Evolving Experience of Percutaneous Management of Type B Aortic Dissection

Abstract

Aortic dissection is a life-threatening condition characterised by high early mortality. While general consensus exists regarding the need of immediate surgical repair for patients with acute ascending aortic dissection, the optimal treatment strategy for type B aortic dissection continues to be a matter of debate. It has been generally advocated that patients who have type B aortic dissection without complications should be treated with medical therapy, historically based on the Wheat's concept of antiimpulse therapy,1Wheat Jr, M.W. Palmer R.F. Bartley T.D. Seelman R.C. Treatment of dissecting aneurysms of the aorta without surgery.J Thorac Cardiovasc Surg. 1965; 50: 364-367Google Scholar decreasing the force of cardiac contraction and systolic blood pressure acting upon the weaker aortic wall. With aggressive antihypertensive therapy up to 85% of patients may survive their initial hospital stay. However, about 30% of acute type B dissections at clinical presentation are complicated by peripheral vascular ischemia or hemodynamic instability, which results in high risk of spontaneous death. The perception that prognosis of type B dissection is better with medical management mostly derives from the negative results for descending aorta surgery.2Glower D.D. Fann J.I. Speier R.H. Morrison L. White W.D. Smith L.R. et al.Comparison of medical and surgical therapy for uncomplicated descending aortic dissection.Circulation. 1990; 82: 39-46Google Scholar, 3Masuda Y. Yamada Z. Morooka N. Watanabe S. Inagaki Y. Prognosis of patients with medically treated aortic dissections.Circulation. 1991; 84: 7-13Google Scholar, 4Umana J.P. Lai D.T. Mitchell R.S. Moore K.A. Rodriguez F. Robbins R.C. et al.Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections?.J Thorac Cardiovasc Surg. 2002; 124: 896-910Google Scholar, 5Crawford E.S. Svensson L.G. Hess K.R. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta.J Vasc Surg. 1991; 13: 36-46Google Scholar, 6Svensson L.G. Crawford E.S. Aortic dissection.in: Svensson L.G. Crawford E.S. Cardiovascular and vascular disease of the aorta. W.B. Saunders Company, Philadelphia1997: 42-83Google Scholar, 7Elefteriades J.A. Hartleroad J. Gusberg R.J. Salazar A.M. Black H.R. Kopf G.S. et al.Long-term experience with descending aortic dissection: the complication-specific approach.Ann Thorac Surg. 1992; 53: 11-21Google Scholar, 8Miller D.C. Mitchell R.S. Oyer P.E. Stinson E.B. Jamieson S.W. Shumway N.E. Independent determinants of operative mortality for patients with aortic dissections.Circulation. 1984; 70: I-153-I-164Google Scholar, 9Gysi J. Schaffner T. Mohacsi P. Aeschbacher B. Althaus U. Carrel T. Early and late outcome of operated and nonoperated acute dissection of the descending aorta.Eur J Cardiothorac Surg. 1997; 11: 1163-1169Google Scholar, 10Kouchoukos N.T. Masetti P. Rokkas C.K. Murphy S.F. Blackstone E.H. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta.Ann Thorac Surg. 2001; 73: 699-707Google Scholar, 11Safi H.J. Miller III, C.C. Reardon M.J. Iliopoulos D.C. Letsou G.V. Espada R. et al.Operations for acute and chronic dissection: recent outcomes in regard to neurological deficit and early death.Ann Thorac Surg. 1998; 66: 401-411Google Scholar, 12Marui A. Mochizuki T. Mitsui N. Koyama T. Kimura F. Horibe M. Toward the best treatment for uncomplicated patients with type B acute aortic dissection: a consideration for sound surgical indication.Circulation. 1999; 100: II275-II280Google Scholar, 13Schor J.S. Yerlioglu E. Galla J.D. Lansman S.L. Ergin M.A. Griepp R.B. Selective management of acute type B aortic dissection: long-term follow-up.Ann Thorac Surg. 1996; 61: 1339-1341Google Scholar, 14Gaze J. Schaffner T. Mohacsi P. Aeschbacher B. Althaus U. Carrel T. Early and late outcome of operated and non-operated acute dissection of the descending aorta.Eur J Cardiothorac Surg. 1997; 11: 1163-1170Google Scholar Direct aortic replacement for acute aortic dissection showed significant mortality and paraplegia rate, even in the outstanding Crawford–Svennson data,5Crawford E.S. Svensson L.G. Hess K.R. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta.J Vasc Surg. 1991; 13: 36-46Google Scholar, 6Svensson L.G. Crawford E.S. Aortic dissection.in: Svensson L.G. Crawford E.S. Cardiovascular and vascular disease of the aorta. W.B. Saunders Company, Philadelphia1997: 42-83Google Scholar reporting 30–36% of paraplegia for extensive aortic replacement for dissection. Long-term follow-up of patients with type B dissection showed unsatisfactory outcome even after successful initial stabilization and optimal medical therapy. Mortality is related either to retrograde progression of dissection with involvement of the proximal aorta or to expansion of the false lumen and formation of a thoracic aneurysm. Several reports in the literature analysed long-term outcome in patients with type B dissection, comparing medical with surgical therapy without evidence of a significant difference between the two groups.1Wheat Jr, M.W. Palmer R.F. Bartley T.D. Seelman R.C. Treatment of dissecting aneurysms of the aorta without surgery.J Thorac Cardiovasc Surg. 1965; 50: 364-367Google Scholar, 2Glower D.D. Fann J.I. Speier R.H. Morrison L. White W.D. Smith L.R. et al.Comparison of medical and surgical therapy for uncomplicated descending aortic dissection.Circulation. 1990; 82: 39-46Google Scholar, 3Masuda Y. Yamada Z. Morooka N. Watanabe S. Inagaki Y. Prognosis of patients with medically treated aortic dissections.Circulation. 1991; 84: 7-13Google Scholar, 4Umana J.P. Lai D.T. Mitchell R.S. Moore K.A. Rodriguez F. Robbins R.C. et al.Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections?.J Thorac Cardiovasc Surg. 2002; 124: 896-910Google Scholar, 5Crawford E.S. Svensson L.G. Hess K.R. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta.J Vasc Surg. 1991; 13: 36-46Google Scholar, 6Svensson L.G. Crawford E.S. Aortic dissection.in: Svensson L.G. Crawford E.S. Cardiovascular and vascular disease of the aorta. W.B. Saunders Company, Philadelphia1997: 42-83Google Scholar, 7Elefteriades J.A. Hartleroad J. Gusberg R.J. Salazar A.M. Black H.R. Kopf G.S. et al.Long-term experience with descending aortic dissection: the complication-specific approach.Ann Thorac Surg. 1992; 53: 11-21Google Scholar, 8Miller D.C. Mitchell R.S. Oyer P.E. Stinson E.B. Jamieson S.W. Shumway N.E. Independent determinants of operative mortality for patients with aortic dissections.Circulation. 1984; 70: I-153-I-164Google Scholar, 9Gysi J. Schaffner T. Mohacsi P. Aeschbacher B. Althaus U. Carrel T. Early and late outcome of operated and nonoperated acute dissection of the descending aorta.Eur J Cardiothorac Surg. 1997; 11: 1163-1169Google Scholar, 10Kouchoukos N.T. Masetti P. Rokkas C.K. Murphy S.F. Blackstone E.H. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta.Ann Thorac Surg. 2001; 73: 699-707Google Scholar, 11Safi H.J. Miller III, C.C. Reardon M.J. Iliopoulos D.C. Letsou G.V. Espada R. et al.Operations for acute and chronic dissection: recent outcomes in regard to neurological deficit and early death.Ann Thorac Surg. 1998; 66: 401-411Google Scholar, 12Marui A. Mochizuki T. Mitsui N. Koyama T. Kimura F. Horibe M. Toward the best treatment for uncomplicated patients with type B acute aortic dissection: a consideration for sound surgical indication.Circulation. 1999; 100: II275-II280Google Scholar, 13Schor J.S. Yerlioglu E. Galla J.D. Lansman S.L. Ergin M.A. Griepp R.B. Selective management of acute type B aortic dissection: long-term follow-up.Ann Thorac Surg. 1996; 61: 1339-1341Google Scholar, 14Gaze J. Schaffner T. Mohacsi P. Aeschbacher B. Althaus U. Carrel T. Early and late outcome of operated and non-operated acute dissection of the descending aorta.Eur J Cardiothorac Surg. 1997; 11: 1163-1170Google Scholar A large retrospective analysis of Umana and colleagues4Umana J.P. Lai D.T. Mitchell R.S. Moore K.A. Rodriguez F. Robbins R.C. et al.Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections?.J Thorac Cardiovasc Surg. 2002; 124: 896-910Google Scholar has recently focused on long-term outcome comparison (36 years) between medical and surgical therapy in 189 patients after acute type B dissection. The actuarial survival estimates for all patients were 71, 60, 35, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients, indicating that medical therapy appears to confer some survival advantage only in the short term but fails to demonstrate any significant advantage in the long term. These suboptimal results have prompted the need of investigation for alternative procedures, which could combine low invasiveness and durable results. The rationale of endovascular treatment of aortic dissection was originally based on evidence in the literature15Fattori R. Bacchi-Reggiani M.L. Bertaccini P. Napoli G. Fusco F. Longo M. et al.Evolution of aortic dissection after surgical repair.Am J Cardiol. 2000; 86: 868-872Google Scholar, 16Neya K. Omoto R. Kyo S. Kimura S. Yokote Y. Takamoto S. et al.Outcome of stanford type B dissection.Circulation. 1992; 86: II1-II7Google Scholar of protective effect of false lumen thrombosis against false lumen (FL) expansion and on the clinical observation that patients in the rare instance of spontaneous thrombosis of the FL have a better long-term prognosis than without it. Conversely, persistent perfusion of the FL has been identified as an independent predictor of progressive aortic enlargement and adverse long-term outcome.17Sueyoshi E. Sakamoto I. Hayashi K. Yamaguchi T. Imada T. Growth rate of aortic diameter in patients with type B aortic dissection during the chronic phase.Circulation. 2004; 110: II-256-II-261Google Scholar Closure of the entry tear of a type B dissection may promote both depressurisation and shrinkage of the false lumen, with subsequent thrombosis, fibrous transformation, remodelling and stabilization of the aorta (Fig. 1). Using the terms aorta, type B dissection, and stent-graft, a comprehensive search of the English-language literature from January 1999 to July 2005 was performed, using the Medline database. All studies focused on endovascular stent-graft treatment of aortic dissection were considered in order evaluate current results with respect to complications and outcome (Table 1). The first report on stent-graft treatment in type B aortic dissection appeared in 1999, in two different series of acute and chronic patients. Dake et al.18Dake M.D. Kato N. Mitchell R.S. Semba C.P. Razavi M.K. Shimono T. et al.Endovascular stent graft placement for the treatment of acute aortic dissection.N Engl J Med. 1999; 340: 1546-1552Google Scholar reported a series of 19 patients with acute dissections treated with homemade devices. Technical success was achieved in all cases. The 30-day mortality rate was 13%. Serious morbidity occurred in three (20%) of these 15 patients. Three patients had persistent flow in the false lumen that had resolved at the 1-month CT scan. All dynamic branch vessel occlusions were corrected by endograft coverage of the proximal entry tear. No subsequent deaths or aneurysm ruptures occurred in a follow-up of 13 months. Nienaber et al.19Nienaber C.A. Fattori R. Lund G. Dieckman C. Wolf W. von Kodolitsch Y. et al.Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.N Engl J Med. 1999; 340: 1539-1545Google Scholar compared 12 patients with chronic type B dissection and aneurismal degeneration (>5.5 cm) treated with commercial available stent-graft device to 12 concurrent patients treated with conventional open surgical repair. Technical success was 100% in the endovascular group, with 10 of 12 patients having immediate thrombosis of the false lumen on intraoperative transesophageal echocardiography (TEE). No patient in the endovascular group died during the 12-month study there was not a single instance of spinal cord ischemia, whereas 33% of the surgical patients died. After this initial experience, several single-center reports have shown technical feasibility and clinical safety of endovascular techniques in type B dissection.20Czermak B.V. Waldenberger P. Fraedrich G. Dessl A.H. Roberts K.E. Bale R.J. et al.Treatment of stanford type B aortic dissection with stent-grafts: preliminary results.Radiology. 2000; 217: 544-550Google Scholar, 21Hausegger K.A. Tiesenhausen K. Schedlbauer P. Oberwalder P. Tauss J. Rigler B. Treatment of acute aortic type B dissection with stent-grafts.Cardiovasc Intervent Radiol. 2001; 24: 306-312Google Scholar, 22Kang S.G. Lee D.Y. Maeda M. Kim E.S. Choi D. Kim B.O. et al.Aortic dissection: percutaneous management with a separating stent-graft—preliminary results.Radiology. 2001; 220: 533-539Google Scholar, 23Sailer J. Peloschek P. Rand T. Grabenwoger M. Thurnher S. Lammer J. Endovascular treatment of aortic type B dissection and penetrating ulcer using commercially available stent-grafts.AJR Am J Roentgenol. 2001; 177: 1365-1369Google Scholar, 24Tiesenhausen K. Amann W. Koch G. Hausegger K.A. Oberwalder P. Riger B. Endovascular stent-graft repair of acute thoracic aortic dissection—early clinical experiences.Thorac Cardiovasc Surg. 2001; 49: 16-20Google Scholar, 25Bortone A.S. Schena S. D'Agostino D. Dialetto G. Paradiso V. Mannatrizio G. et al.Immediate versus delayed endovascular treatment of post-traumatic aortic pseudoaneurysms and type B dissections: retrospective analysis and premises to the upcoming European trial.Circulation. 2002; 106: I234-I240Google Scholar, 26Kato N. Shimono T. Hirano T. Suzuki T. Ishida T. Sakuma H. et al.Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: the complication-specific approach.J Thorac Cardiovasc Surg. 2002; 124: 306-312Google Scholar, 27Hutschala D. Fleck T. Czerny M. Ehrlich M. Schoder M. Lammer J. et al.Endoluminal stent-graft placement in patients with acute aortic dissection type B.Eur J Cardiothorac Surg. 2002; 21: 964-969Google Scholar, 28Herold U. Piotrowski J. Baumgart D. Eggebrecht H. Erbel R. Jakob H. Endoluminal stent graft repair for acute and chronic type B aortic dissection and atherosclerotic aneurysm of the thoracic aorta: an interdisciplinary task.Eur J Cardiothorac Surg. 2002; 22: 891-897Google Scholar, 29Nienaber C.A. Ince H. Petzsch M. Rehders T. Korber T. Schneider H. et al.Endovascular treatment of thoracic aortic dissection and its variants.Acta Chir Belg. 2002; 102: 292-298Google Scholar, 30Palma J.H. de Souza J.A. Rodrigues Alves C.M. Carvalho A.C. Buffolo E. Self-expandable aortic stent-grafts for treatment of descending aortic dissections.Ann Thorac Surg. 2002; 73: 1138-1141Google Scholar, 31Pamler R.S. Kotsis T. Gorich J. Kapfer X. Orend K.H. Sunder-Plassmann L. Complications after endovascular repair of type B aortic dissection.J Endovasc Ther. 2002; 9: 822-828Google Scholar, 32Quinn S.F. Duke D.J. Baldwin S.S. Bascom T.H. Ruff S.J. Swangard R.J. et al.Percutaneous placement of a low-profile stent-graft device for aortic dissections.J Vasc Interv Radiol. 2002; 13: 791-798Google Scholar, 33Rousseau H. Otal P. Kos X. Soula P. Bouchard L. Massabuau P. et al.Endovascular treatment of thoracic dissection.Acta Chir Belg. 2002; 102: 299-306Google Scholar, 34Shim W.H. Koo B.K. Yoon Y.S. Choi D. Jang Y. Lee D.Y. et al.Treatment of thoracic aortic dissection with stent-grafts: midterm results.J Endovasc Ther. 2002; 9: 817-821Google Scholar, 35Beregi J.P. Haulon S. Otal P. Thony F. Bartoli J.M. Crochet D. et al.Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study.J Endovasc Ther. 2003; 10: 486-493Google Scholar, 36Lonn L. Delle M. Falkenberg M. Lepore V. Klingenstierna H. Radberg G. et al.Endovascular treatment of type B thoracic aortic dissections.J Card Surg. 2003; 18: 539-544Google Scholar, 37Lopera J. Patino J.H. Urbina C. Garcia G. Alvarez L.G. Upegui L. et al.Endovascular treatment of complicated type-B aortic dissection with stent-grafts: midterm results.J Vasc Interv Radiol. 2003; 14: 195-203Google Scholar, 38Dialetto G. Covino F.E. Scognamiglio G. Manduca S. Della Corte A. Giannolo B. et al.Treatment of type B aortic dissection: endoluminal repair or conventional medical therapy?.Eur J Cardiothorac Surg. 2005; 27: 826-830Google Scholar, 39Eggebrecht H. Herold U. Kuhnt O. Schmermund A. Bartel T. Martini S. et al.Edovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome.Eur Heart J. 2005; 26: 489-497Google Scholar, 40Leurs L.J. Bell R. Degrieck Y. Thomas S. Hobo R. Lundbom J. on behalf of the EUROSTAR and the UK Thoracic Endograft Registry collaborators. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom thoracic endograft registries.J Vasc Surg. 2004; 40: 670-680Google Scholar, 41Nathanson D.R. Rodriguez-Lopez J.A. Ramaiha V.G. Williams J. Olsen D.M. Wheatley G.H. et al.Endoluminal stent-graft stabilization for thoracic aortic dissection.J Endovasc Ther. 2005; 12: 354-359Google ScholarTable 1Endovascular treatment of Type B aortic dissection: results in the literatureAuthorYearPtsTechnical successEmergency conversionComplications: overallComplications: strokeComplications: paraplegia30-day mortalityLate surgical conversionLate aortic ruptureDake18Dake M.D. Kato N. Mitchell R.S. Semba C.P. Razavi M.K. Shimono T. et al.Endovascular stent graft placement for the treatment of acute aortic dissection.N Engl J Med. 1999; 340: 1546-1552Google Scholar199919190400300Nienaber19Nienaber C.A. Fattori R. Lund G. Dieckman C. Wolf W. von Kodolitsch Y. et al.Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.N Engl J Med. 1999; 340: 1539-1545Google Scholar199912120000000Czermak20Czermak B.V. Waldenberger P. Fraedrich G. Dessl A.H. Roberts K.E. Bale R.J. et al.Treatment of stanford type B aortic dissection with stent-grafts: preliminary results.Radiology. 2000; 217: 544-550Google Scholar2000760200010Hausegger21Hausegger K.A. Tiesenhausen K. Schedlbauer P. Oberwalder P. Tauss J. Rigler B. Treatment of acute aortic type B dissection with stent-grafts.Cardiovasc Intervent Radiol. 2001; 24: 306-312Google Scholar2001550100000Kang22Kang S.G. Lee D.Y. Maeda M. Kim E.S. Choi D. Kim B.O. et al.Aortic dissection: percutaneous management with a separating stent-graft—preliminary results.Radiology. 2001; 220: 533-539Google Scholar2001660000000Sailer23Sailer J. Peloschek P. Rand T. Grabenwoger M. Thurnher S. Lammer J. Endovascular treatment of aortic type B dissection and penetrating ulcer using commercially available stent-grafts.AJR Am J Roentgenol. 2001; 177: 1365-1369Google Scholar2001770n.a.00000Tiesenhausen24Tiesenhausen K. Amann W. Koch G. Hausegger K.A. Oberwalder P. Riger B. Endovascular stent-graft repair of acute thoracic aortic dissection—early clinical experiences.Thorac Cardiovasc Surg. 2001; 49: 16-20Google Scholar2001440000000Bortone25Bortone A.S. Schena S. D'Agostino D. Dialetto G. Paradiso V. Mannatrizio G. et al.Immediate versus delayed endovascular treatment of post-traumatic aortic pseudoaneurysms and type B dissections: retrospective analysis and premises to the upcoming European trial.Circulation. 2002; 106: I234-I240Google Scholar200212120100100Herold28Herold U. Piotrowski J. Baumgart D. Eggebrecht H. Erbel R. Jakob H. Endoluminal stent graft repair for acute and chronic type B aortic dissection and atherosclerotic aneurysm of the thoracic aorta: an interdisciplinary task.Eur J Cardiothorac Surg. 2002; 22: 891-897Google Scholar200218180300102Hutschala27Hutschala D. Fleck T. Czerny M. Ehrlich M. Schoder M. Lammer J. et al.Endoluminal stent-graft placement in patients with acute aortic dissection type B.Eur J Cardiothorac Surg. 2002; 21: 964-969Google Scholar2002990111000Kato26Kato N. Shimono T. Hirano T. Suzuki T. Ishida T. Sakuma H. et al.Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: the complication-specific approach.J Thorac Cardiovasc Surg. 2002; 124: 306-312Google Scholar200238380910221Nienaber29Nienaber C.A. Ince H. Petzsch M. Rehders T. Korber T. Schneider H. et al.Endovascular treatment of thoracic aortic dissection and its variants.Acta Chir Belg. 2002; 102: 292-298Google Scholar200212712704212n.a.3Palma30Palma J.H. de Souza J.A. Rodrigues Alves C.M. Carvalho A.C. Buffolo E. Self-expandable aortic stent-grafts for treatment of descending aortic dissections.Ann Thorac Surg. 2002; 73: 1138-1141Google Scholar200258652n.a.20432Pamler31Pamler R.S. Kotsis T. Gorich J. Kapfer X. Orend K.H. Sunder-Plassmann L. Complications after endovascular repair of type B aortic dissection.J Endovasc Ther. 2002; 9: 822-828Google Scholar200214142411000Quinn32Quinn S.F. Duke D.J. Baldwin S.S. Bascom T.H. Ruff S.J. Swangard R.J. et al.Percutaneous placement of a low-profile stent-graft device for aortic dissections.J Vasc Interv Radiol. 2002; 13: 791-798Google Scholar200215150300400Rousseau33Rousseau H. Otal P. Kos X. Soula P. Bouchard L. Massabuau P. et al.Endovascular treatment of thoracic dissection.Acta Chir Belg. 2002; 102: 299-306Google Scholar200220201210211Shim34Shim W.H. Koo B.K. Yoon Y.S. Choi D. Jang Y. Lee D.Y. et al.Treatment of thoracic aortic dissection with stent-grafts: midterm results.J Endovasc Ther. 2002; 9: 817-821Google Scholar200215140000120Beregi35Beregi J.P. Haulon S. Otal P. Thony F. Bartoli J.M. Crochet D. et al.Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study.J Endovasc Ther. 2003; 10: 486-493Google Scholar200312110410201Lonn36Lonn L. Delle M. Falkenberg M. Lepore V. Klingenstierna H. Radberg G. et al.Endovascular treatment of type B thoracic aortic dissections.J Card Surg. 2003; 18: 539-544Google Scholar2003202001051300Lopera37Lopera J. Patino J.H. Urbina C. Garcia G. Alvarez L.G. Upegui L. et al.Endovascular treatment of complicated type-B aortic dissection with stent-grafts: midterm results.J Vasc Interv Radiol. 2003; 14: 195-203Google Scholar20031090210002Dialetto38Dialetto G. Covino F.E. Scognamiglio G. Manduca S. Della Corte A. Giannolo B. et al.Treatment of type B aortic dissection: endoluminal repair or conventional medical therapy?.Eur J Cardiothorac Surg. 2005; 27: 826-830Google Scholar200428280100300EUROSTAR/UKTE registries40Leurs L.J. Bell R. Degrieck Y. Thomas S. Hobo R. Lundbom J. on behalf of the EUROSTAR and the UK Thoracic Endograft Registry collaborators. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom thoracic endograft registries.J Vasc Surg. 2004; 40: 670-680Google Scholar20041311170n.a.21110Nathanson41Nathanson D.R. Rodriguez-Lopez J.A. Ramaiha V.G. Williams J. Olsen D.M. Wheatley G.H. et al.Endoluminal stent-graft stabilization for thoracic aortic dissection.J Endovasc Ther. 2005; 12: 354-359Google Scholar2005403801511100Eggebrecht39Eggebrecht H. Herold U. Kuhnt O. Schmermund A. Bartel T. Martini S. et al.Edovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome.Eur Heart J. 2005; 26: 489-497Google Scholar200538380400413Total66565257018634912%980.718.92.70.95.11.31.8 Open table in a new tab The widest published series is the combined experience of EUROSTAR registry (European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair) and the United Kingdom Thoracic Endograft registry.40Leurs L.J. Bell R. Degrieck Y. Thomas S. Hobo R. Lundbom J. on behalf of the EUROSTAR and the UK Thoracic Endograft Registry collaborators. Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom thoracic endograft registries.J Vasc Surg. 2004; 40: 670-680Google Scholar The initial and 1-year outcome of endovascular treatment of 443 patients is reported and among them, 131 had aortic dissection. Sixty-two of them were treated under emergency conditions and 42% were at high risk for conventional open surgery. Primary technical success was achieved in 89% of patients; the remaining 11% had either incomplete covering of the entry tear, persistent flow without thrombosis of the largest portion of the false lumen, no expansion of the true lumen, or endoleak. Neurological complications consisted of paraplegia in one patient who underwent emergency repair, and stroke in two patients who underwent elective procedures. The overall 30-day mortality rate was 8.4%. One year after treatment 94% of patients followed up during this interval (67 patients) had satisfactory findings at CT examination. New endoleaks were observed in 2.8% of patients. Late death occurred in 1.5% of patients, and the cumulative survival rate after 1 year was 90%. The talent thoracic retrospective registry (TTR) analysed data on patients who underwent endovascular treatment of the thoracic aorta in seven European referral centers with the Talent device (unpublished data). Four hundred and fifty seven patients have been enrolled and among them 180 had type B dissection. The in-hospital mortality did not differ between patients with dissection as compared to other aortic diseases: there was 5% of mortality for the whole group and 4.5% in-hospital mortality for patients with type B dissection. Of note, the only two patients of the entire series who died during the interventional procedure were type B dissection patients treated under emergency conditions. During the follow-up, which has been complete in 422 patients (mean 24 months ranging from 1 to 85 months), no statistical difference was observed in long term mortality and outcome between patients treated with endovascular stent-graft for aortic dissection or for other thoracic aortic diseases. The INSTEAD trial was designed as a multicenter, randomized trial that is ongoing in Europe.42Nienaber C.A. Zannetti S. Barbieri B. Kische S. Schareck W. Rehders T.C. et al.Investigation of stent grafts in patients with type B aortic dissection: design of the INSTEAD trial—a prospective, multicenter, European randomized trial.Am Heart J. 2005; 149: 592-599Google Scholar The purpose of the study is to compare the outcomes of type B aortic dissection subjected to interventional thoracic stent grafting combined as an adjunct with tailored antihypertensive treatment (stent-graft group) to those of tailored antihypertensive treatment alone (medical treatment group). Acute cases are excluded as well as chronic long-standing aortic dissection (>24 months from initial clinical presentation). Results from INSTEAD trial are expected in 2006. Published data confirm the technical feasibility and a relative low rate of complications with respect to surgical repair (Table 1). However, long-term follow-up and outcome information, in order to document the sustained benefit of endovascular repair, are still limited. With growing experience in endovascular stent-graft treatment the spectrum of acute and midterm complications has broadened to include potentially disastrous events. Late aneurismal degeneration of the thrombosed false lumen has been reported by Kato et al.,43Kato N. Hirano T. Kawaguchi T. Ishida M. Shimono T. Yada I. et al.Aneurysmal degeneration of the aorta after stent graft repair of acute aortic dissection.J Vasc Surg. 2001; 33: 513-518Google Scholar and also several case reports have highlighted the risk of retrograde extension of the dissection into the ascending aorta, potentially caused by stent-graft induced intimal injury.44Fattori R. Lovato L. Buttazzi K. Di Bartolomeo R. Gavelli G. Extension of dissection in stent-graft treatment of type B aortic dissection: lessons learned from endovascular experience.J Endovasc Ther. 2005; 12: 306-311Google Scholar Even though extension of dissection is known event in the course of type B dissection disease, wire or sheath manipulation during the endovascular procedure could increase the risk of this dreadful complication. Continuous progress in stent-graft technology, improving morphology and flexibility, may lead to more suitable stent-graft configuration for aortic dissection. However, these unexpected complications underline the particular fragility of the aortic wall and the need of careful selection criteria and rigorous follow-up. Knowledge regarding the extent and specific pathophysiology and anatomy of each dissection is critical prior to intervention. In the diagnostic work up of patients candidate to endovascular treatment of type B dissection, high resolution imaging modalities such as MRI and MDCT, are fundamental in order to define the essential anatomic characteristics and are on the basis of procedural success.45LePage M.A. Quint L.E. Sonnad S.S. Deeb G.M. Williams D.M. Aortic dissection: CT features that distinguish true lumen from false lumen.AJR Am J Roentgenol. 2001; 177: 207-211Google Scholar, 46Moore A.G. Eagle K.A. Bruckman D. Moon B.S. Malouf J.F. Fattori R. et al.Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: international registry of acute aortic dissection (IRAD).Am J Cardiol.