15 of 46). Further, the time between symptom onset and lysis was inversely correlated with the Villalta score (P < .05). Conclusions: Timely CDT after DVT symptom onset reduces the incidence of PTS. BTK access is an appropriate selection to entire-limb DVT, with safety and efficacy. Author Disclosures: G. Liu: Nothing to disclose.
IF11 IF11. Clinical Features and Natural Course of Isolated Spontaneous Abdominal Aortic Dissection (ISAAD) Ji-Hee Kang, MD, Seon-Hee Heo, MD, Shin-Young Woo, MS, Yang-Jin Park, PhD, Duk-Kyung Kim, PhD, Young-Wook Kim, PhD. Samsung Medical Center, Seoul, Republic of Korea Objectives: Aortic dissections (ADs) often affect the thoracic aorta, garnering much attention from cardiologists and aortic surgeons. Isolated spontaneous abdominal AD (ISAAD) can be defined as an AD confined to the abdominal aorta not attributed to traumatic or iatrogenic etiology. Contrary to thoracic AD, ISAAD is rare and has been not well known in its etiology, natural course, or an optimal management so far. We attempted to see the clinical features and natural course of ISAAD. Methods: To detect ISAAD, we searched the patient database of a single institution with key words of “aortic dissection” or “dissection” and “aorta” within the interpretation text of the computed tomography (CT) images performed from 2003 to 2015. Diagnosis of ISAAD was made by reconfirming a typical finding of “double-lumen sign” on axial views of contrastenhanced CT scans. Abdominal ADs that extended from the distal thoracic aorta or were secondary to traumatic or iatrogenic cause were excluded from the study. We retrospectively reviewed demographic and clinical features, coexisting disease, aorta-related events, and morphologic changes on CT images during the followup period.
Table I. Demographic, clinical and morphologic characteristics of 210 patients with isolated spontaneous abdominal aortic dissection (ISAAD) Characteristic Age, year Gender, male Symptomatic Coexisting disease or risk factor Hypertension Renal cyst Diabetes mellitus Abdominal aortic aneurysm Chrome renal failure Coronary heart disease Current or former smoker Chronic obstructive pulmonary disease Vasculitisa Connective tissue diseaseb Computed tomography findings Affected aorta Supraceliac aorta Paravisceral aorta Infrarenal aorta Degree of aortic wall calcification None <25% of aortic circumference 25%-50% of aortic circumference 50% of aortic circumference Length of aortic dissection, mm Location of dissection entry 12 to 3 o’clock direction 3 to 6 o’clock direction 6 to 9 o’clock direction 9 to 12 o’clock direction Extension of aortic dissection Celiac artery Superior mesenteric artery Renal artery Inferior mesenteric artery Iliac artery
No. (%) or median (range) (N ¼ 210) 69.3 (30-93) 155 (73.8) 27 (12.9) 132 84 51 30 5 50 83 16 5 4
(62.9) (40) (24.3) (14.3) (2.4) (23.8) (39.5) (7.6) (2.4) (1.9)
17 (8.1) 11 (5.2) 182 (86.7) 67 112 23 8 17.5 51 50 53 59
(31.9) (53.3) (11.0) (3.8) (2-290) (24.2) (23.8) (25.2) (28.1)
0 2 (0.9) 1 (0.5) 0 24 (11.4)
a
Vasculitis includes 4 patients with Takayasu arteritis and 1 with Kawasaki disease. b Connective tissue disease includes 2 patients with Marfan syndrome and 2 patients with Ehlers-Danlos syndrome.
Results: During the study period of 12 years, 1958 patients with AD were detected on the primary screening. Among them, 210 ISAAD patients (median age, 69.3 years; range, 30-93 years; male, 73.8%) were enrolled for the analysis excluding trauma or iatrogenic cause (n ¼ 6). Demographic, clinical and morphologic features of ISAAD are summarized in Table I. As shown in the Table, ISAAD often affects the infrarenal aorta (86.7%) and rarely extends to the visceral branch (1.4%). During the follow-up period of 40 months (median, 1-158 months), there were progression of AD in 7%, false lumen enlargement in 8.5%, and aortic rupture in 1.4%. The two aortic ruptures occurred in patients with Ehlers-Danlos syndrome. Five (2.4%) elective abdominal aortic aneurysm (AAA) repairs (1 open repair and 4 EVARs) were performed due to large AAA size indicated for treatment at the initial presentation. There was no aorta-related death other than the 2 aortic rupture patients. The follow-up results are summarized in Table II.
JOURNAL OF VASCULAR SURGERY Volume 63, Number 6S
Abstracts 43S
Conclusions: On the follow-up examinations of CT scan, ISAAD showed progression of AD; expansion of false lumen or visceral artery involvement is uncommon. Aortic rupture occurred only in patients with connective tissue disease. Therefore, ISAAD can be observed with the same treatment criteria with other AAA patients unless it causes symptom or underlying cause is connective tissue disease. Table II. Follow-up results of 142 patients with isolated spontaneous abdominal aortic dissection (ISAAD) Results Duration of follow-up, months Age, year Male gender Progression of dissection Prograde Retrograde No progress Remodeling False lumen diameter Enlarged Thrombosis (total) No change Aortic rupturea Aorta-related deatha
No. (%) or median (range) 40.3 (1-158) 67.5 (30-90) 105 (73 .9) 4 6 130 2
(2.8) (4.2) (91.5) (1.4)
12 4 121 2 2
(8.5) (2.8) (85.2) (1.4) (1.4)
a
Two aortic ruptures developed in patients with Ehlers-Danlos syndrome, and both patients died.
Author Disclosures: S. Heo: Nothing to disclose; J. Kang: Nothing to disclose; D. Kim: Nothing to disclose; Y. Kim: Nothing to disclose; Y. Park: Nothing to disclose; S. Woo: Nothing to disclose.
IF12. IF12 Anatomic Feasibility of Next-Generation Stent Grafts to Treat Type A Aortic Dissection in the Japanese Population Naoki Fujimura, MD, PhD1, Shinji Kawaguchi, MD2, Hideaki Obara, MD, PhD3, Akihiro Yoshitake, MD, PhD2, Masanori Inoue, MD, PhD2, Satoshi Otsubo, MD, PhD1, Yuko Kitagawa, MD, PhD2, Hideyuki Shimizu, MD, PhD2. 1Saiseikai Central Hospital, Minatoku-ku, Tokyo, Japan; 2Keio University School of Medicine, Shinjuku, Tokyo, Japan; 3Keio University School of Medicine, Shinjuku, Tokyo, Jersey Objectives: The purpose of this study is to analyze the anatomical characteristics of type A aortic dissection (TAAD) in the Japanese population and evaluate the feasibility of two next-generation stent grafts dedicated to the ascending/arch aortic lesion. Methods: Consecutive patients receiving surgical treatment for TAAD at two institutions from 2007 to 2015 in Japan were reviewed. Patients with high-quality preoperative computed tomography (CT) angiograms adequate for the analysis using three-dimensional (3D) workstation were included and analyzed. The anatomical feasibility of two next generation stent grafts,
Zenith Ascend and Zenith A-branch (both Cook Medical, Inc, Bloomington, Ind), were evaluated using the instructions for use (IFU) proposed by the manufacturer. Results: Of 172 TAAD patients, 41 patients were excluded due to inadequate preoperative CT scans, leaving 131 patients (62.6% male; mean age, 63.3 6 14.5; mean height, 162.8 6 10.2 cm) for the analysis. Dissection was present at sinotubular junction (STJ) in 107 patients (81.7%) and mean diameter at STJ was 39.4 6 6.0 cm. Location of the entry tear (ET) was the STJ in 32 patients, ascending aorta in 47 patients, aortic arch in 30 patients, and descending aorta in 21 patients. Mean length from STJ to innominate artery (IA) and STJ to ET was 81.9 6 12.5 cm and 59.5 6 52.7 cm, respectively. Mean diameter for IA, left common carotid artery (CCA), and left subclavian artery (SCA) was 15.2 6 2.8 cm, 8.5 6 1.6 cm, and 10.3 6 1.6 cm, respectively. Mean angle (clock position) for IA, left CCA, and left SCA was 10.3 6 13.3 , e8.8 6 12.5 , and e3.3 6 13.4 , respectively. Mean aortic radius was 31.9 6 7.0 cm. IFU proposed for Zenith Ascend was ET at ascending aorta, aortic diameter of 24 to 40 mm at the landing zone, proximal neck length >10 mm (STJ-ET), distal neck length >10 mm (ETIA), STJ-IA distance >65 mm and aortic radius > 40 mm. IFU proposed for Zenith A-branch was aortic diameter of 24 to 38 mm at the landing zone, neck length >20 mm, STJ-IA distance >59 mm, branch vessels diameter of 8 to 20 mm, branch length >36 mm, and ICA-left CCA angle <45 . When we applied these IFUs, none of the patients were within IFU for Zenith Ascend and only 18 patients (13.7%) were within IFU for Zenith A-branch. Primary mode of failure for Zenith Ascend was aortic radius (16 of 131 [12.2%]) and proximal neck diameter (31 of 131 [23.7%]) for Zenith Abranch. Conclusions: Expansion of proximal aortic diameter, small aortic radius, and ET at the STJ level still precludes most of Japanese TAAD patients from endovascular treatment even in the next-generation stent grafts. Author Disclosures: N. Fujimura: Cook Medical: other financial or material support; M. Inoue: Nothing to disclose; S. Kawaguchi: Nothing to disclose; Y. Kitagawa: Nothing to disclose; H. Obara: Nothing to disclose; S. Otsubo: Nothing to disclose; H. Shimizu: Nothing to disclose; A. Yoshitake: Nothing to disclose.
IF13. IF13 Outcomes of the Candy-Plug Technique to Achieve Thrombosis of Thoracic False-Lumen Postdissection Aneurysms Nikolaos Tsilimparis, MD, PhD, Fiona Rohlffs, MD, Franziska Heidemann, MD, E. Sebastian Debus, MD, PhD, Tilo Kölbel, MD, PhD. University Heart Center Hamburg, Hamburg, Germany