The use of endovascular techniques for the treatment of complications of aortic dissection

Abstract

Intravascular ultrasonography, balloon angioplasty, stent placement, and endovascular septal fenestration have been used in the evaluation and treatment of vascular complications of acute and chronic aortic dissection in five patients. There were three men and two women with an average age of 52 years (range 39 to 64 years). There were three chronic type A dissections, one acute type B, and one subacute type B dissection. Intravascular ultrasonography was used in all five cases. The three patients with chronic type A dissections underwent unilateral renal artery angioplasty (RA PTA) and stent placement; one patient with an acute type B dissection and associated fibromuscular dysplasia underwent bilateral RA PTA without stent placement. These procedures were performed to ameliorate severe hypertension. The final patient, with a subacute type B dissection, underwent iliac artery stenting to correct severe lower extremity ischemia. During a second intervention, this patient, who also had bowel ischemia and nonresolving acute renal failure, underwent balloon dilatation of a preexisting septal fenestration to augment visceral blood supply and bilateral RA PTA and stent placement in an effort to improve renal function. This patient eventually died of gut ischemia. After RA PTA and stent placement, one patient had a major intrarenal hemorrhage that required coil embolization and transfusion. In the four survivors, RA PTA and stent placement resulted in immediate improvement in blood pressure control. This response has been sustained during follow-up intervals ranging from 8 to 18 months (average 10 months). Intravascular ultrasonography can clearly demonstrate the pathologic anatomy associated with aortic dissection (even when angiography is ambiguous) and is essential for guiding therapeutic endovascular interventions. Further exploration of the efficacy of these endovascular techniques is warranted in this high-risk group of patients with aortic dissection who have appropriate clinical indications.