Elective stent-graft treatment of aortic dissections.
ABSTRACT To retrospectively review 8 years' experience with stent-graft treatment of aortic dissections at a single institution.
Forty-six patients (31 men; mean age 59 years, range 38-88) underwent stent-graft treatment for 9 Stanford type A and 37 type B aortic dissections (9 acute phase, 13 subacute, 24 chronic). Custom-designed self-expanding stainless steel Z stents covered with polytetrafluoroethylene were used (n=20) until low-profile modular stent-grafts became available for percutaneous delivery (n=26).
Endovascular stent-graft deployment was technically successful in 44 (96%) patients; the 2 failed cases owing to intraprocedural migration and graft torsion were converted to surgery. There were 5 type I endoleaks for a clinical success (entry tear exclusion) of 85% (39/46). Complications included 3 cases of transient renal failure, 2 puncture site pseudoaneurysms, 1 guidewire-induced new intimal tear (converted), and 2 cases of stent-induced saccular aneurysms (1 converted). Follow-up at a mean 34 months (range 12-96) showed complete resolution of the thoracic false lumen in 14 (74%) of 19 acute/subacute patients treated successfully; 3 (16%) showed a reduced thoracic false lumen diameter. In the 23 chronic-phase patients treated successfully, 8 (35%) had complete resolution of the thoracic false lumen, and 11 (48%) showed size reduction. Enlargement of the abdominal aortic false lumen due to persistent flow into re-entry tear(s) occurred in 3 (13%).
Stent-graft treatment is a feasible and effective treatment modality in aortic dissection. However, close follow-up is mandatory to monitor new intimal tear, saccular aneurysms, or enlargement of the abdominal aortic false lumen.
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ABSTRACT: Retrograde type A aortic dissection has been deemed a rare complication after endovascular stent graft placement for type B dissection. However, this life-threatening event appears to be underrecognized and is worth being investigated further. Eleven of 443 patients developed retrograde type A aortic dissection during or after stent grafting for type B dissection from August 2000 to June 2007. Of these 11 patients, 3 had Marfan syndrome. The Kaplan-Meier estimate of the rate of freedom from this event at 36 months is 97.4% (95% confidence interval, 0.95 to 0.99). The new entry was located at the tip of the proximal bare spring of the stent graft in 9 patients, was within the anchoring area of the proximal bare spring in 1, and remained unknown in 1 patient. Eight patients were converted to open surgery, and 2 received medical treatment. One patient suddenly died 2 hours after the primary stent grafting, and 2 died within 1 week after the surgical conversion, so mortality reached 27.3%. During the follow-up from 3 to 50 months, type I endoleak was identified in 1 patient 3 months after the surgical exploration and disappeared at 6 months. Retrograde type A aortic dissection after stent grafting for type B dissection appears not to be rare and results from mixed causes. Fragility of the aortic wall and disease progression may predispose to it, whereas stent grafting-related factors make important and provocative contributions. Avoiding aortic arch stent grafting in Marfan patients, preferably selecting the endograft without the proximal bare spring for patients with a kinked aortic arch or with Marfan syndrome (if endografting is used), improving the device design, and standardizing endovascular manipulation might lessen its occurrence.Circulation 02/2009; 119(5):735-41. · 15.20 Impact Factor
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ABSTRACT: To investigate the results of emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset. A retrospective analysis of the clinical data of 30 patients with complicated Stanford type B aortic dissections who underwent emergency endovascular repair between June 2007 and October 2008. Endovascular repairs were performed within 24 hours of symptom onset. Stent-grafts were deployed at the first entry tear through the femoral artery under fluoroscopic guidance. Follow-up computed tomography scans were performed at 1, 3, 6, 12, and 18 months after treatment. The mean patient age was 64 years (range, 43-83 years). There were 3 cases associated with rupture, 6 cases associated with refractory hypertension, 15 cases associated with persistent pain, 2 cases associated with retrograde dissection, and 4 cases associated with malperfusion. The technical success rate was 100%, and the incidence of immediate postoperative endoleaks was 13.4%. One patient died of dissection rupture within 30 days. The mean follow-up period was 12 ± 8 months. A small, persistent endoleak (<10%) occurred in 1 patient, and 1 patient died of acute liver failure 2 months after the operation. No stent dislocation, false lumen expansion, or paraplegia occurred. The false lumen was completely thrombosed in 6 patients and partially thrombosed in 19 patients. The mortality rate was 6.67%. Our results suggest that emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset is associated with good outcomes and can decrease mortality.The Journal of thoracic and cardiovascular surgery 04/2011; 141(4):926-31. · 3.41 Impact Factor
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ABSTRACT: Stent graft-induced new entry (SINE), defined as the new tear caused by the stent graft and excluding those arising from natural disease progression or iatrogenic injury from the endovascular manipulation, has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for Stanford type B dissection in our center. SINE appears to be remarkably life threatening. We investigated the incidence, mortality, causes, and preventions of SINE after TEVAR for Stanford type B dissection. Data for 22 patients with SINE were retrospectively collected and analyzed from 650 patients undergoing TEVAR for type B dissection from August 2000 to June 2008. An additional patient was referred to our center 14 months after TEVAR was performed in another hospital. The potential associations of SINE with Marfan syndrome, location of SINE and endograft placement, and the oversizing rate were analyzed by Fisher exact probability test or t test. We found 24 SINE tears in 23 patients, including SINE at the proximal end of the endograft in 15, at the distal end in 7, and at both ends in 1. Six patients died. SINE incidence and mortality reached 3.4% and 26.1%, respectively. Two SINE patients were diagnosed with Marfan syndrome, whereas there were only 6 Marfan patients among the 651 patients. The 16 proximal SINEs were evidenced at the greater curve of the arch and caused retrograde type A dissection. The eight distal SINEs occurred at the dissected flap, and five caused enlarging aneurysm whereas three remained stable. The endograft was placed across the distal aortic arch during the primary TEVAR in all 23 patients. The incidence of SINE was 33.33% among Marfan patients vs 3.26% among non-Marfan patients (P = .016). There was no significant difference in mortality between proximal and distal SINE (25% vs 28.6%, P > .99), incidence of SINE between endograft placement across the arch and at the straight portion of descending thoracic aorta (23 of 613 vs 0 of 38, P = .39), and the oversizing rate between SINE and non-SINE patients (13% ± 4.5% vs 16% ± 6.5%, P = .98). SINE appears not to be rare after TEVAR for type B dissection and is associated with substantial mortality. The stress yielded by the endograft seems to play a predominant role in its occurrence. It is important to take this stress-induced injury into account during both design and placement of the endograft.Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2010; 52(6):1450-7. · 3.52 Impact Factor