Endovascular Treatment Of Acute Type Research Articles

Lobato technique for acute type B aortic dissection complicated by thoracoabdominal aortic aneurysm and total true lumen occlusion of the infrarenal aorta.

A 63-year-old man had presented for emergency endovascular treatment of acute type B aortic dissection complicated by acute occlusion of the true lumen of the infrarenal aorta and a Crawford type III thoracoabdominal aortic aneurysm. These findings precluded the use of a conventional endovascular approach. A novel technique was developed with the insertion of guidewires through the left femoral and subclavian arteries to deliver stent grafts to cover the dissection entry tear and exclude the thoracoabdominal aortic aneurysm. A femorofemoral bypass was performed to preserve the circulation. The procedure and follow-up course were uneventful. This technique appears to be a promising tool for thoracic endovascular aortic repair in emergency setting. More experience with the method is warranted.

Anatomy of the retrograde type A aortic dissection after endovascular repair of type B aortic dissection: a case report

Aortic dissection requires immediate medical attention. The optimal treatment approach of Type B aortic dissection is still a matter of debate. Possible options include open surgery, endovascular aortic repair (EVAR), and hybrid procedure. The indication for surgery is the dissection that involves the ascending aorta and the aortic arch (Type A Stanford, Types I and II DeBakey). Hybrid or endovascular procedures seem to be an attractive alternative treatment for patients with the complex aortic disease and a high risk of surgery. Endovascular treatment of acute Type B aortic dissections is designed to prevent the retrograde dissection of the ascending aorta and the aortic arch. The occurrence of retrograde Type A aortic dissection (RTAD) is rare, but the mortality rate is high. We report a case of a 55-year-old gentleman who had undergone thoracic EVAR. Thirty months after the given procedure he presented with RTAD and underwent supracoronary aortic replacement. The article is intended to remind the clinicians of the importance of early detection of the possible complications when performing EVAR, and the significance of a rapid response.

Invited commentary

The last 20 years have brought dramatic changes in our approach to aortic dissections. Advances have come not only in devices but also in imaging, medical therapy, and even our fundamental understanding of the anatomic pathology. But it is really the stent graft devices, and their promise of lower morbidity and mortality, that have emboldened us to more aggressively treat type B dissections. This study is this first meta-analysis comparing open to endovascular treatment of acute type B aortic dissections published within the past 5 years. With the way technology advances, one could claim this is the first such meta-analysis of our current modern age. Whereas the study has obvious limitations, let's look at the clear conclusions. Endovascular therapy for acute type B dissections appears to offer a definitive survival advantage in the postoperative period that is maintained through the first year. At 5 years, however, the picture becomes grim, with <50% survival regardless of therapy type. Although it is impossible to tell from the original series that compose this study, I hypothesize that the meta-analysis is a comparison not only of treatment type but also of treatment eras. Most of the open surgeries were likely performed early in the series, with most of the stent grafts being placed late. So we are really looking at a documentation of our evolving strategies for dealing with acute type B dissections. Thankfully it shows improvement, for early survival anyway. Of course, what is missing from this analysis is a medical management treatment limb. Patients with acute type B aortic dissections have a poor 5-year survival regardless of therapy. There must be a clear and perhaps even leading role for nonoperative management. This analysis, like the International Registry of Acute Aortic Dissection, seems to deliver as many questions as answers. Acute type B aortic dissections are a complex process with seemingly unlimited variables. To reach a treatment consensus, we should strive for the highest level of reporting standards. Going forward, modern series should include detailed indications for treatment for every case. Technical information, such as device type, landing zone, and length of coverage, is necessary to report when endovascular therapy is employed. For patients receiving conservative/medical management, documentation should include pharmaceutical regimen, treatment parameters, and of course the Great White Whale, patient compliance. There is no randomized, controlled clinical trial coming to deliver us from this confusion. We must gather what we can from studies like this and move forward with new, improved reporting standards. Systematic review and meta-analysis of acute type B thoracic aortic dissection, open, or endovascular repairJournal of Vascular SurgeryVol. 69Issue 5PreviewThe purpose of this study was to compare perioperative and mortality outcomes of endovascular aortic repair against open repair in acute type B thoracic aortic dissection. Full-Text PDF Open Archive

Endovascular treatment of acute Type A aortic dissection-the Endo Bentall approach.

Outcome after classical surgical repair of acute Type A aortic dissection has steadily improved over the years and several modifications in cannulation and perfusion added to this achievement. However, subgroups remain where results of classical surgical repair still have room for improvement, particularly patients with severe preoperative malperfusion as well as elderly patients with a limited physiological reserve. So far, only small case series or case reports have been published on the endovascular treatment of dissected ascending aortas. However, a tube alone is not sufficient to fix the entire complex underlying problem in the vast majority of patients with acute Type A aortic dissection. In addition, these published reports are either due to a favorable anatomy or due to very localized disease processes, which are the exception and not the rule. The concept of an endovascular valve-carrying conduit may significantly increase the number of patients suitable for endovascular therapy and it may soon be common practice.

Endovascular treatment of acute type B dissection complicating graft-bypass repair for aortic coarctation

Abstract Objectives The early dissection of the descending aorta after the repair of aortic coarctation is very rare. Herein, we present a special endovascular technique used for acute type B dissection complicating graft bypass for aortic coarctation. Methods The 48 year-old male patient with the diagnosis of adult type aortic coarctation had bypass procedure between the aortic arch and the descending aorta. Six weeks after the first operation, the patient was readmitted with severe back pain and had the diagnosis of acute type B dissection which involved the descending aorta at the distal part of the graft anastomosis. Results Two separate stent-grafts were deployed respectively 31 × 150 mm and 34 × 200 mm (C-TAG™ WL Gore&Asc., Flagstaff, AZ, USA). The previous Dacron bypass graft was used as a proximal landing zone for the first stent-graft. The distal landing zone for the second stent was the area between the celiac trunk and superior mesenteric artery. Therefore, the covered stent-graft was implanted to the celiac trunk (Viabahn™ 7 × 50 mm WL Gore&Asc, AZ, USA) to maintain its patency before the deployment of the second graft. The segment of coarctation was closed with a vascular plug (Amplatzer™ vascular plug II) to prevent persistent perfusion of aneurysmal false lumen. Conclusion The endovascular approach offers multiple less invasive options based on a patient-specific problem.

Endovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of True and False Lumen Diameter Changes

The aim of this study was to determine the technical success after endovascular treatment of acute type B aortic dissections and to evaluate true and false lumen diameter changes at long-term follow-up. Twenty-eight patients with acute type B-dissection who were treated by stent graft repair presented with rupture (n = 1), contained rupture (n = 2), compromised branch vessels (n = 14), pleural effusion (n = 11), rapid aortic diameter progression (n = 5), persistent pain (n = 3), refractory hypertension (n = 10), and an aortic diameter of more than 4 cm (n = 4). Taking into account the perfusion status of the false lumen, diameter changes were monitored in the thoracic aorta at the level of the stented segment (L1), distal to the stent graft (L2), and at the level of the celiac trunk (L3). Severe complications in 9 patients (32%) resulted in 3 deaths for a 30-day mortality rate of 10.7%. Primary sealing of the entry tear was achieved in 86%. At all levels, the true lumen diameter increased significantly after stent graft placement. At the 1-year follow-up, the false lumen in L1 was thrombosed in 90% and the mean difference of diameter reduction was highly significant. In L2, complete false lumen thrombosis occurred in 60% with a significant diameter decrease. In L3, the false lumen thrombosed in only 22%, and the mean difference of false lumen diameter increase reached significance at the 2-year follow-up. Ninety percent of patients were treated successfully with thrombosis of the false lumen in the stented segment. False lumen perfusion distal to the stent graft resulted in diameter increase in several patients leaving these segments an area of concern.

Combined Surgical and Endovascular Treatment of Aortic Type A Dissection

We describe a combined approach for treatment of a type A aortic dissection with surgical repair of the ascending aorta and transluminal stenting of the descending aorta, therefore minimizing the consequences on the untreated aortic arch and descending aorta. From December 2002 to June 2003, 5 consecutive patients (4 men, 1 woman) suffering from type A aortic dissection were treated with resection of the ascending aorta or aortic hemi-arch. Before the open distal aortic anastomosis the Endofit endovascular graft (Endomed Inc, Phoenix, AZ), was deployed under direct vision distally to the origin of the left subclavian artery. Intraoperative stent graft placement was successful in all patients. There was no hospital mortality. Early results were satisfactory with a completely thrombosed false lumen in 2 patients and a partially thrombosed false lumen in 3 patients, 10 days after operation. Follow-up computed tomographic scan showed a completely thrombosed false lumen in 4 patients and a partially thrombosed false lumen in 1 patient. This study shows that combined surgical and endovascular treatment of acute type A dissection is a feasible option, but further evaluation is necessary.

Combined Surgical and Endovascular Treatment of Acute Aortic Dissection Type A: Preliminary Results

Background. The established treatment modality of acute Stanford type A dissection includes repair of the ascending aorta and various portions of the aortic arch, whereas the descending aorta is left untreated. We report a simultaneous approach of open repair of the ascending aorta with transluminal stent grafting of the descending aorta to minimize the consequences of an untreated descending aorta. Methods. From April 2001 to February 2002, 8 consecutive patients (3 women [37.5%] and 5 men [62.5%]) with a mean age of 55.7 years (range, 45 to 70 years) were intended to be treated with the combined method of surgical repair of the ascending aorta and transluminal stent grafting into the descending aorta during the period of deep hypothermic circulatory arrest. Circulatory arrest time ranged between 30 and 67 minutes (average, 38.8 minutes). Specially designed Talent stent grafts (32 to 40 mm in diameter, length 13 cm) were inserted under direct vision and deployed with the proximal end at the origin of the left subclavian artery. Results. Intraoperative stent graft placement was successful in 7 patients (87.5%). Because of severe kinking of the distal arch, stent insertion failed in 1 patient (12.5%). One patient with a history of preoperative stroke in the middle cerebral artery died because of intracerebral bleeding on postoperative day 2, resulting in an in-hospital mortality of 12.5%. Mean intensive care unit stay was 6.4 days (range, 2 to 21 days) and overall hospital stay was 18.2 days (range, 7 to 33 days). Completion computed tomographic scans revealed complete thrombosis of the false lumen in 2 patients and partial thrombosis in 4 patients. Follow-up was complete and ranged from 1 to 9 months (mean, 5.4 months). Conclusions. This preliminary study shows that combined surgical and endovascular treatment of acute type A dissection is feasible, and at least partial thrombosis of the false lumen can be achieved, potentially minimizing the risk of further dilatation or rupture. Additionally, the stent graft expands the otherwise sickle-shaped true lumen, thereby ameliorating distal aortic perfusion. Long-term results are warranted to demonstrate the effectiveness of this new combined treatment modality.