Endograft exclusion of acute and chronic descending thoracic aortic dissections

Abstract

To analyze the results of endograft exclusion of acute and chronic descending thoracic aortic dissections (Stanford type B) with the AneuRx (n = 5) and Talent (n = 37) thoracic devices and to compare postoperative outcomes of endograft placement acutely (<2 weeks) and for chronic interventions. Patients treated for acute or chronic thoracic aortic dissections (Stanford type B) with endografts were included in this study. All patients (n = 42) were enrolled in investigational device exemption protocols from August 1999 to March 2005. Three-dimensional computed tomography reconstructions were analyzed for quantitative volume regression of the false lumen and changes in the true lumen over time (complete >95%, partial >30%). Forty-two patients, all of whom had American Society of Anesthesiologists (ASA) risk stratification > or =III and 71% with ASA > or = IV, were treated for Stanford type B dissections (acute = 25, chronic = 17), with 42 primary and 18 secondary procedures. All proximal entry sites were identified intraoperatively by intravascular ultrasound (IVUS). The procedural stroke rate was 6.7% (4/60), with three posterior circulation strokes. Procedural mortality was 6.7% (4/60). The left subclavian artery was occluded in 11 patients (26%) with no complaints of arm ischemia, but there was an association with posterior circulation strokes (2/11) (18%). No postoperative paraplegia was observed after primary or secondary intervention. Complete thrombosis of the false lumen at the level of endograft coverage occurred in 25 (61%) of 41 patients < or =1 month and 15 (88%) of 17 patients at 12 months. Volume regression of the false lumen was 66.4% (acute) and 91.9% (chronic) at 6 months. Lack of true lumen volume (contrast) increase and increasing false lumen volume (contrast) suggests continued false lumen pressurization and the need for secondary reintervention. Thirteen patients (31%) required 18 secondary interventions for proximal endoleaks in 6, junctional leaks in 3, continued perfusion of the false lumen from distal re-entry sites in 3, and surgical conversion in 4 for retrograde dissection. Preliminary experience with endografts to treat acute and chronic dissections is associated with a reduced risk of paraplegia and lower mortality compared with open surgical treatment, the results of medical treatment alone, or a combination.