Management of acute type B aortic dissections and acute limb ischemia

Division of Cardiothoracic and Vascular Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA.
The Journal of cardiovascular surgery (Impact Factor: 1.46). 08/2011; 52(4):507-17.
Source: PubMed


AIM: The aim of this study was to review the management of acute type B aortic dissection (TBAD) with acute limb ischemia. A search using the "Pubmed" resulted in 254 records by combining the Medical Subject Heading keywords (listed separately). The articles were assessed for their validity, correct pathology and patient cohort. Inclusion criteria included all patients with complicated acute TBAD who were candidates for open of thoracic endovascular aortic repair (TEVAR). The exclusion criteria included type A, asymptomatic acute or chronic TBAD, penetrating ulcer or intramural hematoma. TBAD with limb ischemia has a poor prognosis if not diagnosed, triaged and treated promptly. Clinical presentation and diagnostic strategy as well as various imaging are reviewed. Early mortality rate for complicated acute TBAD (with malperfusion to lower extremity) is 12%. The management has moved from open operation to primary TEVAR. In cases with anatomic obstruction, open surgical techniques such as femoral-femoral bypass, axillo-femoral bypass or surgical fenestration can be successful in relief of malperfusion to the affected limb. One-year-survival rates are 85%. A complete to partial reverse aortic remodeling occurred in 78% of survivors of acute TBAD, if primary TEVAR is applied. Acute TBAD with limb ischemia remains a clinical challenge that requires prompt diagnosis and treatment. TEVAR of acute TBAD is associated with relatively low morbidity and mortality, and is more often used as primary approach for patients with limb ischemia. The outcomes with TEVAR compare favorably to the open repair, and initiate reverse aortic remodeling in majority of the survivors.

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    ABSTRACT: Acute aortic dissection frequently causes life-threatening organ ischemia. The optimal therapy for acute type-B aortic dissection is still controversial. Surgery for acute dissection with organ malperfusion is known to carry a high morbidity and mortality; however endovascular treatment is becoming an alternative form of treatment. We report a clinical case of emergency percutaneous thoracal aorta endovascular stenting and renal artery stenting in a patient who had renal malperfusion and acute renal failure due to acute type-B dissection. The present case is a fundamental examples of collaboration between the cardiologist and cardiovascular surgeon in a hybrid procedure.
    04/2012; 24(2):141-4. DOI:10.1016/j.jsha.2012.02.002
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    ABSTRACT: OBJECTIVES: This study aims to assess the relevance of the definition of acute dissection, to analyse whether there is a sub-acute phase and to determine early outcome of thoracic endovascular aortic repair (TEVAR) in acute complicated type B aortic dissection. DESIGN: Dual-centre consecutive case series. MATERIALS: Between 1999 and 2011, 102 patients underwent TEVAR for non-traumatic acute complicated type B dissection in Zurich, Switzerland, and Uppsala, Sweden. In addition, 22 patients treated for an acute dissection-related complication occurring >14 days after onset of symptoms were included. Median age was 68 years, 35% were women. METHODS: Demographic, procedural and outcome data were collected prospectively. The patients were followed up on 1 January 2012. RESULTS: In the 22 sub-acute patients (18%), there were no early deaths or neurological complications. The predominant complication in these patients was rapid aortic enlargement, whereas rupture was more prevalent in patients treated within 14 days. In total, there were nine (7%) early deaths, three (2%) post-intervention paraplegias and six cases of stroke (5%). CONCLUSIONS: TEVAR was performed with low early mortality and few neurological complications. A significant proportion of patients presented with acute complications >14 days after onset of symptoms, indicative of a sub-acute phase in the transition between acute and chronic dissection, questioning the relevance of the current definition.
    European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 04/2013; 45(6). DOI:10.1016/j.ejvs.2013.03.013 · 2.49 Impact Factor
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    ABSTRACT: It was found that bypass graft alone could achieve great effects in treating aortic dissection. In order to investigate the mechanical mechanism and the haemodynamic validity of the bypassing treatment for DeBakey III aortic dissection, patient-specific models of DeBakey III aortic dissection treated with different bypassing strategies were constructed. One of the bypassing strategies is bypassing between ascending aorta and abdominal aorta, and the other is bypassing between left subclavian artery and abdominal aorta. Numerical simulations under physiological flow conditions based on fluid-structure interaction were performed using finite element method. The results show that blood flow velocity, pressure and vessel wall displacement of false lumen are all reduced after bypassing. This phenomenon indicates that bypassing is an effective surgery for the treatment of DeBakey III aortic dissection. The effectiveness to cure through lumen is better when bypassing between left subclavian artery and abdominal aorta, while the effectiveness to cure blind lumen is better when bypassing between ascending aorta and abdominal aorta.
    Computer Methods in Biomechanics and Biomedical Engineering 02/2014; 18(11). DOI:10.1080/10255842.2014.881806 · 1.77 Impact Factor