Endovascular management of acute complicated type B aortic dissection: adjunct procedures

Abstract

Background: This study aims to evaluate the results of endovascular treatment (TEVAR) and the contribution of adjunct procedures in acute complicated type B aortic dissections. Methods: Thirty patients (26 males, 4 females; mean age 55.2±14.7 years, range 24 to 86 years) with acute complicated type B dissection underwent endovascular treatment. The dissection was complicated by malperfusion in eight patients (26.7%), impending rupture in four (13.3%), uncontrollable hypertension in 12 (40%), and severe treatmentresistant pain in six (20%). Self-expanding stent-grafts (Talent® and Valiant®, Medtronic Inc.) were used. Ostium of the left subclavian artery was covered intentionally in 19 patients (63.3%). Additional stenting was necessary in eight patients (26.7%). Of a total of 12 bare metal stents used in these patients, stents were inserted in the renal arteries in six (20%), iliac arteries in three (10%), and celiac arteries in two (6.7%) patients. Median follow-up was 55 months (range, 25 to 99 months). Results: The mean number of stent-grafts implanted was 1.42 (range, 1 to 3). One patient had inadvertent partial closure of the left common carotid artery ostium due to proximal migration of the stent-graft which caused no early neurological complications. Right hemiplegia occurred 15 months later due to his discontinuation of the anticoagulant therapy in the same patient. In another patient with visceral malperfusion, early laparoscopic exploration following the stenting of the celiac and the left renal arteries revealed no ischemia of the bowels. One patient with postoperative angina pectoris required stenting of the right coronary artery. There was no stroke in any patients, while reversal of paraplegia was observed in one patient early after the procedure. The mean lengths of intensive care unit and hospital stays were 3.2±3.4 and 9.8±7.1 days, respectively. There was no 30-day mortality. The one-year survival rate was 96.7%. Conclusion: Although endovascular treatment of complicated type B aortic dissections has a high success rate, TEVAR may not be the sole solution. Findings of malperfusion should be carefully sought in the early postoperative period. The adjunct procedures such as stenting of the visceral arteries or open surgical revascularization should always be considered particularly in young patients.