Complicated Acute Type B Dissections: A Single-Center Experience with Endovascular Treatment

Abstract

Background: Complicated acute type B dissections treated surgically carry a high risk of mortality. Endovascular interventions with stent-graft prostheses are a less invasive alternative and may obviate the need for surgery in most cases. We report here on our five years' experience with endovascular stenting in complicated acute type B dissections. Patients and Methods: Between March 2001 and January 2006, 32 patients (27 males, 5 females) with a mean age of 61.4 ± 11.32 years (range 29–80) underwent stent grafting for complicated acute type B dissections. Indications were progression of dissection with impending rupture (n = 10), uncontrollable hypertension (n = 9), intractable thoracic pain (n = 7), and malperfusion syndrome (n = 6). Talent™-Medtronic (n = 34) and Excluder™-Gore (n = 3) stent-grafts were used. In 5 patients two stents were necessary. In addition to stent grafting, aortic fenestration was performed in all three cases with lower limb ischemia. Results: Endovascular stent placement was successful in all patients. Hospital mortality was 9.3 % (3/32). No deaths occurred during follow-up (mean 32 months). Conclusion: Endovascular stenting of complicated acute type B dissections represents a safe alternative to surgery. Endovascular stent-grafts of appropriate sizes should be readily available in the hospital for emergency use, thus avoiding delays in treatment.

acute type B dissection - endovascular - complications - stents - aortic dissection

References

• 1 Estrera A L, Miller 3rd C C, Safi H J et al. Outcomes of medical management of acute type B aortic dissection.  Circulation. 2006;  114 (Suppl. 1) I384-I385
• 2 Suzuki T, Mehta R H, Ince H et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD).  Circulation. 2003;  108 (Suppl. 1) II312-II317
• 3 Tefera G, Acher C W, Hoch J R, Mell M, Turnipseed W D. Effectiveness of intensive medical therapy in type B aortic dissection: a single-center experience.  J Vasc Surg. 2007;  45 (6) 1114-1118
• 4 Elefteriades J A, Lovoulos C J, Coady M A, Tellides G, Kopf G S, Rizzo J A. Management of descending aortic dissection.  Ann Thorac Surg. 1999;  67 2002-2005
• 5 Schoder M, Czerny M, Cejna M et al. Endovascular repair of acute type B aortic dissection: long-term follow-up of true and false lumen diameter changes.  Ann Thorac Surg. 2007;  83 1059-1066
• 6 Dake M D, Kato N, Mitchell R S et al. Endovascular stent–graft placement for the treatment of acute aortic dissection.  N Engl J Med. 1999;  340 1546-1552
• 7 Nienaber C A, Fattori R, Lund G et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.  N Engl J Med. 1999;  340 1539-1545
• 8 Xu S D, Huang F J, Yang J F et al. Endovascular repair of the acute type B aortic dissection: early and mid-term results.  J Vasc Surg. 2006;  43 1090-1095
• 9 Duebener L F, Lorenzen P, Richardt G et al. Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections.  Ann Thorac Surg. 2004;  78 1261-1267
• 10 Lonn L, Delle M, Falkenberg M, Thony F, Aubert A, Blin D. Endovascular treatment of type B thoracic aortic dissection.  J Card Surg. 2003;  18 539-544
• 11 Prendergast B D, Boon N A, Buckenham T. Aortic dissection: advances in imaging and endoluminal repair.  Cardiovasc Intervent Radiol. 2002;  25 85-97
• 12 Eggebrecht H, Nienaber C A, Neuhauser M et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis.  Eur Heart J. 2006;  27 489-498
• 13 Bockler D, Schumacher H, Ganten M et al. Complications after endovascular repair of acute symptomatic and chronic expanding Stanford type B aortic dissections.  J Thorac Cardiovasc Surg. 2006;  132 361-368
• 14 Sandridge L, Kern J A. Acute descending aortic dissections: management of visceral, spinal cord, and extremity malperfusion.  Semin Thorac Cardiovasc Surg. 2005;  17 256-261
• 15 Umana J P, Miller D C, Mitchell R S. What is the best treatment for patients with acute type B aortic dissections – medical, surgical, or endovascular stent-grafting?.  Ann Thorac Surg. 2002;  74 1840-1843
• 16 Scheinert D, Krankenberg H, Schmidt A et al. Endoluminal stent-graft placement for acute rupture of the descending thoracic aorta.  Eur Heart J. 2004;  25 694-700
• 17 Eggebrecht H, Herold U, Kuhnt O et al. Endovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome.  Eur Heart J. 2005;  26 489-497
• 18 Fattori R, Napoli G, Lovato L et al. Descending thoracic aortic diseases: stent-graft repair.  Radiology. 2003;  229 176-183
• 19 Tiesenhausen K, Amann W, Koch G, Hausegger K A, Oberwalder P, Rigler B. Cerebrospinal fluid drainage to reverse paraplegia after endovascular thoracic aortic aneurysm repair.  J Endovasc Ther. 2000;  7 132-135
• 20 Caronno R, Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Castelli P. Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease.  Surg Endosc. 2006;  20 915-918
• 21 Riesenman P J, Farber M A, Mendes R R, Marston W A, Fulton J J, Keagy B A. Coverage of the left subclavian artery during thoracic endovascular aortic repair.  J Vasc Surg. 2007;  45 90-94
• 22 Rehders T C, Petzsch M, Ince H et al. Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance.  J Endovasc Ther. 2004;  11 659-666
• 23 Dake M D. Endovascular stent-graft management of thoracic aortic diseases.  Eur J Radiol. 2001;  39 42-49