Complicated Aortic Dissection Research Articles

AAN 2. Early Experience With a Novel Thoracic Stent Design for the Prevention of Distal Stent Graft-Induced New Entry Tears (d-SINE)

Distal oversizing is proposed as a contributing factor to distal stent graft-induced new entry tears, especially in managing the complications of aortic dissection. However, distal radial force can only be partially reduced by a tapered design or the use of distal restrictive stents or stent grafts. We report our early outcomes with a disease-specific, factory-modified Zenith Alpha thoracic stent graft (Cook Medical, Bloomington, Ind). Dissection-specific features include no proximal barbs; >20 cm in length and substantially tapered (custom-made, but usually by 10 mm); reduced radial force in the second and third distal stents and removal of the final stent, leaving 30 mm of unsupported graft; and an “endovascular elephant trunk.” A retrospective review was performed of all customized stent cases. Indications for use, technical difficulties, and incidence of further aortic sequelae were examined. Between February 2017 and July 2018, there were 14 patients who were treated (mean age, 55 years; range, 45-79 years; 4 female patients). Median follow-up was 15.5 months (range, 2-18 months). All intervention was performed for postdissection aneurysmal disease; nne patients had previous proximal aortic intervention, and four had an underlying connective tissue disorder. Three patients had scheduled further distal aortic treatment at the time of study intervention. Technical success was 100% and 30-day mortality 0%. No propagation of disease was noted on follow-up imaging. There was one late aneurysm-related death in a patient awaiting a fenestrated endovascular aneurysm repair. Use of this disease-specific stent graft design is not associated with any early technical issues or evidence of stent graft-induced new entry tears on short-term follow-up. Its impact on improving long-term outcome remains to be demonstrated.

Complicated acute typeB aortic dissection-what does endovascular therapy contribute?

Acute aortic dissection typeB is asevere and life-threatening vascular emergency. Complications such as rupture and/or malperfusion of organs are the main reasons for early mortality. The aim is to provide an overview on important diagnostic radiological findings, conservative as well as endovascular therapeutic options for patients presenting with rupture or malperfusion syndromes. Medical treatment consisting of blood pressure and heart rate control as well las adequate analgesia remains the cornerstone therapy of all typeB aortic dissections. In case of organ malperfusion, various endovascular therapies, e. g., endoluminal fenestration of dissection flap, thoracic stent-graft implantation (TEVAR) or branch vessel stenting, are available. In the case of aortic rupture, TEVAR has become the standard owing to its lower mortality compared to open surgical repair. For the treatment of complicated typeB aortic dissection, a number of endovascular options are available. For optimal treatment, profound knowledge of the disease, of the diagnostic workup, and of the interventional procedures is mandatory.

Treatment of a Complicated Chronic Aortic Dissection with Distal False Lumen Embolization

Treatment of a Complicated Chronic Aortic Dissection with Distal False Lumen Embolization

Aortic remodelling after thoracic endovascular aortic repair for acute and subacute type B aortic dissection.

Thoracic endovascular aortic repair (TEVAR) in the current era has gained widespread acceptance as the modality of choice for the treatment of complicated aortic dissection (AD). However, reports on clinical results of TEVAR treatment of AD patients are mainly comparisons and analyses of results between patients in the acute and chronic phases, few reports have described the postoperative aortic remodelling of patients with subacute AD after TEVAR. The aim of this study was to investigate aortic remodelling after TEVAR in acute and subacute Stanford type B AD patients. The clinical data of 38 Stanford type B AD patients who received TEVAR treatment in our hospital between July 2012 and December 2017 were retrospectively analysed. The maximum diameters of the aorta, the mean diameters of the true lumens (TLs) and the false lumens (FLs) of the aorta in the dissection range before and after TEVAR treatment were measured. All diameters between different groups or in the same group before and after therapy were compared using nonparametric tests. Count data were examined using the χ2 test. The 38 patients were 31.0-82.0 years old with a mean age of 57.0±11.0 years, including 31 men and 7 women, with 22 patients in the acute phase and 16 patients in the subacute phase. Among the 38 patients included in this study, 7 (18.4%) patients had endoleaks after treatment. No perioperative deaths occurred. Analyses of computed tomography angiography measurement results showed that the baseline maximum diameters of the aorta, TLs and FLs before TEVAR between the acute and subacute groups were not significantly different (P=0.193, P=0.301 and P=0.067, respectively). After TEVAR treatment, the maximum diameters of the aorta and the diameters of the FLs were different between the two groups (P=0.005 and P=0.012), but the diameters of the TLs were not (P=0.069). The diameters of the TLs increased, and those of FLs decreased significantly in the acute and subacute groups after TEVAR (P<0.001, P<0.001, P<0.001 and P=0.007, respectively); the maximum diameters of the aorta decreased significantly in the acute group (P<0.001), but they did not change obviously in the subacute group (P=0.121). TEVAR offers satisfactory results for the treatment of type B AD. Acute AD may be associated with better aortic remodelling compared to subacute AD after TEVAR.

Satisfactory short-term outcomes of the STABILISE technique for type B aortic dissection

ObjectiveThe aim of this study was to evaluate the perioperative and short-term results in a cohort of patients treated during the last year at our institution with the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique for acute complicated aortic dissection. MethodsBetween June 2016 and June 2017, 10 patients (all male; mean age, 62.6 ± 7.4 years) received treatment for acute complicated aortic dissection with the STABILISE technique. After a standard provisional extension to induce complete attachment procedure using the commercially available endovascular dissection system (Cook Medical, Bloomington, Ind), the distal stent graft area and the bare stent area were ballooned to completely exclude the thoracic false lumen (FL) and to obtain a single-channeled abdominal aorta. Computed tomography was routinely performed within the first postoperative week before discharge and then at 3 months, at 6 months, and yearly thereafter. The technical and clinical success rates were analyzed. ResultsThe 30-day technical and clinical success rates were 100%, with complete thrombosis of the thoracic FL and no type I endoleak. Malperfusion was resolved in all cases. No aortic ruptures were recorded, and no open conversion was required. One case of delayed spinal cord ischemia fully resolved within the discharge period. Predischarge computed tomography showed complete thrombosis of the thoracic FL in all cases. In two cases, some degree of patency of the abdominal FL was observed. At short-term follow-up, the overall aortic diameters remained stable with no further dilation. ConclusionsThe STABILISE technique was safe and feasible in this cohort of patients, with complete thrombosis of the thoracic FL and creation of a single-channeled aorta in most cases. Further studies are needed to ascertain the long-term behavior of the treated aorta.

Marfan syndrome diagnosis and management

Marfan syndrome is the most common inherited multisystem disorder of connective tissue. This autosomal dominant condition has an incidence of 2-3 per 10,000 individuals. Although genetic diagnostic techniques are available, the diagnosis is primarily made using the Ghent diagnostic criteria. Early identification and appropriate management improves the prognosis of patients with Marfan syndrome who are prone to the life-threatening cardiovascular complications of aortic dissection and rupture. Beta-blockers have been demonstrated to slow aortic growth and thus delay the time to aortic surgery. Operative intervention has markedly changed the prognosis of patients with Marfan syndrome and can be safely performed on an elective basis. The advance in the understanding of the cause of Marfan syndrome, as well as early recognition of the disorder and subsequent institution of medical and surgical therapy has resulted in dramatic improvement.

Treatment solution: treatment of choice in a case of haemodynamic instability after endovascular repair of a complicated acute type-B aortic dissection.

Treatment solution: treatment of choice in a case of haemodynamic instability after endovascular repair of a complicated acute type-B aortic dissection.

Incidence and Risk Factors of Delirium in Patients After Type-A Aortic Dissection Surgery

To study the incidence and related risk factors for postoperative delirium after type-A aortic dissection in patients who underwent Sun's procedure (total arch replacement using a tetrafurcate graft with stented elephant trunk implantation). A retrospective study. A cardiac surgical intensive care unit. The study comprised 100 patients admitted to the intensive care unit for type-A aortic dissection. All patients underwent Sun's procedure with uniform preoperative and anesthetic treatment. Delirium was evaluated using the Confusion Assessment Method for the intensive care unit. Baseline demographics and preoperative, intraoperative, and postoperative data were recorded and analyzed retrospectively via univariate analysis and multivariate logistic regression. The incidence of postoperative delirium was 34%, according to Confusion Assessment Method for the intensive care unit criteria. Univariate analysis revealed that 17 variables differed significantly among patients with and without delirium. Additional multivariate stepwise logistic regression analysis confirmed that cerebrovascular disease history, surgery duration, cardiopulmonary bypass duration, intubation time, and hypoxia were strongly associated with postoperative delirium. Delirium is a common postoperative complication of aortic dissection. Cerebrovascular disease history, surgery and cardiopulmonary bypass duration, postoperative hypoxia, and intubation time are independently associated with the development of delirium. Early diagnosis of delirium and modifying these factors properly may be helpful to improve patients' prognosis.

Effect of Intravascular Ultrasound-assisted Thoracic Endovascular Aortic Repair for "Complicated" Type B Aortic Dissection.

Background:Intravascular ultrasound (IVUS) examination can provide useful information during endovascular stent graft repair. However, its actual clinical utility in thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (type B-AD) remains unclear, especially in complicated aortic dissection. We evaluated the effect of IVUS as a complementary tool during TEVAR.Methods:From September 2011 to April 2012, we conducted a prospective cohort study of 47 consecutive patients with “complicated” type B-AD diagnosed. We divided the patients into two groups: IVUS-assisted TEVAR group and TEVAR using angiography alone group. The general procedure of TEVAR was performed. We evaluated the perioperative and follow-up events. Patient demographics, comorbidities, preoperative images, dissection morphology, details of operative strategy, intraoperative events, and postoperative course were recorded.Results:A total of 47 patients receiving TEVAR were enrolled. Among them (females, 8.51%; mean age, 57.38 ± 13.02 years), 13 cases (27.66%) were selected in the IVUS-assisted TEVAR group, and 34 were selected in the TEVAR group. All patients were symptomatic. The average diameter values of IVUS measurements in the landing zone were greater than those estimated by computed tomography angiography (31.82 ± 4.21 mm vs. 30.64 ± 4.13 mm, P < 0.001). The technique success rate was 100%. Among the postoperative outcomes, statistical differences were only observed between the IVUS-assisted TEVAR group and TEVAR group for total operative time and the amount of contrast used (P = 0.013 and P < 0.001, respectively). The follow-up ranged from 15 to 36 months for the IVUS-assisted TEVAR group and from 10 to 35 months for the TEVAR group (P = 0.646). The primary endpoints were no statistical difference in the two groups.Conclusions:Intraoperative IVUS-assisted TEVAR is clinically feasible and safe. For the endovascular repair of “complicated” type B-AD, IVUS may be helpful for understanding dissection morphology and decrease the operative time and the amount of contrast used.

False Lumen Embolization During TEVAR for Complicated Aortic Dissections Is Associated With a Lower 30-Day Mortality and Improved Long-Term Survival

False Lumen Embolization During TEVAR for Complicated Aortic Dissections Is Associated With a Lower 30-Day Mortality and Improved Long-Term Survival

Unusual changing localization of acute myocardial ischemia in a case of an aortic dissection

Aortic dissection is a life-threatening illness in which early diagnosis and treatment are critical for survival. Subepicardial hematoma is a rare complication of aortic dissection with retrograde propagation, and such a case, of a 62-year-old woman, is presented here. The autopsy showed that the woman suffered an aortic dissection with the formation of a subepicardial hematoma, as a consequence of retrograde aortic dissection propagation, which led to the gradual compression of the coronary arteries and compromised the circulation of the heart. Rising pressure in the subepicardial hematoma produced confusing ECG readings, which changed over time suggesting varying location of myocardial infarct. These ECG findings, together with nonspecific laboratory and other clinical signs, prevented the establishment of a correct diagnosis of aortic dissection in this patient.

Circumferential Intimal Intussusception in a Case of Stanford Type-A Dissection.

Intimointimal intussusception is a rare but serious complication of aortic dissection (1). Under hemodynamic forces, this cylindrical flap of tissue can intussuscept within the false lumen causing distal obstruction (1). A 58 year-old male patient was referred to us with chest pain that had started 3 days previously. On physical examination he had no neurological problems. Upper extremity pulses were filiform but lower extremity pulses were palpable. Echocardiography (Vivid S5, General Electric, America) showed minimal aortic regurgitation with 65% ejection fraction and minimal pericardial effusion. The patient had no malperfusion findings. A contrast-enhanced computed tomography (CT) (Toshiba Asteion 4, Japan) scan of the patient’s chest and abdomen showed no flaps in the ascending aorta (Figure 1a, Figure 1b), but a dissection flap appeared below the innominate artery (Figure 1a, Figure 1b, Figure 2a and Figure 2b). A nested double lumen was seen in both arcus and descenden aorta (Figure 1a, Figure 1b, Figure 2a and Figure 2b). We made a diagnosis of Stanford type-A acute dissection. FIG. 1. a, b. Preoperative horizontal section of CT Angiography (a). Preoperative horizontal section of CT Angiography (b). FIG. 2. a, b. Preoperative vertical section of CT Angiography. In Figure 2a and Figure 2b, dissection of the membrane started below the innominate artery and innominate artery occlusion can be seen. Figure 2 shows arcus aorta with subclavien artery and descenden aorta. ... Patient and relatives’ informed consent was obtained for surgery and scientific purposes. Emergency surgery was performed. After median sternotomy, hematoma was seen on the aorta (Figure 3). Antegrade cerebral perfusion was used and complete circumferential intussusception into the descending aorta was seen with the open aortic arch technique. The aortic valve had no problems and we replaced the ascending aorta successfully. The patient’s postoperative course was uneventful, and he was discharged in good condition 7 days after the operation. FIG. 3. Hematoma was seen over the aorta and right ventriculum. A 6 mm chimney graft was applied. In all cases with antegrade invagination, circumferential dissection occurred exclusively above the coronary ostia, which coincides with wall stress distributions in the ascending aorta (2). Antegrade intussusception may occlude the arch vessels partly or completely, causing neurologic symptoms. As many as 30% of aortic dissection cases are complicated by malperfusion of a critical organ (3). Alongside other complications, cerebral malperfusion is the most devastating (4). To react appropriately, early detection is mandatory. Interestingly, in our case, the patient had extremity pulses that were usually palpable but there was no sign of malperfusion. An enhanced CT scan is the primary diagnostic procedure for almost all aortic dissection. However, the diagnosis of aortic dissection with intimal intussusception is difficult because of the lack of a flap in the ascending aorta and the unusual form of invaginated flaps. Transesophageal echocardiography and magnetic resonance imaging are also sensitive diagnostic procedures for aortic dissection, but require much more time for making an accurate diagnosis. Appropriate and prompt diagnosis will permit timely and lifesaving surgical interventions for the patient.

Effective treatment with para-aminomethylbenzoic acid for chronic disseminated intravascular coagulation associated with aortic dissection

Chronic disseminated intravascular coagulation is a rare complication of aortic dissection. Surgical correction or low molecular weight heparin is treatment of choice, but for a severe bleeding problem due to excessive fibrinolysis, para-aminomethylbenzoic acid would be a simple and effective therapeutic approach.

Pulmonary artery intramural hematoma: unusual complication of aortic dissection

A 56 year-old patient presented to the emergency room with chest pain and 26mmHg blood pressure gap between right arm and left lower limb. The hypothesis of aortic dissection was evaluated through chest CT, which showed a Stanford type A aortic dissection with extension through the pulmonary artery and the presence of an intramural hematoma extending along the main and right pulmonary arteries.

Disección de aorta tipo B no complicada: ¿debe ser todavía el tratamiento médico la mejor opción? Sí, el tratamiento conservador es la mejor opción

Acute type-B dissection is one of the most dreaded diseases that can occur in the aorta. Classically, the preferred medical treatment has been the perfect control of the blood pressure and the pain. However, the advent of endovascular therapy and its successful implementation in complicated aortic dissections (patients with hemodynamic instability, peripheral ischemia, visceral malperfusion or contained rupture) has expanded its use in all cases. This has led to considerable controversy regarding the appropriate treatment of this disease, especially in uncomplicated aortic dissections. To date, endovascular therapy appears to cause more thrombosis of the false lumen and a more favorable remodeling of the aorta during the follow-up, but missing data shows that this approach improves the overall survival of these patients. The authors of these articles analyze the effectiveness of endovascular therapy in uncomplicated dissections of the descending aorta, reviewing the latest evidence for and against its use.

VESS4. The Implications of False Lumen Embolization During TEVAR and EVAR on Thrombosis, Pressurization, Remodeling, and Mortality

To evaluate the implications of thoracic and abdominal aortic false lumen embolization (FLE) during thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) for complicated aortic dissections. Ninety-six consecutive patients who presented with complicated acute and chronic type B thoracic aortic dissections (TAD) who underwent TEVAR with FLE (n = 32 [33.3%]) and without FLE (n = 52 [54.2%]), as well as abdominal aortic dissections (AAD) who underwent EVAR with FLE (n = 4 [4.2%]) and without FLE (n = 8 [8.3%]). In a subset of 26 patients, before FLE, a wireless cardioMEMS Endosure pressure sensor was placed in the false lumen and used to quantify the false lumen to systemic systolic, diastolic, mean, pulse pressure indices. All data were prospectively collected and outcomes analyzed. The 30-day mortality in patients with FLE (n = 1 [2.3%]) was significantly lower than patients without FLE (n = 5 [9.6%]), and none of the patients with FLE developed spinal cord ischemia. After TEVAR and FLE, nine patients (29.0%) had persistent retrograde false lumen endoleaks that required repeat embolization procedures. FLE and complete thrombosis was achieved in 100% of EVAR patients. At a mean 18-month follow-up, 88% (23 of 26 patients) had a significant decrease in all false lumen-to-systemic pressure indices, and 65% (17 of 26 patients) had a false lumen remodeling with >5 mm maximum diameter reduction. At midterm follow-up, there are no thoracic or abdominal related ruptures, conversions, or deaths. FLE during TEVAR for complicated acute and chronic TAD and AAD is associated with a lower mortality and is effective in reducing false lumen pressures and maximum diameter. This adjunctive technique should be considered when managing complicated aortic dissections.

Renal Sympathetic Denervation in Patients with Aortic Dissection

We report on feasibility, safety, and mid-term outcomes of renal sympathetic denervation (RSD) in hypertensive patients after endovascular treatment for aortic dissection. Six patients were subjected to RSD after receiving endovascular treatment for complicated aortic dissection. Between April 2011 and May 2012, RSD procedure was applied for persistent hypertension despite maximized antihypertensive drug therapy using the Symplicity® catheter system. Endovascular aortic treatment was performed for malperfusion or rapid expansion by virtue of a stent-graft system (Valiant®, n = 5) or an open cell stent (Smart®; n = 1). Systolic blood pressure (BP) was 189.8 ± 32.2 mmHg and diastolic BP 96.2 ± 11.1 mmHg at baseline on 24 hours readings; after RSD, a successful reduction to 129.5 ± 11.8 mmHg (P = 0.004) for systolic and to 77.7 ± 10.7 (P = 0.004) for diastolic BP at 3-month follow-up was documented on ambulatory 24-hour BP readings with sustained reduction at 1-year follow-up (127.2 ± 11.8 mmHg [P = 0.002] and 77.7 ± 7.7 [P = 0.011]). RSD using the Symplicity® catheter system is feasible and safe in hypertensive patients previously subjected to endovascular repair for complicated aortic dissection.

Reintervention after thoracic endovascular aortic repair of complicated aortic dissection

This study assessed predictive factors for reintervention after thoracic endovascular aortic repair (TEVAR) for complicated aortic dissection (C-AD). An institutional review of consecutive TEVAR for C-AD was performed. Between 2000 and 2011, 41 patients underwent TEVAR for a C-AD involving the descending thoracic aorta. Primary indications included aneurysm >55 mm in 24, rapid aneurysmal enlargement or impending rupture in 6, saccular aneurysm >20 mm in 1, malperfusion in 1, intractable chest pain in 3, and rupture in 6. Technical success was achieved in 100%. The 30-day mortality rate was 5% (n = 2). Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing ≥20% (odds ratio [OR], 16; P = .011), bare-spring stent in the proximal landing zone of the stent graft (OR, 12; P = .032), and anticoagulant therapy (OR, 78; P = .03) were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention (P = .002), whereas complete false lumen thrombosis at the stent graft level was protective (P < .05). This study confirms the feasibility of TEVAR for C-AD, although the rate of reintervention is high. Excessive oversizing, a bare-spring stent graft in the proximal landing zone, large aortic dilatation, and anticoagulant therapy were factors associated with reintervention. Complete false lumen thrombosis at the stent graft level was protective.

Chronic Complicated Aortic Dissection

Chronic Complicated Aortic Dissection

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection