From ESC GL 2014

1. MANAGEMENT IN ACUTE AORTIC
SYNDROME : WHEN IS TEVAR NEED?
F2 Parach Sirisriro
3rd Dec 2018

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. 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. OUTLINE
Definition
Pathology and Classification
Clinical presentation and complication
Treatment
Indication for TEVAR
Conclusion

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. PATHOLOGY

8. PATHOLOGY OF ACUTE AORTIC
SYNDROME

9. 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

10. AORTIC DISSECTION

11. PATHOPHYSIOLOGY
Static dissection Dynamic dissection
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

12. AORTIC
DISSECTION
CLASSIFICATION
DEBAKEY AND
STANFORD
CLASSIFICATIONS
JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026

13. TEMPORAL CLASSIFICATION
JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026

14. RISK FACTORS
FOR
DISSECTION
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

15. RISK FACTORS
FOR
DISSECTION
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

16. INTRAMURAL HEMATOMA (IMH)

17. EVOLUTION OF
INTRAMURAL
HEMATOMA

18. ● 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

19. ● 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

20. PREDICTOR OF IMH COMLICATION
European Heart Journal (2014):doi:10.1093/eurheartj/ehu2

21. PENETRATING AORTIC ULCER

22. PENETRATING
AORTIC ULCER

23. • ● 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

24. Clinical presentation and complication

25. • 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
−

26. 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

27. 2014 ESC Guidelines on the Diagnosis and
Treatment of Aortic Diseases
- Imaging Techniques -

28. Diagnostic value of various imaging modalities of acute aortic
syndrome
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

29. Management and indication for TEVAR

30. DIAGNOSIS
AND
MANAGEMENT
ALGORITHM
FOR ACUTE
AORTIC
DISSECTION.
ACS, ACUTE
CORONARY
SYNDROME

31. CLINICAL DATA USEFUL TO ASSESS THE A PRIORI
PROBABILITY OF ACUTE AORTIC SYNDROME
European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

32. RECOMMENDATIONS FOR DIAGNOSTIC WORK-UP IN AAS
European Heart Journal (2014):doi:10.1093/eurheartj/ehu28

33. DIAGNOSIS AND
MANAGEMENT
ALGORITHM FOR
ACUTE AORTIC
SYNDROME

35. European Heart Journal (2014):doi:10.1093/eurheartj/ehu281

36. 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

37. 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

39. Management of Intramural Hematoma (IMH)

40. Management of Penetrating aortic ulcer (PAU)
Complicated PAU → Refractory pain or signs of contained rupture (rapidly growing ulcer, periaortic hematoma,
pleural effusion)

41. Management of (contained) rupture the thoracic aortic aneurysm

42. Management of traumatic aortic injury

43. OUTCOME OF TREATMENT ACUTE
AORTIC SYNDROME
JAMA. 2016;316(7):754-763. doi:10.1001/jama.2016.10026

44. COMPARING AMERICAN, ASIA AND EUROPE GUILDELINE FOR ARTIC DISEASE

45. COMPARING AMERICAN, ASIA AND EUROPE GUILDELINE FOR ARTIC DISEASE

46. Conclusion

47. 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.

48. 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

49. THANK YOU