Balloon Fenestration Research Articles

Balloon Fenestration of Iatrogenic Celiac Artery Dissection

Iatrogenic dissections of the celiac artery during catheterization are rare complications. Herein a case is reported in which complete occlusion of the celiac artery occurred during transcatheter arterial chemoembolization and was immediately successfully recanalized with balloon fenestration of the intimal flap. Follow-up angiography showed patent celiac and common hepatic arteries with mild focal residual stenosis of the common hepatic artery orifice.

Percutaneous Management of Ischemic Complications in Patients with Type-B Aortic Dissection

To review our experience with the use of percutaneous methods to manage the ischemic complications of type-B aortic dissection. Retrospective review of our interventional radiology database identified 11 patients with acute type-B aortic dissection who underwent 13 endovascular procedures to attempt revascularization of 23 ischemic vascular territories (four mesenteric, 11 renal, eight lower extremities). Percutaneous interventions included balloon fenestration (four patients), aortic true lumen stent placement (three patients), and branch vessel stent placement (eight patients). Successful initial reperfusion of 21 of 23 vascular territories (91%) was achieved with use of percutaneous methods alone, with no 30-day mortality, in-hospital mortality, or paraplegia. One additional patient underwent successful initial treatment with use of a combined interventional/surgical approach to reperfuse an ischemic limb. One patient developed acute thrombosis of a dissected renal artery during stent placement. Increased aortic true lumen collapse later resulted in further ischemia in two patients. During follow-up (mean, 16 mo), no patient has had evidence of false lumen enlargement or late recurrent ischemia. Endovascular methods offer a less-morbid nonsurgical treatment alternative for patients with acute complicated type-B aortic dissection.

Interventional management of aortic dissection.

Modern high-resolution imaging techniques have provided new insights into the pathogenesis of aortic dissection during recent years. Distinct pathologic entities or potential precursors of classic false-lumen aortic dissection such as intramural hematoma or penetrating atherosclerotic ulcer have been identified. As a result, a novel classification according to Svensson used in addition to the standard differentiation according to DeBakey or Stanford has been introduced. Due to improved diagnostic imaging, preoperative mortality has decreased but mortality remains substantial (up to 1.4% per hour within the first 2 days) related to complications of aortic dissection such as aortic rupture, bleeding, pericardial tamponade, critical branch vessel ischemia, multiorgan failure, and myocardial infarction. Transesophageal echocardiography, angiography, magnetic resonance imaging or computed tomography as well as intravascular ultrasound are used for a complete vascular "staging" of patients with aortic dissection after initial stabilization (with or without surgery). New catheter-based interventional techniques have been developed to improve the poor prognosis of aortic dissection: 1 Percutaneous balloon fenestration (PTF) of the intimal flap improves perfusion in case of bowel, limb, or renal ischemia. 2. Aortic stent-graft placement allows for occlusion of the intimal entry tear by implantation of a membrane-covered, self-expanding stent-graft to initiate progressive thrombus formation within the false lumen. Compared to the traditional surgical approaches, both techniques have a low complication rate. The development of these techniques may help to further improve to decrease patients' morbidity and mortality.

Acute aortic dissection with side branch vessel occlusion: Open surgical options

Acute aortic dissection is one of the most common catastrophes affecting the aorta. Because dissection can involve any aortic segment, the disease can manifest itself through a variety of clinical presentations. The most spectacular manifestation is frank rupture, usually into the pericardial or pleural cavity. Dissections of the ascending aorta are associated with rapidly fatal complications such as cardiac tamponade, major stroke, or massive myocardial infarction, justifying emergent operation. Dissections of the descending aorta are managed medically with surgery reserved for those patients with aortic rupture, aneurysmal dilatation, or ischemic symptoms. Aortic branch occlusion occurs in up to one third of patients with aortic dissection and is associated with increased risk of early death and serious complications. The therapeutic armamentarium of the vascular surgeon has evolved during the last 20 years to include endovascular (balloon fenestration or branch stenting) and surgical options. This article will focus on the open surgical management of patients with acute aortic dissection complicated by side branch occlusion and organ or limb malperfusion.

Aortic Intimal Dehiscence: A Complication of Percutaneous Balloon Fenestration for Aortic Dissection

A patient with acute type B dissection and a tube configuration of the intimal flap presented with signs of advanced mesenteric and renal ischemia as well as decreased pulses in the lower extremities. The patient was referred for emergency percutaneous fenestration of the abdominal aorta as a salvage procedure and a possible bridge to later surgery. After fenestration, femoral pulses became transiently stronger and then disappeared. The patient died after exploratory laparotomy. Postmortem examination demonstrated dehiscence of the infrarenal abdominal aortic intima with occlusion of the aortic bifurcation.

Stent-graft entry closure and balloon fenestration for a case of aortic dissection accompanied by organ malperfusion

J Thorac Cardiovasc Surg 2001;121:1216-8

Transaortic Septectomy as Treatment for Chronic Mesenteric Ischemia After Aortic Dissection

Visceral ischemia can present as an acute or chronic complication of aortic dissection, which is associated with high morbidity and mortality rates, up to 50-87%. Furthermore, the optimal management strategy for this problem is unclear. The authors present a case of chronic mesenteric ischemia complicating a Stanford type A aortic dissection which was treated with transaortic septectomy. A 56-year-old man presented with chronic abdominal pain and a 30-pound weight loss after operative repair of an ascending aortic dissection with replacement of his aortic valve and ascending aorta. Two prior attempts at balloon fenestration of his aortic dissection in the area of his mesenteric vessels had failed to improve his symptoms. Angiography, computed tomography scan, and duplex evaluation of the aorta revealed a 5 cm suprarenal aorta with the false lumen occupying the majority of the diameter. The origins of the mesenteric vessels from the true lumen were compressed by the septum. The patient underwent a septectomy and aortoplasty of his suprarenal aorta via a retroperitoneal approach. A postoperative duplex scan showed widely patent origins of the celiac, superior mesenteric, and renal arteries. The patient's postprandial pain completely resolved before hospital discharge. Aortoplasty and septectomy presents a newly described treatment of complications of aortic dissection and has been utilized in the acute and chronic settings. It allows successful treatment of aneurysmal and occlusive complications in the dissected aorta. The evaluation and operative treatment of a patient with both these complications is discussed.

Percutaneous Balloon Fenestration and Endovascular Stent Placement for Type B Acute Aortic Dissection with Renal Ischemia

This case illustrates the feasibility and effectiveness of percutaneous balloon fenestration and endovascular renal artery stenting for Type B acute aortic dissection with associated renal ischemia. Percutaneous balloon fenestration and endovascular stent placement should be considered as an alternative to traditional surgical approaches to restore blood flow to arteries compromised by acute aortic dissection.

Percutaneous balloon fenestration in a case of traumatic abdominal aortic dissection with lower extremity ischemia

A 38-year-old man was involved in a traffic accident and experienced a heavy blow to the abdomen. He had traumatic abdominal aortic dissection with right lower extremity ischemia. He underwent percutaneous balloon fenestration, which is safe and minimally invasive, for relief of right lower extremity ischemia. He has been working for 2 years without any signs of vascular compromise. Percutaneous balloon fenestration is one of the few treatments for traumatic abdominal aortic dissection. (J Vasc Surg 2000;32: 616-8)

Minimally invasive therapy options in aortic dissections

Current day therapy for aortic dissection is aimed at the relief of branch vessel ischemia and the prevention of aortic rupture or aneurysm formation. Malperfusion complicating aortic dissection has historically been treated by surgery. Operations in patients with branch-vessel involvement may be technically difficult and the operative mortality is reported to be between 25% and 51%. This may rise to above 70% in patients with critical mesenteric or renal ischemia. Over the past decade, successful relief of such ischemia using the interventional radiological techniques of balloon fenestration, stent implantation and/or thrombolysis has been reported. In addition to being less invasive, this approach is associated with a lower mortality, ranging between 0% and 25%. Patency of the false lumen increases the probability of aortic rupture or aneurysm formation. Recent studies have reported successful closure of the proximal entry site with the help of stent grafts. The aim of the intervention is to initiate a thrombosis of the false lumen and thus stabilize the dissection. Based on a review of the literature and our own experience, we discuss the percutaneous management of branch vessel ischemia complicating aortic dissection as well as the role of stent graft implantation in patients with aortic dissection.

Percutaneous balloon fenestration and stenting in acute aortic dissection

Percutaneous balloon fenestration and stenting in acute aortic dissection

Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection

Objectives: Acute aortic dissection frequently causes life-threatening ischemia of end-organs, historically associated with mortality exceeding 60%. Reperfusion with the use of interventional radiologic methods has evolved as a promising treatment. We report results of our initial 6 years of experience with percutaneous balloon fenestration of the intimal flap and endovascular stenting. Methods: Forty patients (32 male and 8 female) with a median age of 53 years (range 16-86 years) underwent percutaneous treatment for peripheral ischemic complications of 10 type A and 30 type B acute aortic dissections since 1991. Twenty patients had ischemia of multiple organ systems. Thirty patients had renal, 22 had leg, 18 had mesenteric, and 1 had arm ischemia. Results: Fourteen patients were treated with stenting of either the true or false lumen combined with balloon fenestration of the intimal flap, 24 with stenting alone, and 2 with fenestration alone. Successful revascularization was achieved in 93% ± 4% (±70% confidence levels) of patients (37/40). Nine patients had procedure-related complications. The 30-day mortality rate was 25% ± 7% (10/40), often related to irreversible ischemia of intra-abdominal organs that was present before the procedure. Of the remaining 30 patients, 5 have died and the remaining 25 continue to have relief of ischemic symptoms at a mean follow-up of 29 months. Conclusion: Percutaneous balloon fenestration of the intimal flap and endovascular stenting is an effective treatment for life-threatening ischemic complications of acute aortic dissection. (J Thorac Cardiovasc Surg 1999;117:1118-27)

Percutaneous Creation of Acute Type-B Aortic Dissection: An Experimental Model for Endoluminal Therapy

To evaluate the feasibility of a percutaneously created type-B aortic dissection as an experimental model for percutaneous therapy. This model was used to evaluate the hemodynamic effects of single-balloon fenestration of the intimal flap. Acute type-B dissections were created in descending aortae of 15 swine via a femoral (n = 6) or carotid (n = 9) approach. The initial subintimal tear was made with use of a Colapinto needle. The dissections were extended to a predefined position in the aorta. The proximal and distal tears were balloon dilated. The mural flap was balloon fenestrated in six animals, just above the celiac artery. Aortograms were obtained to establish the presence and extent of the dissection. Manometry was performed in both lumina to evaluate the hemodynamics of the dissected aorta and the effects of balloon fenestration in this model. Pathologic specimens were also examined. Creation of dissection was successful in 11 of 15 animals, with six developing true lumen narrowing (group A). The other five animals (group B) had flow in both lumina without evidence of true lumen narrowing. After the creation of a single-balloon fenestration in the group A swine, the arteriograms revealed no evidence of blood admixture between the true and false lumina, and there was no change in the intravascular pressures. Examination of the explanted aortae showed a more extensive circumferential dissection in group A animals as compared with group B. The percutaneously created acute type-B aortic dissection is a feasible model for experimentation. The hemodynamics of the aorta did not change after single-balloon fenestration in this model.

Type 1 Aortic Dissection Complicated by Lower Extremity and Renal Ischemia Treated with Surgical Aortic Replacement and Percutaneous Balloon Fenestration

After successful replacement of the ascending aorta and the aortic arch for a Type 1 aortic dissection, a persistent intimal tear resulted in expansion of the false lumen and in lower extremity and renal ischemia. This was successfully treated with percutaneous fenestration of the suprarenal abdominal aorta by means of a transseptal needle and balloon angioplasty. There were no complications, and benefits continued to result from the procedure at 4 months' follow-up.

The Dissected Aorta: Percutaneous Treatment of Ischemic Complications—Principles and Results

Describe the principles and results of percutaneous treatment of ischemic complications of aortic dissection. Twenty-four patients with aortic dissection complicated by ischemic compromise of the liver or bowel (n = 15), kidney (n = 18), or lower extremity (n = 13) were evaluated by means of aortography, intravascular ultrasound, and manometry, and were treated percutaneously. Visceral arteries were classified as obstructed or nonobstructed. Obstruction was classified as static, in which the dissecting hematoma extended into and narrowed the lumen of a branch artery, or dynamic, in which the dissection flap prolapsed into the vessel origin or narrowed the true lumen (TL) above it. Treatment consisted of vascular stents alone (n = 4), or balloon fenestration (n = 20) without (n = 8) or with (n = 12) vascular stents. Obstruction was present in 77 arteries and was static in 12 arteries, dynamic in 45 arteries, static and dynamic in 17 arteries, and indeterminate in three arteries. Percutaneous treatment did not alter false lumen (FL) pressure, but reduced the peak systolic interluminal pressure gradient from 28 mm Hg to 2 mm Hg and restored flow in 71 of 77 arteries (92%). Six patients died within 30 days (25% operative mortality), none as a result of the procedure. Two additional patients died in follow-up from complications of an expanding FL. Technical complications in two patients due to altered hemodynamics after initial intervention were recognized and corrected percutaneously during the same procedure. Percutaneous fenestration and endovascular stent deployment are indicated to restore blood flow to arteries compromised by aortic dissection. The prognosis of patients is related to the ischemic injury sustained prior to the percutaneous interventional procedure and, in patients with acute type I dissection who have not undergone surgery, to the preoperative stability of the FL.

True lumen obliteration in complicated aortic dissection: endovascular treatment.

To evaluate endovascular treatment of ischemic complications caused by true lumen obliteration in aortic dissection. Endovascular techniques were used to treat true lumen obliteration in 11 patients with complicated aortic dissection. In all cases, the true lumen was compressed to a paper-thin sliver by the expanded false lumen. Two patients had Stanford type A (chronic) and nine had type B (six acute, three chronic) dissections. Obliteration of the true lumen was associated with branch vessel ischemia that included renal (n = 7), mesenteric (n = 6), and lower-extremity (n = 6) arterial compromise. Two patients were treated with aortic stents, four with balloon fenestration of the intimal flap, and three with both stent placement and fenestration. In two patients, ischemic complications caused by true lumen obliteration could not be treated with endovascular techniques. Revascularization was technically successful with relief of clinical symptoms in nine patients. Revascularization was unsuccessful in one patient in whom surgical revascularization of the superior mesenteric artery was necessary and in one in whom hypertension was managed medically. One patient developed thrombosis of a renal artery in which a stent had been placed. The 30-day mortality rate was 9%, and the mean follow-up was 10.1 months (range, 2 weeks to 39 months). True lumen obliteration can be safely and effectively treated with endovascular stent placement and balloon fenestration.

Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration.

The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection. Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections. Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia. Sixteen patients were treated with EVS including 11 with renal, 6 with lower extremity, 2 with superior mesenteric artery, and 2 with aortic stents. Three patients had BF of the intimal flap, and three had BF in combination with EVS. Revascularization with clinical success was achieved in all 22 patients. Two patients died 3 days and 13.4 months after the procedure was performed, respectively. Of the remaining 20 patients, 1 is lost to follow-up, and 19 have persistent relief of clinical symptoms. Mean follow-up time is 13.7 months (range 1.1 to 46.5 months). One case was complicated by guidewire-induced perinephric hematoma. EVS and BF provide a safe and effective percutaneous method for managing peripheral ischemic complications of aortic dissection.

Percutaneous treatment of a traumatic aortic dissection by balloon fenestration and stent placement.

Percutaneous treatment of a traumatic aortic dissection by balloon fenestration and stent placement.

Creation of Reentry Tears in Aortic Dissection by Means of Percutaneous Balloon Fenestration: Gross Anatomic and Histologic Considerations

To study the safety and efficacy of percutaneous fenestration in aortic dissection, transmural tears in canine and human aortae were created with conventional angioplasty balloons. Tears created in the aortae of five living dogs were compared with tears created in postmortem specimens. Percutaneous fenestration was performed in a woman with acute type I dissection and ischemic hepatitis who died in multisystem failure, and the balloon tear was documented at autopsy. Additional tears in the human aorta were studied in necropsy specimens of normal, Marfanoid, atherosclerotic, and acutely and chronically dissected thoracic and abdominal aortae. In the canine aorta, transmural balloon tears resulted in rapid death of all five animals, and the tears were approximately 10% longer than tears created post mortem with the same balloon. In human aortic specimens, most transmural and all transseptal tears were linear and were oriented nearly perpendicular to the longitudinal axis of the aorta. Tears that were initiated near calcified plaques or large aortic branches extended in unpredictable directions. The transverse orientation of the tears coincided with the long axis of smooth muscle cells in the media of the intact aorta or the dissection septum. Percutaneous balloon fenestration, when performed in areas of the aorta relatively free of atherosclerosis, results in transverse tears in the aortic dissection septum. Percutaneous fenestration of the aortic dissection septum appears feasible and should be considered as a treatment option in carefully selected cases of aortic dissection with ischemic complications. A final conclusion regarding the safety and efficacy of percutaneous fenestration undertaken to relieve organ ischemia requires further clinical experience.