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Simultaneous multi-tear exclusion: An optimal strategy for type B thoracic aortic dissection initially proved by a single center's 8 years experience
Abstract
Endovascular stent-grafting is widely used to treat thoracic aortic dissection. However, little information is available regarding outcome following simultaneous exclusion of multiple tears. This report details eight years of experience using simultaneous multi-tear exclusion for treatment of Stanford type B thoracic aortic dissection resulting in successful aortic remodeling without adverse events.
From September 1998 to January 2006, 29 type B thoracic aortic dissection patients (24 men, 5 women; 27 chronic, 2 acute; mean age 58 years, range 45 - 77 years) were treated by simultaneous multi-tear exclusion in our center. Magnetic resonance angiography was used as the preoperative evaluation method. Different kinds of stent-grafts were used. The patients were followed up with contrast-enhanced spiral computed tomography at 6 months postoperatively and yearly thereafter.
Twenty-nine surgeries were completed successfully using at least 2 stent-grafts per patient (range: 2 - 6, mean: 2.7). No major procedure-related complications, such as rupture, paraplegia, aortic branch ischemia or cerebral infarction, were observed. During follow-up, favorable remodeling of the aorta was observed.
The mid-term result of thoracic aortic dissection with simultaneous multi-tear exclusion was satisfactory. With the improvement of stent-grafts, simultaneous multi-tear exclusion should find wider application and become an optimal strategy for thoracic aortic dissection.
... Tears on the thoracic descending aorta and infrarenal abdominal aorta could be occluded by graft sent, while the treatment of the branched area of abdominal aorta was relatively complicated due to the existence of abdominal branch vessels. Moreover, according to the literature and cases treated in our center, distal tears located in the branched area of abdominal aorta took up 49-88% of total number of tears [5,6]. It takes high risk as well as high cost to occlude the tears while keeping the patency of the branches. ...
This study aims to evaluate the effect of coil-stent tear occlusion device in treating entry tears located in branched area of abdominal aorta. An abdominal aortic dissection animal model was constructed by mesh suturing method. The animal models were treated by the occlusion device and were evaluated by computed tomography angiography (CTA) 1 month later. Eighteen pigs were adopted in the abdominal aortic dissection modeling experiment, two of them died of cardiopulmonary arrest during the operation. Sixteen models survived, two of them were found complete false lumen thrombosis by CTA 3 days after the operation. The false lumen kept patency in the remaining 14 cases which were then implanted with the occlusion device. The procedure was successful in 13 cases except for one. The coil-stent tear occlusion device provides a novel method for tears located in the branched area of abdominal aorta, and is worth of further study.
Objective: To analyze the technique success rate of endovascular stent-graft therapy in treating type B aortic dissection and to discuss the occurrence of both mild and severe complications including stroke, paraplegia, etc. Methods: The medical documents concerning endovascular stent-graft therapy for type B aortic dissection published from 1999 to 2009 were searched for through Medline. A total of 12 academic papers with 761 cases were collected. After making inclusion and exclusion criteria, the data obtained from the literature were analyzed. Results: The analysis of all the available data showed that the technical success rate of endovascular stent-graft therapy for type B aortic dissection was 97.66%. The occurrence of minor complications, sever complications, stroke and paraplegia was 17.44%, 4.02%, 1.29% and 1.30%, respectively. The mortality was 3.55% within 30 days, and it was 4.08% during follow-up period (ranging from 12 months to 48.3 months). The occurrence of aortic rupture or retrograde aortic dissection formation in follow-up period was 3.06%. Conclusion: Endovascular stent-graft therapy for type B aortic dissection is technically feasible with fewer complications, nowadays it becomes the treatment of first choice. Nevertheless, as the follow-up time is rather short and the randomly controlled studies are lack, whether or not this technique carries statistically significant difference in therapeutic results when compared to other treatments needs to be further studied.
An expert multidisciplinary panel in the treatment of type B aortic dissection reviewed available literature to develop treatment algorithms using a consensus method. Data from 63 studies published in 2006-2012 were retrieved for a total 1,548 patients treated medically 1,706 with open surgery and 3,457 with Thoracic Endovascular Repair (TEVAR). For acute (first 2 weeks) type B aortic dissection the pooled early mortality rate was 6.4% with medical treatment and increased to 10.2% with TEVAR and 17.5% with open surgery , mostly for complicated cases. Limited data for treatment of subacute (2-6 weeks after onset) type B aortic dissection showed an early mortality rate of 2.8% with TEVAR. In chronic (after 6 weeks) type B aortic dissection 5-year survival of 60-80% is expected with medical therapy since complications are likely. If interventional treatment was applied pooled early mortality rate was 6.6% with TEVAR and 8.0% with open surgery. Management for uncomplicated acute, subacute and chronic type B aortic dissection is by medical treatment with close imaging monitoring. Hemodynamic instability, organ malperfusion, increasing periaortic hematoma and hemorrhagic pleural effusion on imaging identify patients with complicated acute type B aortic dissection requiring urgent aortic repair. Recurrence of symptoms, aortic aneurysmal dilation (>55 mm) or a yearly increase >4mm after the acute phase are predictors of adverse outcome and need of delayed aortic repair ("complicated chronic aortic dissections") . The expert panel is aware that this consensus document provides proposal for strategies based on non-robust evidence for management of type B aortic dissection and that literature results are largely heterogeneous and should be interpreted cautiously.
Objective:
The location, number, size, and configuration of intimal tears in aortic dissection have important therapeutic and prognostic implications. Planning of procedures to treat complications of aortic dissection may require precise delineation of the intimal tears. The purpose of this article is to illustrate the ability of MDCT using multiplanar image reformatting and virtual angioscopy to depict the location and appearance of intimal tears and fenestrations within dissection flaps in cases of thoracic aortic dissection.
Conclusion:
MDCT with virtual angioscopy can depict the configuration of intimal tears in cases of thoracic aortic dissection, which may facilitate therapeutic planning.
To examine the incidence of and the indications for re-intervention, as well as the changes in aortic morphology, in patients with chronic type B aortic dissection who underwent endovascular intervention for false lumen aneurysms.
A retrospective analysis was conducted of 10 patients (8 men; mean age 63 years, range 45-79) who underwent stent-graft repair of aneurysmal false lumen expansion related to chronic type B aortic dissection at a median 16 months (range 2-71) from the initial diagnosis. All grafts had been oversized by 10% relative to the normal non-dissected aorta and were implanted to cover the primary entry tear. Follow-up computed tomography scans were analyzed to define changes in aortic morphology.
Mean radiological follow-up was 56 months (median 64.5; range 19-86.5). There was no perioperative mortality or stroke; no cases of aortic rupture were recorded during follow-up. One patient suffered a procedure-related stroke with postoperative hemiparesis following re-intervention for proximal erosion 15 months after the initial treatment. In 6 of the 7 re-interventions performed in 6 patients at a median 42 months after the index procedure, stent-graft extension was required to treat erosion of the dissection membrane that had resulted in endoleak with false lumen reperfusion. The extent of dissection, duration of follow-up, or length of aortic coverage was not predictive of the need for re-intervention during follow-up. At last follow-up, the mean false lumen diameter at the level of the stented aorta was significantly smaller than at baseline (11+/-15 versus 24+/-15 mm, p<0.01). This was associated with false lumen thrombosis at the level of the stent-graft in 9 of 10 cases, although 7 patients had persistent false lumen perfusion distal to the stent-graft.
Endovascular stent-graft treatment is effective therapy for chronic type B dissection patients with false lumen aneurysms. Erosion of the dissection membrane, causing proximal or distal endoleak, is the most common reason for re-intervention during midterm follow-up.
Endovascular stent-graft treatment has emerged as an alternative for patients with type B aortic dissection (AD), either at acute or chronic phase, in selected patients. This study aimed to investigate the results of endovascular stent-graft repair for acute and chronic type B AD.
From May 2002 to July 2007, 67 patients with type B AD were treated by endovascular stent-graft placement. There were 32 patients in the acute phase (AAD group) and 35 patients in the chronic phase (CAD group). The patients were followed up from 1 to 65 months (average, 17 +/- 16 months). The immediate and follow-up clinical outcomes were documented and compared between the 2 groups.
Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 67 patients. Compared with patients in the CAD group, those in the AAD group had higher percentages of pleural effusion (15.6% vs 0, P = 0.02) and visceral/leg ischemia (21.9% vs 2.9%, P = 0.02). Procedure related complications, including endoleak and post-implantation syndrome occurred more frequently in AAD group than in CAD group (21.9% vs 2.9% and 31.3% vs 8.6%, respectively; P = 0.02 and P = 0.02). Kaplan-Meier analysis showed no significant difference in survival rate at 4 years between the 2 groups (86.4% vs 92.3%, P = 0.42 by Log-rank test). But the 4-year event-free survival rate was higher in patients with chronic dissection than in patients with acute dissection (96.2% vs 73.9%; P = 0.02 by Log-rank test).
Endovascular repair with stent-graft was safe and effective for the treatment of both acute and chronic type B AD. However, both immediate and long term major complications occurred more frequently in patients with acute dissection than in those with chronic dissection.
The standard treatment for acute aortic dissection is either surgical or medical therapy, depending on the morphologic features of the lesion and any associated complications. Irrespective of the form of treatment, the associated mortality and morbidity are considerable.
We studied the placement of endovascular stent-grafts across the primary entry tear for the management of acute aortic dissection originating in the descending thoracic aorta. We evaluated the feasibility, safety, and effectiveness of transluminal stent-graft placement over the entry tear in 4 patients with acute type A aortic dissections (which involve the ascending aorta) and 15 patients with acute type B aortic dissections (which are confined to the descending aorta). Dissections involved aortic branches in 14 of the 19 patients (74 percent), and symptomatic compromise of multiple branch vessels was observed in 7 patients (37 percent). The stent-grafts were made of self-expanding stainless-steel covered with woven polyester or polytetrafluoroethylene material.
Placement of endovascular stent-grafts across the primary entry tears was technically successful in all 19 patients. Complete thrombosis of the thoracic aortic false lumen was achieved in 15 patients (79 percent), and partial thrombosis was achieved in 4 (21 percent). Revascularization of ischemic branch vessels, with subsequent relief of corresponding symptoms, occurred in 76 percent of the obstructed branches. Three of the 19 patients died within 30 days, for an early mortality rate of 16 percent (95 percent confidence interval, 0 to 32 percent). There were no deaths and no instances of aneurysm or aortic rupture during the subsequent average follow-up period of 13 months.
These initial results suggest that stent-graft coverage of the primary entry tear may be a promising new treatment for selected patients with acute aortic dissection. This technique requires further evaluation, however, to assess its therapeutic potential fully.
Purpose:
To investigate efficacy of stent-graft repair for the treatment of patients with chronic aortic dissection.
Materials and methods:
Fifteen patients with chronic aortic dissection were treated with endovascular stent-grafts. Entry tears were located in the descending thoracic aorta in all patients. The mean maximum diameter of the descending thoracic aorta was 47 mm +/- 8. The mean diameter of the true lumen at the same level was 20 mm +/- 5. The mean interval between diagnosis and stent-graft procedure was 32 months +/- 91. Stent-grafts were fabricated from expanded polytetrafluoroethylene and Z-stents.
Results:
Stent-grafts were placed successfully in all patients. Two stent-grafts were required in one patient. Entry closure and thrombosis of the false lumen of the descending thoracic aorta were also achieved in all patients. No procedure-related complications were observed except for postimplantation syndrome, including fever and leukocytosis. The diameter of the true lumen was significantly increased (mean, 31 mm +/- 6) at the level of the descending thoracic aorta (P <.01) and the diameter of the aorta was significantly decreased (mean, 44 mm +/- 8) at the same level (P <.01). There were no deaths and no instances of aortic rupture during the subsequent average follow-up period of 24 months. Secondary stent-graft procedures were required to treat the abdominal component of dissection during follow-up in one patient.
Conclusions:
Stent-graft repair of chronic aortic dissection is a safe and effective method and may be an alternative to surgical graft replacement in selected patients. However, further evaluation is mandatory before this method is widely employed.
The usual treatment for thoracic aortic aneurysms is surgical replacement with a prosthetic graft, but the associated morbidity and mortality are considerable. We studied the use of transluminally placed endovascular stent-graft devices as an alternative to surgical repair.
We evaluated the feasibility, safety, and effectiveness of transluminally placed stent-graft to treat descending thoracic aortic aneurysms in 13 patients over a 24-month period. Atherosclerotic, anastomotic, and post-traumatic true or false aneurysms and aortic dissections were treated. The mean diameter of the aneurysms was 6.1 cm (range, 5 to 8). The endovascular stent-grafts were custom-designed for each patient and were constructed of self-expanding stainless-steel stents covered with woven Dacron grafts.
Endovascular placement of the stent-graft prosthesis was successful in all patients. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent-graft in 12 patients, and partial thrombosis in 1. Two patients initially had small, residual patent proximal tracts into the aneurysm sac, but both tracts thrombosed within two months after the procedure. In four patients, two prostheses were required to bridge the aneurysm adequately. There have been no deaths or instances of paraplegia, stroke, distal embolization, or infection during an average follow-up of 11.6 months. One patient with an extensive chronic aortic dissection required open surgical graft replacement four months later because of progressive dilatation of the arch.
These preliminary results demonstrate that endovascular stent-graft repair is safe in highly selected patients with descending thoracic aortic aneurysms. This new method of treatment will, however, require careful long-term evaluation.
Editor's note : Readers will note that there is some overlap in the information presented between this report and the article on aortic dissection by Drs. Fann and Miller, which appeared in this section in the May 1995 issue ofAnnals of Vascular Surgery. This second article on thoracoabdominal aneurysms by Drs. Panneton and Hollier is published because it focuses specifically on the subject of descending thoracic and thoracoabdominal dissections, those most frequently encountered by practicing vascular surgeons. Despite the duplication, the additional information was thought to be worthy of publication.
The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis.
We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent-graft was placed by unilateral arteriotomy.
Stent-graft placement resulted in no morbidity or mortality, whereas surgery for type B dissection was associated with four deaths (33 percent, P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 months. Transluminal placement of the stent-graft prosthesis was successful in all patients, with no leakage; full expansion of the stents was ensured by balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, and thrombosis of the false lumen was confirmed in all 12 patients after a mean of three months by magnetic resonance imaging. There were no deaths or instances of paraplegia, stroke, embolization, side-branch occlusion, or infection in the stent-graft group; nine patients had postimplantation syndrome, with transient elevation of C-reactive protein levels and body temperature plus mild leukocytosis. All the patients who received stent-grafts recovered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04).
These preliminary observations suggest that elective, nonsurgical insertion of an endovascular stent-graft is safe and efficacious in selected patients who have thoracic aortic dissection and for whom surgery is indicated. Endoluminal repair may be useful for interventional reconstruction of thoracic aortic dissection.
To evaluate the feasibility and safety of endovascular stent-graft placement in treating Stanford type B aortic dissection.
Seven patients underwent endovascular stent-graft placement for type B aortic dissection. Five patients had acute and two had chronic dissection. In five patients, the proximal entry tear was within 2 cm of the origin of the left subclavian artery, and in two patients it was beyond this site. In three patients, the noncovered proximal portion of the stent-graft was placed across the origin of the left subclavian artery. The efficacy of the procedure was assessed at follow-up studies 3, 6, 12, and 24 months after intervention.
The procedure was technically and clinically successful in six patients (86%). The left subclavian artery remained patent in all patients. In two patients with involvement of aortic branches, endovascular stent-graft placement restored adequate blood flow to the compromised branches. One patient was readmitted 1 month later because the dissection extended into the ascending aorta. In all but this patient, closure of the entry tear and thrombosis of the false lumen along the stent-graft were achieved. All false lumina shrank considerably. The mean follow-up time was 14 months (range, 1-25 months).
Type B aortic dissections within and beyond 2 cm of the origin of the left subclavian artery can be treated safely and effectively by means of endovascular stent-graft placement.
Stent-graft repair of acute aortic dissection has only recently begun, and the true efficacy and safety of this technique have not yet been clarified. In this report, we describe a significant, previously unreported complication following stent-graft repair of acute aortic dissection. Materials and Methods: Fourteen patients with acute aortic dissection underwent stent-graft repair. All of the entry tears were located in the descending thoracic aorta. Five patients had type A aortic dissection, and nine patients had type B aortic dissection. The entry tears were closed with stent-grafts, which were fabricated from expanded polytetrafluoroethylene and Z-stents.
Stent-graft placement was successfully performed without any complications in all patients. Entry closure was achieved in 13 (93%) of 14 patients. The mean follow-up period was 18 months (range, 9 days to 36 months). During this period, four patients had saccular aneurysms in the proximal descending thoracic aorta. A saccular aneurysm was noted during a mean follow-up period of 63 days (range, 38-99 days). Two of these patients were treated with stent-grafts. Conventional surgical repair is planned in one patient. The other patient is being treated with conservative management.
Stent-graft repair is a technically feasible and effective method for the treatment of acute aortic dissection in selected patients. However, careful follow-up is mandatory to check for the development of saccular aneurysms.
Acute aortic dissection is a life-threatening medical condition that is associated with high morbidity and mortality.
Of 198 patients treated with a self-expanding polyester-covered stent-graft for various pathologic aortic conditions in our institution, we selected 70 consecutive patients with type B aortic dissection who were undergoing treatment. The stent-graft was introduced through the femoral artery in the angiography suite, under general anesthesia with systemic heparinization and induced hypotension.
The procedure was performed in 70 patients; of these, 58 had descending aortic dissection and 12 had atypical dissections. The procedure was successful in 65 patients (92.9%), as documented by exclusion of the false lumen of the thoracic aorta. Eleven patients (18.9%) had persistent blood flow in the false lumen of the abdominal aorta due to distal reentries. Five patients (7.1%) underwent conversion to surgery. Insertion of additional stent-grafts was required in 34 patients (48.6%). At 29 months of follow-up, 91.4% of the patients were alive.
Stent-grafts are an important means of treating aortic dissections, which may replace conventional medical treatment of this condition for the majority of patients.
The management of aortic dissections remains controversial. Knowledge regarding the extent and specific pathophysiology of each dissection is critical prior to intervention. Cross-sectional imaging techniques coupled with intravascular ultrasound or hemodynamic measurements are vital. In the setting of ischemia with significant true lumen compromise, the placement of a proximal endovascular graft has a high likelihood of dramatically improving the diameter of the true lumen, alleviating distal ischemia. Caution must be taken when branch vessels are involved in the dissection. Adequate true lumen flow with persistent end-organ ischemia is best handled with branch vessel stenting. Combined true lumen compresssion and branch vessel dissection requires both visceral vessel stenting and proximal endovascular grafting. Using these techniques, we have been able to achieve a mortality rate of less than 35% in a patient population that previously suffered mortality rates in excess of 50%. However, application of these technologies to asymptomatic or nonischemic dissections is not warranted outside the context of investigational trials.
To report the midterm results of the endovascular treatment of complicated type-B aortic dissection with use of stent-grafts.
Ten patients with acute (n = 4) or chronic (n = 6) complicated type-B dissection were treated with custom-made stent-grafts. Indications for treatment included uncontrollable hypertension with dissection extension (n = 3), renal ischemia (n = 1), and false lumen aneurysm (n = 6). Stainless-steel Z-stents covered with polyester grafts were placed in the initial six patients. Nitinol stents covered with ultrathin polytetrafluoroethylene were used in the remaining four patients. The patients were followed-up with helical computed tomography for a maximum of 30 months (mean, 20 mo).
There was one technical failure related to the access site. Early complications included deep venous thrombosis (n = 1) and embolic stroke (n = 1). Complete thrombosis of the thoracic false lumen was achieved in six patients and partial thrombosis was achieved in three. Aneurysms developed at the ends of the stainless-steel stents in two patients, requiring additional stent-graft placement. Despite successful remodeling of the thoracic aorta, three of four patients with distal reentry into the abdominal aorta experienced progressive abdominal aortic aneurysm (AAA). AAA rupture developed in two patients; one rupture was fatal and the other was treated with emergency surgery.
Endovascular treatment of complicated type-B aortic dissection is technically feasible and effective. Closely monitoring the treated aorta is essential to detect early aneurysm formation at the ends of rigid stents. Despite adequate sealing of the tears in the thoracic aorta, dissection with distal reentry phenomenon into the abdominal aorta may evolve into AAA with late rupture.
To report endovascular treatment of an expanding aneurysmal false lumen several years after successful stent-graft deployment in the descending thoracic aorta for type B aortic dissection.
A 54-year-old woman who had a stent-graft placed at the entry site of a type B aortic dissection 5 years prior presented with abdominal discomfort and palpable abdominal mass. Successful remodeling of the thoracic aorta was demonstrated by computed tomography; however, a false lumen aneurysm in the abdominal aorta had expanded from 4.8 to 6.5 cm and caused symptoms. She was successfully treated with 3 additional stent-grafts at 3 re-entry sites. Six months after the procedure, the false lumen aneurysm was completely excluded.
Endovascular repair of the re-entry sites can prevent further expansion of false lumen aneurysm, which occurs in some patients with type B dissection treated with stent-grafts.
A 72-year-old man was admitted because of progressive right upper-abdominal distension and pain as well as concurrent remittent fever for 5 months. He had undergone a radical gastrectomy and catheter intubation in the common hepatic artery for chemotherapy 12 months before admission. The diagnosis of giant infected hepatic-celiac artery pseudoaneurysm was established. Coils embolotherapy was given in another hospital, but it failed. After admission, a computed tomographic aortogram showed a mass 10.3 x 8.5 x 8.1 cm in size in the right upper abdomen that originated from the common hepatic artery and the celiac artery. A celiac-super mesenteric artery (SMA) double catheter simultaneous digital subtraction angiography (DSA) further revealed that the entrance of the aneurysm opened directly from the abdominal aorta, the distance between the orifice of SMA and celiac axis was only 0.5 cm, and the diameter of the celiac trunk had been aneurysmally enlarged to 2.0 cm. A blood culture was positive for Bacillus pyocyaneus. After detailed discussion and preparation, a stent-graft complex was negotiated through the left femoral artery and deployed successfully into the abdominal aorta to seal the orifice of celiac trunk under the dynamic supervision of DSA. Completion angiography revealed that the hepatic-celiac pseudoaneurysm was completely excluded from aortic flow by the endoluminal stent-graft complex, while the SMA and renal arteries remained perfectly patent. The patient recovered uneventfully and was discharged without any residual symptoms. At a 5-year follow-up, the patient remained asymptomatic and was leading a normal life.
