Stent-graft Repair Research Articles

Fenestrated Stent Graft Repair of Abdominal Aortic Aneurysm: Hemodynamic Analysis of the Effect of Fenestrated Stents on the Renal Arteries

ObjectiveWe wanted to investigate the hemodynamic effect of fenestrated stents on the renal arteries with using a fluid structure interaction method.Materials and MethodsTwo representative patients who each had abdominal aortic aneurysm that was treated with fenestrated stent grafts were selected for the study. 3D realistic aorta models for the main artery branches and aneurysm were generated based on the multislice CT scans from two patients with different aortic geometries. The simulated fenestrated stents were designed and modelled based on the 3D intraluminal appearance, and these were placed inside the renal artery with an intra-aortic protrusion of 5.0-7.0 mm to reflect the actual patients' treatment. The stent wire thickness was simulated with a diameter of 0.4 mm and hemodynamic analysis was performed at different cardiac cycles.ResultsOur results showed that the effect of the fenestrated stent wires on the renal blood flow was minimal because the flow velocity was not significantly affected when compared to that calculated at pre-stent graft implantation, and this was despite the presence of recirculation patterns at the proximal part of the renal arteries. The wall pressure was found to be significantly decreased after fenestration, yet no significant change of the wall shear stress was noticed at post-fenestration, although the wall shear stress was shown to decrease slightly at the proximal aneurysm necks.ConclusionOur analysis demonstrates that the hemodynamic effect of fenestrated renal stents on the renal arteries is insignificant. Further studies are needed to investigate the effect of different lengths of stent protrusion with variable stent thicknesses on the renal blood flow, and this is valuable for understanding the long-term outcomes of fenestrated repair.

Stent-Graft Repair of Aortobronchial Fistula: A Review

To evaluate the role of aortic stent-graft implantation in managing aortobronchial fistula (ABF). A search of the Medline, EMBASE, and Cochrane databases for studies reporting on ABF treated with stent-grafts from 1996 to 2008 retrieved 44 articles with data on 82 ABFs. Most (57 ABFs) were published in 30 case reports; the others were retrieved from 14 acute aortic series. In the perioperative period, 4 (4.9%) deaths (3 from hemorrhage) were reported, but no paraplegia/stroke. Local graft-related complications were more common, including arm ischemia (n = 4) and iliac ruptures (n = 3). Long-term data were available for only a few studies. Recurrent hemorrhage (14%) occurred from 2 weeks to 9 years after repair. Reinterventions to manage recurrences were generally based on redo endografting. A contaminated field and the emergency setting make stent-graft repair of ABFs challenging. After successful stent-graft deployment, the risks of recurrence and mortality are concerning. One can infer from the data that endografting might be a reasonable temporary bridge solution, but potentially unstable in the long term. Open repair likely will remain indicated once the patient has been stabilized physiologically with emergent stent-graft repair.

A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta

Thoracic endovascular aortic repair (TEVAR) is applicable to a spectrum of thoracic aortic pathology with half of the procedures performed world-wide for indications other than degenerative aneurysm of the descending thoracic aorta (DTA). This multicenter, prospective study queried perioperative and one-year results of TEVAR using the commercially available GORE TAG device, in the treatment of acute complicated Type B dissection (cTBD), traumatic aortic tear (TT), and ruptured degenerative aneurysm (RDA) of the DTA. This prospective, non-randomized, literature controlled study included 59 patients; cTBD, n = 19; RDA, n = 20; TT, n = 20. The primary end-point was the composite of death and total paraplegia in subjects at <or= 30 days post-treatment compared with a cohort from current literature. Secondary end-points included adverse events related to device, procedural and systemic complications, and one-year survival. All 59 patients had successful endoprosthesis deployment. Fifteen of 19 (79%) patients in the cTBD group had either rupture or malperfusion syndromes at presentation. Combined 30-day mortality/paraplegia rate was 13.6% (8/59), with seven (11.9%) deaths (cTBD [3], RDA [3] and TT [1]) and 1 (TT, 1.7%) case of paraplegia. The primary end-point for the TEVAR cohort was significantly lower (P = .008) when compared with a composite literature control of 800 patients (combined 30-day mortality/paraplegia of 29.6%). Thirty-day complications of any nature occurred in 48 (81%) patients; 11 (18.6%) were device related, and 43 (73%) experienced one or more systemic adverse events. Six (10%) patients required additional TEVAR implantations and 3 (5%) patients (one in each pathology group) required conversion to open surgery. Seventeen (29%) patients had endoleaks of any kind or degree through 30 days; cTBD (7), TT (2), RDA (8). Nine patients (15.3%) had perioperative strokes with two resultant deaths. During mean follow-up time of 409 +/- 309 days, an additional 12 patients died, one patient required open conversion (cTBD), and two patients had major device related events. Actuarial survival at one year was 66% (range, 52%-77%) for the entire cohort; (cTBD) 79% (range, 53%-92%), (TT) 79% (range, 53%-92%) and (RDA) 37% (range, 16%-59%). On regression analysis, age at treatment (1.05 [range, 1.01-1.09]; P = .008) and chronic obstructive pulmonary disease (COPD) (4.3 [range, 1.3-14.4]; P = .02) were predictive of death at one year. This study confirmed treatment advantages for TEVAR for thoracic aortic catastrophes when compared with literature-based results of open repair. One-year treatment results indicate a low incidence of graft-related complications. TEVAR is the preferred initial treatment for the DTA catastrophes studied herein.

Endovascular Management of Stanford Type A (Ascending) Aortic Dissection

With advances in endovascular technology and stent graft improvement over the past decade, it might be only a matter of time before pure endovascular management of ascending aortic dissection becomes a viable option. Successful endovascular stent graft repair of thoracic aortic dissection involving the ascending aorta and aortic arch requires a sufficient proximal landing zone with a portion of healthy aorta for the stent graft to fix and seal, while preserving aortic valvular competence, coronary and supra-aortic perfusion.

Intravascular Ultrasound-Assisted Aortic Stent Graft Repair: A Useful Adjunct in Azotemic Patients

Intravascular Ultrasound-Assisted Aortic Stent Graft Repair: A Useful Adjunct in Azotemic Patients

Stent Graft Repair of Iatrogenic Femoral Arteriovenous Fistula: A Useful Therapeutic Approach in a Hostile Groin

The incidence of iatrogenic femoral arteriovenous fistulas (IFAVF) has increased in contemporary practice. We herein report the case of a 55-year-old obese woman with significant surgical comorbidities who sustained an IFAVF between the superficial femoral artery (SFA) and the femoral vein. Given her substantial risk factors, she was treated with a SFA stent-graft (iCast 6 x 22 mm) using a contralateral endovascular approach. She remains asymptomatic at 15 months with ongoing resolution of the AVF. This report highlights the utility of stent-graft repair of an IFAVF in high surgical risk patients or in those with ''hostile'' anatomy.

Endovascular Treatment of Traumatic Thoracic Aortic Injuries: Short- and Medium-term Follow-up

Successful thoracic endovascular aortic repair (TEVAR) with low rates of complications has been referred to in the treatment of traumatic thoracic aortic injuries; however, we still do not know the long-term behavior. In this series, short- and intermediate-term results of TEVAR of traumatic aortic injuries are analyzed. The clinical charts and courses of 20 patients (mean age, 31.8 years; age range, 15-65 years; 14 [70%] men) with traumatic thoracic aortic injuries treated with TEVAR were retrospectively reviewed. Mean delay from trauma to intervention was 15 days (range, 0-180 days). The initial success rate was 100%, with no deaths or intraoperative leaks, although in 4 (20%) patients, injuries were repaired in the arterial access site. The mean postoperative follow-up was 43.53 months (range, 5.5-108.0 months). Four (20%) patients required reintervention: 2 postoperative revascularizations of the left subclavian artery (20% of the patients in whom the ostium was intentionally occluded) and 2 aortic reinterventions (endovascular treatment of a collapsed stent graft and open repair after thrombosis of another stent graft). All reinterventions were successfully performed and no additional complications were registered during follow-up. Asymptomatic findings related to the stent graft included lack of proximal device-wall apposition in 8 patients (40%), intragraft mural thrombus formation during the first 6 months in 7 patients (35%), and an asymptomatic fracture of the longitudinal reinforcing bar of the stent graft 4 years later in 1 patient (5%). Although not completely exempt of complications, TEVAR provides a reliable method for the treatment of traumatic thoracic aortic injuries with good results in the short- and medium-term follow-up. All complications have been treated successfully. Long-term evolution of lack of proximal device-wall apposition and intragraft mural thrombus formation should be closely monitored to prevent long-term complications.

Computed tomography virtual intravascular endoscopy in the evaluation of fenestrated stent graft repair of abdominal aortic aneurysms

This study aimed to investigate the diagnostic value of computed tomography virtual intravascular endoscopy (VIE) in the follow-up of patients with abdominal aortic aneurysm (AAA) treated with fenestrated stent grafts. A total of 19 patients (17 males and 2 females; mean age: 75 years) with AAA undergoing fenestrated stent grafts were retrospectively studied. Pre- and post-fenestration computed tomography data were reconstructed for the generation of VIE images of aortic ostia and fenestrated stents and compared with two-dimensional axial and multiplanar reformation (MPR) images. Serum creatinine was measured pre and post fenestration to evaluate the renal function. The mean intra-aortic length measured by VIE, two-dimensional axial and MPR were 4.7, 4.4 and 4.6 mm, respectively, for the right renal stent; 5.0, 4.9 and 5.0 mm, respectively, for the left renal stent; and 5.9, 6.0 and 6.0 mm, respectively, for the superior mesenteric artery stent. Comparisons of these measurements did not show significant difference (P > 0.05). The mean diameters of renal artery ostia measured on VIE visualization pre and post fenestration were 9.2 x 8.3 and 10 x 8.9 mm for the right renal ostium; 8.3 x 7.1 and 9.9 x 8.9 mm for the left renal ostium, with significant changes observed (P < 0.01). No renal dysfunction was observed in this group. VIE is a valuable visualization tool in the follow-up of fenestrated stent graft repair of AAA by providing intraluminal appearance of fenestrated stents and measuring the length of stent protrusion.

Ischemic Colitis After Endovascular Aortoiliac Aneurysm Repair

To examine the incidence, cause, and outcomes of ischemic colitis after endovascular stent graft repair of aortoiliac aneurysms (EVAR). Medical record review. University teaching hospital. Eight hundred nine patients treated during 10 years were included in the study. Preoperative data regarding the size of the aneurysm, hypogastric coil embolization, and inferior mesenteric artery patency were evaluated by means of computed tomographic scans and aortograms. Ischemic colitis was diagnosed by lower endoscopy or pathology reports. Ischemic colitis after EVAR. Eleven patients (1.4%) developed ischemic colitis. Seven patients' episode occurred less than 30 days from repair (early), whereas 4 occurred 30 days or more from repair (late). Ten of 11 patients had preoperative inferior mesenteric artery occlusion. Microembolization was seen histologically in 2 patients in the early group, both of whom died. A significant increase in ischemic colitis was seen in patients undergoing preoperative unilateral hypogastric coil embolization (P = .02). Three of the patients with late ischemic colitis had comorbidities other than the EVAR to explain the ischemia. The incidence of ischemic colitis is decreased in patients undergoing EVAR vs open repair. The cause of the ischemia is multifactorial and seems to differ between patients in the early and late groups. Microembolization tends to produce severe ischemic colitis and is usually fatal. There should be a low threshold for performing endoscopy in any patient thought to have ischemic colitis after EVAR.

Aortoesophageal fistula: an uncommon complication after stent-graft repair of an aortic thoracic aneurysm

To report the incidence and management of aortoesophageal fistula (AEF) secondary to endovascular stent-graft repair of the descending thoracic aorta. We analyze a case of AEF as a late complication of stent-graft repair of a thoracic aortic aneurysm in a 74-year-old male. We also include a discussion on alternatives of treatment based on a review of the literature currently available in MEDLINE. This patient was admitted to our hospital because of constitutional symptoms. The diagnosis was established by computed tomography and upper gastrointestinal endoscopy. The patient died 50 days after admission. AEF is a catastrophic complication of endovascular stent-graft placement. Treatment options are very limited, as these patients are usually not candidates for open surgery. Conservative treatment is often associated with fatal results.

Endovascular Treatment for Chronic Type B Dissection:Limitations of Short Stent-Grafts Revealed at Midterm Follow-up

To examine the incidence of and the indications for re-intervention, as well as the changes in aortic morphology, in patients with chronic type B aortic dissection who underwent endovascular intervention for false lumen aneurysms. A retrospective analysis was conducted of 10 patients (8 men; mean age 63 years, range 45-79) who underwent stent-graft repair of aneurysmal false lumen expansion related to chronic type B aortic dissection at a median 16 months (range 2-71) from the initial diagnosis. All grafts had been oversized by 10% relative to the normal non-dissected aorta and were implanted to cover the primary entry tear. Follow-up computed tomography scans were analyzed to define changes in aortic morphology. Mean radiological follow-up was 56 months (median 64.5; range 19-86.5). There was no perioperative mortality or stroke; no cases of aortic rupture were recorded during follow-up. One patient suffered a procedure-related stroke with postoperative hemiparesis following re-intervention for proximal erosion 15 months after the initial treatment. In 6 of the 7 re-interventions performed in 6 patients at a median 42 months after the index procedure, stent-graft extension was required to treat erosion of the dissection membrane that had resulted in endoleak with false lumen reperfusion. The extent of dissection, duration of follow-up, or length of aortic coverage was not predictive of the need for re-intervention during follow-up. At last follow-up, the mean false lumen diameter at the level of the stented aorta was significantly smaller than at baseline (11+/-15 versus 24+/-15 mm, p<0.01). This was associated with false lumen thrombosis at the level of the stent-graft in 9 of 10 cases, although 7 patients had persistent false lumen perfusion distal to the stent-graft. Endovascular stent-graft treatment is effective therapy for chronic type B dissection patients with false lumen aneurysms. Erosion of the dissection membrane, causing proximal or distal endoleak, is the most common reason for re-intervention during midterm follow-up.

Endovascular Stent Grafting for Acute Thoracic Aortic Pathology

Endovascular repair of the thoracic aorta has shown reduced morbidity and mortality compared with open surgery. We describe our experience with endovascular stent grafting in the treatment of acute thoracic aortic pathology. From October 2003 to January 2008, 25 patients underwent endovascular stent graft repair of the thoracic aorta. The underlying pathology was a complicated Stanford type B dissection (n = 13), a symptomatic or ruptured thoracic aorta aneurysm (n = 6), a symptomatic penetrating atherosclerotic ulcer (n = 5), or a traumatic aortic injury (n = 1). There were 21 males and four female patients with a mean age of 61.3 years (30-91 years). Routine surveillance included clinical evaluation and contrast-enhanced spiral computed tomography scans before discharge and at 3, 6, and 12 months after the procedure and yearly thereafter. Stent graft placement was technically successful in all patients. There was no intraoperative mortality. Hospital mortality was of two patients (8%). Paraparesis occurred in one patient (4%). Average intensive care unit and hospital stay was 1 and 10 days, respectively. The mean follow-up was 30 months (range, 7-53). Late mortality was in one patient (4%), due to a type A dissection. During the follow-up, four patients (16%) required a second procedure for type I endoleak. Mortality and morbidity in our small series were low. Close follow-up is mandatory and long-term results have to be awaited.

Secure fixation following EVAR with the Powerlink XL System in wide aortic necks: Results of a prospective, multicenter trial

Endovascular stent graft repair of abdominal aortic aneurysms (AAA) with the Endologix Powerlink System (Endologix, Inc, Irvine, Calif) has been shown to be a safe and effective alternative to open surgery in patients having an aortic neck diameter of up to 26 mm. We assessed the safety and effectiveness of AAA repair in patients with wide aortic necks (up to 32 mm in diameter) using the Powerlink XL System. Between September 2005 and June 2008, a prospective, multicenter, pivotal US Food and Drug Administration trial of the Powerlink XL System for endovascular aneurysm repair was conducted at 13 centers. Using a sizing algorithm based on computed tomography scan (CT)-based measurements, a total of 78 patients (N = 60 [pivotal trial]; N = 18 [continued access]) presenting with AAA and an infrarenal aortic neck up to 32 mm in diameter received a bifurcated stent graft via anatomical fixation at the aortoiliac bifurcation and proximal sealing with a Powerlink XL infrarenal proximal extension stent graft. Postoperatively, results were assessed with contrast-enhanced CT scans and abdominal x-rays at one, six, and 12 months, with continued annual follow-up to five years. Predominantly male (91%), patients presented at a mean age of 73 +/- 8.6 years with mean maximum aortic neck and AAA diameters of 31 +/- 1.9 mm (range, 25 to 32 mm) and 5.7 +/- 1.0 cm (range, 4.3 to 10 cm), respectively. Challenging infrarenal aortic neck anatomy, defined as the presence of severe thrombus and/or reverse taper, was present in 85% of patients. Technical success was achieved in 98.7% of patients, with one patient requiring femoral-femoral bypass intraoperatively. Aneurysm exclusion was achieved in 100% of patients over a mean procedure time of 129 +/- 66 minutes. Patients were discharged at a mean of 2.2 days postoperatively. At the one-month CT scan, the independent core lab identified a Type II endoleak in 13 patients, distal Type I and Type II endoleak in one patient, and unknown endoleak in three patients. At 30 days, there were no deaths, conversions, ruptures, or migrations. Through one year follow-up, Type II endoleak predominated (9/10 patients with endoleak), with one proximal Type I and no Type III, IV, or unknown endoleak; no conversions, ruptures, or migrations have been observed. The one-year all-cause mortality rate was 6.4%, with 100% freedom from aneurysm-related mortality. Secondary procedures were performed within one year in five patients (6.4%) for treatment of proximal Type I endoleak (n = 2), proximal Type I/Type II endoleak (n = 1), and distal Type I endoleak (n = 2). Reduced or stable aneurysm sac diameter at one year is observed in 96% of patients. The combination of an anatomically-fixed Powerlink bifurcated stent graft and a Powerlink XL infrarenal proximal extension appears safe and effectively excludes aneurysms in patients with wide aortic necks. These results suggest that fixation at the aortic bifurcation can provide secure fixation for patients with large diameter diseased proximal aortic necks.

Endovascular Stent-Graft Repair of Major Abdominal Arteriovenous Fistula:

To evaluate the outcomes of endovascular stent-graft repair of major abdominal arteriovenous fistulas. The English literature was systematically searched using the MEDLINE electronic database up to January 2009. All reports on endovascular stent-graft repair of major abdominal arteriovenous fistula were considered. Our experience of abdominal arteriovenous fistula was involved in the data analysis. The primary outcome measures were technical success and perioperative, 30-day, and overall mortality. Data for the final analysis were extracted from 21 papers reporting on 22 patients and from the medical records of a patient treated at our institution. The most common causal associations of these fistulae were the presence of an aortoiliac aneurysm and previous endovascular aneurysm repair, accounting for 56% and 13% of all associations, respectively. The technical success rate was 96% (22/23). No perioperative or 30-day mortality was noticed during a mean follow-up of 9 months. The most common procedure-related complication was type II endoleak, which was found in 22% (5/23) of the patients. This event was either self limiting or required minimal percutaneous intervention. Endovascular stent-graft repair of major abdominal arteriovenous fistula is a safe and effective treatment option, with good short- and midterm results. However, no long-term data exist, and larger series are required to draw solid conclusions regarding the outcomes of this method.

Primary Aortoenteric Fistula and Endovascular Repair

Primary aortoenteric fistulae are difficult conditions to diagnose and manage. A 35-year-old male developed massive upper gastrointestinal hemorrhage due to a primary aortoduodenal fistula. Previous radiation therapy and retroperitoneal lymph node dissection for germ cell cancer with resultant dense retroperitoneal fibrosis made open aortic repair impossible. Endovascular balloon occlusion of the aorta and stent graft repair of the primary aortoduodenal fistula was performed. At 1-year follow-up, there is no clinical or radiographic evidence of stent-graft infection. Endovascular techniques and repair are important approaches to consider during the management of complicated primary aortoenteric fistulae when open surgical repair is not feasible.

Endovascular management of chronic aortic dissection in patients with Marfan syndrome

Marfan syndrome patients are prone to aortic dilatation, dissection, and rupture. Success of aortic root replacement has generated a cohort of patients surviving longer and presenting with distal aortic dissection and enlargement. Thoracic endovascular stent-graft repair (TEVR) is being increasingly utilized to exclude aneurysms resulting from chronic aortic dissection. This report explores the role of TEVR in Marfan patients with this pathology. Review of a prospectively maintained database identified seven patients with Marfan syndrome offered endovascular repair of aneurysmal chronic aortic dissection. All patients had previous aortic root repair. Talent or Valiant (Medtronic Vascular, Santa Rosa, Calif) aortic stent-grafts were used to occlude the dissection entry tear and cover the thoracic aorta. Electronic data, case notes, and radiological surveillance were analyzed. Seven consecutive patients (six male; mean age, 45.9 +/- 10 years, range, 29 to 63) underwent successful thoracic stent-graft deployment. Mean aortic aneurysmal diameter was 63.4mm (+/-11.2) with six of seven dissections extending to the aortic bifurcation. No perioperative neurological events occurred. Thirty-day mortality was 1/7 (14%) due to congestive cardiac failure. At median 16 month follow-up, two of six cases (33%) required intervention for endoleak. Aortic false lumen thrombosis (FLT) occurred in 5/6 (83%) cases and partial FLT occurred in 1/6 (17%). All thoracic aortas continued to dilate during follow-up. Crude median aortic growth rate was 7.2 mm/year (range, 3.5 to 19 mm). TEVR in Marfan syndrome patients with chronic aortic dissection is technically feasible. However, post intervention surveillance confirms that the aorta continues to dilate despite graft deployment and false lumen thrombosis. Endovascular repair may offer a viable option in patients who have contraindications to open surgery, but longer follow up of more patients is required to define the place of this therapy.

Invited Commentary

We very much appreciate the opportunity to analyze the manuscript by Zipfel and colleagues [1]. They have stated that prophylactic subclavian artery revascularization may reduce significant neurologic complications. They concluded that prophylactic reconstruction of subclavian artery is safer than later elective reconstruction after stent graft repair of thoracic aorta disease. However, the authors demonstrated no statistical difference in neurologic complications between the patients in the protected and unprotected series.

Hybrid Repair of Bilateral Subclavian Artery Aneurysms in a Patient with Marfan Syndrome

A 32-year-old man with Marfan syndrome presented with enlarging, asymptomatic bilateral subclavian artery aneurysms. He has an extensive surgical history including aortic arch and descending thoracic aorta replacement. The L aneurysm was treated first with an L carotid-vertebral artery vein bypass, aneurysm debranching, and stent-graft repair of aneurysm via the L brachial artery approach. The R aneurysm was treated by placing a stent graft from the proximal R common carotid artery across the R subclavian artery origin and landing in the prosthetic innominate bypass graft via an L common carotid artery conduit. An aneurysm debranching and R carotid-subclavian artery bypass completed the procedure. A proximal type I endoleak was detected in the R aneurysm sac on follow-up computed tomography angiography. This was treated with sternotomy, aorta to L common carotid artery bypass, stent graft removal, and oversewing of the R subclavian artery origin. The patient recovered uneventfully. Subclavian artery aneurysms are rarely diagnosed in patients with Marfan disease. Although durability remains unproven, hybrid repair should be considered in patients with subclavian artery aneurysms, to minimize the morbidity commonly associated with open repair.

Traitement par stent grafts des pathologies de l’aorte thoracique descendante

To report our experience with endovascular stent-graft repair of descending thoracic aorta diseases in high risk patients. Between 2000 and 2007, 49 high surgical risk patients (mean age: 64.6 years) underwent stent-graft placement, including 24 cases presenting acutely. Mean follow-up was 25.4 months. Etiologies included 15 aneurysms, 11 dissections, 10 penetrating ulcers, 9 false aneurysms, 2 ruptures of the aortic isthmus, 2 intramural hematomas. Access failure occurred in one patient. The overall mortality was 27.1% (n=13), nine related to the presenting pathology or treatment. Thirty-day mortality was 10.4% (n=5). Complications included vascular injury at the iliac or femoral artery access (10.2%), 1 case of flaccid paraplegia, 2 cases of transient paraparesis, 2 strokes, 2 stent migrations and 1 stent rupture. The rate of early endoleak was 39.6% while the rate of delayed endoleak was 14.6%. Seven patients (14.6%) required repeat endovascular interventions. Explantation was required in 2 cases. The latest available follow-up showed no lesion enlargement in 70.7% (n=29/41) of our patients. Descending thoracic aortic pathology can be treated using endografts in high risk patients, although significant morbidity and mortality remain. Because of the high rate of endoleaks, close follow-up is required.

Stent graft repair of descending aortic dissection in patients with Marfan syndrome: An effective alternative to open reoperation?

Aneurysms or dissections can involve multiple aortic segments in patients with Marfan syndrome, requiring staged replacement of the entire aorta. The optimal treatment of descending aortic dissection in these patients is a major challenge. We investigated the feasibility and outcomes of endovascular repair of the descending aorta in patients already submitted to open aortic root/arch surgery. From March 1998 to July 2008, 12 patients (10 male and 2 female patients; mean age, 37.8 +/- 11.6 years) affected by Marfan syndrome underwent endovascular treatment for dissection of the descending aorta after previous open aortic root/arch surgery. Stent graft procedures were performed urgently in 5 patients and electively in 7 patients. Neither in-hospital deaths nor perioperative paraplegia or stroke occurred. Follow-up (median, 31 months; range, 3-57 months) was 100% complete. One patient needed surgical conversion for persistent type I endoleak, leading to false lumen expansion 3 months after endovascular repair. Extension of the dissection occurred in 2 patients 1 month and 2 years after the procedure, respectively. No late death or aortic rupture was observed. Endovascular repair of the dissected descending thoracic aorta can be performed in patients with Marfan syndrome with a low risk of death or major complications. In case of staged procedures, stent graft treatment can be considered a possible alternative to open reoperation. Long-term durability remains to be determined.