Endovascular treatment of acute and chronic aortic dissection: Midterm results from the Talent Thoracic Retrospective Registry

Preemptive treatment in the acute and early subacute phase of uncomplicated type B aortic dissections with poor prognosis factors

Objective

Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic dissection (TBAD). This study aimed to compare preemptive endovascular treatment and optimal medical treatment (OMT) and OMT alone in patients presenting uncomplicated TBAD with predictors of aortic progression.

Design

Retrospective multicenter study.

Methods

We analyzed patients with uncomplicated TBAD and risk factors of progression in two French academic centers. Aortic events [defined as aortic-related (re)intervention or aortic-related death after initial hospitalization], postoperative complications, non-aortic events, and radiologic aortic progression and remodeling were recorded and analyzed. Analysis was performed on an intention-to-treat basis.

Results

Between 2011 and 2021, preemptive endovascular procedures at the acute and early subacute phase (<30 days) were performed on 24 patients (group 1) and OMT alone on 26 patients (group 2). With a mean follow-up of 38.08 ± 24.53 months, aortic events occurred in 20.83% of patients from group 1 and 61.54% of patients from group 2 (p < .001). No patient presented aortic-related death during follow-up. There were no differences in postoperative events (p = 1.00) and non-aortic events (p = 1.00). OMT patients had significantly more aneurysmal progression of the thoracic aorta (p < .001) and maximal aortic diameter (p < .001). Aortic remodeling was found in 91.67% of patients in group 1 and 42.31% of patients in group 2 (p < .001). A subgroup analysis of patients in group 1 showed that patients treated with preemptive TEVAR and STABILISE had reduced maximum aortic diameters at the 1-year (p = .010) and last follow-up (p = .030) compared to those in patients treated with preemptive TEVAR alone.

Conclusion

Preemptive treatment of uncomplicated TBAD with risk factors of progression reduces the risk of long-term aortic events. Over 60% of medically treated patients will require intervention during follow-up, with no benefit in terms of postoperative events. Even after surgical treatment, patients in the OMT group had significantly more aneurysmal progression, along with poorer aortic remodeling.

Initial Single-Center Experience With the Knickerbocker Technique During Thoracic Endovascular Aortic Repair to Block Retrograde False Lumen Flow in Patients With Type B Aortic Dissection

OBJECTIVE

Effectiveness of thoracic endovascular aortic repair in type B aortic dissection is impaired by persistent retrograde false lumen flow via distal re-entry tears. Controlled, stentgraft-assisted balloon dilatation of the true lumen at its lower end, or Knickerbocker technique, may block retrograde false lumen flow and consequently improve effectiveness by inducing immediate thrombosis along the entire descending thoracic aorta.

MATERIALS AND METHODS

A single-center retrospective analysis was performed for all consecutive patients with aortic dissection treated with the Knickerbocker technique to block retrograde false lumen flow.

RESULTS

Eleven patients were included for analysis. Intraoperative control angiography showed successful occlusion of the false lumen at the level of balloon dilatation in 9 out of 11 patients (82%). There was one perioperative mortality (9%), due to stroke. There were 2 early reinterventions, due to retroperitoneal bleeding and due to chyle leakage in the neck after left subclavian artery bypass. Median clinical follow-up duration was 6 (interquartile range [IQR] 2-11] months. There were 2 deaths during follow-up, one at 2 months after TEVAR from unknown cause of death, and one after 11 months due to rupture of an ascending aortic pseudoaneurysm. The Knickerbocker technique led to positive aortic remodeling. At 3 months follow-up, 100% of patients showed complete false lumen thrombosis in the thoracic aorta proximal to the level of balloon dilatation, with decreasing false lumen diameters (100%) and stable (44%) or decreasing (56%) total aortic diameters. In most patients, the false lumen distal to the stentgraft (i.e. at visceral level) remained patent (11% false lumen thrombosis rate), leading to ≥2 mm dilatation at this level (78% of patients) and in the infrarenal abdominal aorta (56% of patients) at 3 months postoperatively. No distal stent-graft-induced new entry tears were noticed during follow-up.

CONCLUSION

The Knickerbocker technique is feasible and effective, leading to positive aortic remodeling of the aorta covered by stentgraft in all of a small cohort of patients.

CLINICAL IMPACT

Persistent, retrograde false lumen perfusion from distal re-entries following thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection, may lead to progressive, aneurysmal dilatation. Controlled, stent graft-assisted balloon dilatation of the true lumen in the distal descending aorta (i.e. Knickerbocker technique) during TEVAR effectively excludes the false lumen from persistent flow resulting in positive aortic remodeling in our small cohort of patients, and hence potentially eliminates the risk of late post-dissection aneurysm formation in the descending thoracic aorta.

Combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair for complicated type B aortic dissections

BACKGROUND

Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but life-threatening condition. The incidence of aortic dissection is 3 to 6 per 10,000 per year in the Western population, and can be up to 43 per 10,000 per year in the Eastern population. Over 20% of people with an aortic dissection do not reach a hospital alive. After admission, the mortality rates for people with an aortic dissection are between 10% and 20% for those who received endovascular treatment, and between 20% and 30% for those who had open surgery. Thoracic endovascular aortic repair (TEVAR) is the standard endovascular method to treat complicated type B aortic dissection (aortic dissections without involvement of the ascending aorta). Although TEVAR is less invasive than open surgery and has a better long-term aortic remodeling effect than conservative medical treatment, favourable aortic remodelling is usually limited to the thoracic aortic segment. TEVAR cannot be extended into the abdominal aorta because it could cover the ostia of the reno-visceral arteries. Thus, the abdominal aorta is still at risk of progressive aneurysmal degeneration. The PETTICOAT (provisional extension to induce complete attachment) technique, with proximal endograft and distal bare metal stent, was proposed in 2006 to address this issue. The concept of this technique was to implant a distal bare metal stent into the aortic true lumen, distal to the proximal endograft, to stabilize the distal collapsed intimal flap, while allowing blood flow to reno-visceral arteries. Therefore, the PETTICOAT technique was considered to be related to a more extensive aortic remodelling for people with type B aortic dissection, especially in the area of the abdominal aorta. However, it is still unclear whether the PETTICOAT technique is superior to standard TEVAR.

OBJECTIVES

To assess the effects of combined proximal descending aortic endografting plus distal bare metal stenting versus conventional proximal descending aortic stent graft repair for treating complicated type B aortic dissections.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2018. We also undertook reference checking and citation searching to identify additional studies.

SELECTION CRITERIA

We considered all randomised controlled trials which compared the outcome of complicated type B aortic dissection, when treated by combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed all references identified by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We identified no randomised controlled trials and therefore cannot draw any definite conclusion on this topic. Evidence from non-randomised studies appears to be favourable in the short-term, for combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) to solve the problem of unfavourable distal aortic remodeling. Randomised controlled trials are warranted to provide solid evidence on this topic. Evidence from cohort studies with large sample sizes would also be helpful in guiding clinical practice.

Optimal blood pressure control for patients after thoracic endovascular aortic repair of type B aortic dissection

BACKGROUND

Guidelines recommend tight systolic blood pressure (SBP) control for favorable outcomes of type B aortic dissection (BAD) but are still limited by the optimal cut-off value of SBP. The purpose of this study was to evaluate the optimal cut-off value of SBP in BAD patients after thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2011 to April 2017, 269 consecutive patients with BAD after TEVAR were included in the study. All patients were followed up according to a strict follow-up protocol. Cox regression analysis was used to examine the association between SBP at discharge and 90-day aortic related adverse events (ARAE).

RESULTS

All 269 patients completed 90 days of follow-up, and the unadjusted ARAE-free rates at 90-day was 95.1 ± 1.3%. The cut-off value of SBP at discharge identified by receiver operator curve was 130 mmHg for 90-day ARAE. In multivariable models, binary SBP at discharge was significant associated with 90-day ARAE (HR 3.780; 95% CI 1.236-11.556; p = 0.020). Hybrid operation (OR 2.046; 95%CI 1.015-4.122; p = 0.045) and insertion of ≥2 stents (OR 2.950; 95%CI 1.172-7.426; p = 0.022) were demonstrated to be independently associated with poor SBP control (SBP > 130 mmHg) using Logistic analysis.

CONCLUSIONS

The optimal cut-off value of SBP at discharge was 130 mmHg which can be used to predict short-term ARAE. Blood pressure in patients with hybrid operation and ≥ 2 stents should be given more focus.

Proposed classification of endoleaks after endovascular treatment of Stanford type-B aortic dissections

Objectives

Despite two decades of experience, no dedicated classification system exists to document and prognosticate patterns of endoleak encountered after endovascular therapy of type-B aortic dissection. This nomenclature gap has led to inconsistent management and underreporting of significant findings associated with adverse outcomes after endovascular treatment of type-B aortic dissection. Our goal was to propose a reproducible and prognostically relevant classification.

Methods

A multidisciplinary team of seven experienced open and endovascular aortic surgeons was assembled to provide consensus opinion. Extensive literature review was conducted. Deficiencies in the current classification approach of the various patterns of persistent filling of false lumen after endovascular therapy were identified.

Results

Our focus was to categorize high-risk and low-risk subgroups within endoleaks after endovascular treatment of type-B aortic dissection. In this classification, type-Ia endoleak refers to persistent filling of the false lumen in an antegrade manner. Causes include failure to cover the primary entry tear and sizing or technical related proximal seal failure. False lumen filling via distal entry tears is classified as type Ib endoleak, which is further sub-classified into b1 (major branch-related tears), and b2 (multiple small branches related tears). Retrograde ascending aortic dissection and stent graft-induced new entry were classified as type-I endoleaks (type-Ir and type-Is, respectively). Another focus was reclassification type-II endoleaks, with type-IIa endoleak referring to conventional retroleak from one or more posterior branches and type-IIx referring to retroleak from major branches (visceral or left subclavian arteries).

Conclusions

The majority of endoleaks after endovascular treatment of type-B aortic dissection are related to persistent or new filling of the false lumen. We propose a new false lumen-based classification schema for endoleaks occurring after endovascular therapy of type-B aortic dissection.

Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival.

METHODS

All TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors.

RESULTS

TEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI.

CONCLUSIONS

SAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.

Dissecção aórtica de tipo B de Stanford: relato de caso e revisão de literatura

O complexo tratamento de dissecção da aorta ainda apresenta controvérsias devido à gravidade do caso e à necessidade de individualização da terapêutica. A gravidade relaciona-se ao difícil diagnóstico pelas queixas inespecíficas e pelas graves complicações inerentes à evolução da doença (ruptura aórtica, síndrome de má perfusão, dissecção retrógrada, dor ou hipertensão refratária). Este relato apresenta um homem de 61 anos, tabagista e hipertenso mal controlado, que evoluiu para dissecção aórtica de tipo B de Stanford. Foi abordado através de técnica endovascular com uso de endoprótese com stent para tratamento do caso após falha do tratamento medicamentoso. O tratamento endovascular mostrou-se uma ferramenta eficaz para o tratamento definitivo, com boa taxa de sobrevida ao final do primeiro ano após o procedimento.

Palliative stent graft placement combined with subsequent open surgery for retrograde ascending dissection intra-thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) is an effective strategy for type B dissection. Retrograde ascending dissection (RAD) intra-TEVAR is a rare complication on clinic. In this case, a 48-year-old Chinese man with Stanford type B aortic dissection suffered acute RAD during the TEVAR. And palliative stent grafts placement was performed in a local hospital, which earned the time for transfer and subsequent total arch replacement surgery in Zhongshan Hospital Fudan University. This report suggests that the palliative strategy may be an option for RAD in some specific situation.

Emergency endovascular stent grafting in acute complicated type B dissection

OBJECTIVE

The objective of this study was to assess midterm results of emergency endovascular stent grafting for patients with life-threatening complications of acute type B aortic dissection.

METHODS

Between March 1999 and November 2011, 110 patients (86 men, 24 women) with complications of acute type B aortic dissection (mean age, 61 years; range, 19-87 years) were treated with thoracic endovascular aortic repair for malperfusion (55.5%) or aortic rupture (53.6%) in five major European referral centers and one U.S. referral center. Additional comorbidities included hypertension in 90 patients (82%), diabetes in 14 patients (13%), and chronic obstructive pulmonary disease in six patients (6%). Eleven patients (10%) had undergone previous aortic surgery.

RESULTS

Overall hospital mortality was 12% (n = 13), with 14 late deaths after hospital discharge. In-hospital complications occurred in 32 patients (36%); 10 patients developed postoperative renal failure, five patients experienced new permanent neurologic symptoms, and six patients (5.4%) experienced retrograde type A aortic dissection. Furthermore, nine patients (8%) developed an early type I endoleak. Actuarial survival at 1 and 5 years was 85% and 73%, respectively. Postprocedural computed tomography angiography showed complete or partial thrombosis of the false lumen at the stent graft level in 61% and 23% of all patients, respectively. Freedom from treatment failure according to the Stanford classification was 82%, 75%, and 59% at 1, 3, and 5 years.

CONCLUSIONS

Endovascular repair of complicated acute type B aortic dissection is proven to be a technically feasible and effective treatment modality in this relatively difficult patient cohort. Short-term and midterm results are persuasive; however, the long-term efficacy needs to be further evaluated.

Systematic review of outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection

OBJECTIVE

Available data on outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection are limited. The objective of this study was to provide a systematic review of outcomes of this approach.

METHODS

Studies involving combined proximal stent-grafting with distal bare stenting for management of aortic dissection were systematically searched and reviewed through MEDLINE databases.

RESULTS

A TOTAL OF FOUR STUDIES WERE INCLUDED: 108 patients treated for management of acute (n=54) and chronic (n=54) aortic dissection. The technical success rate was 95.3% (range, 84-100%). The 30-day mortality rate was 2.7% (range from 0% to 5%). The morbidity rate occurring within 30 days was 51.8% (range from 0% to 65%) and included stroke (2.7%), paraplegia (2.7%), retrograde dissection (1.8%), renal failure (14.8%), severe cardiopulmonary complications (5.5%) and bowel ischemia (0.9%). The incidence of type I endoleak was 9.2% (10/108). During follow-up, 5 (4.6%) deaths were related to aortic rupture or aortic repair. Mean re-intervention rate was 12.9%. Two cases (1.9%) of delayed retrograde type A dissection and one case of aortobronchial fistula (0.9%) were reported. The most common delayed complication was thoracic stent-graft migration (4.7%). The rate of device failure was 9.2%. Favorable aortic remodeling was observed: studies reporting midterm follow-up of the true lumen demonstrated a high rate of both false lumen regression and true lumen expansion. At 12 months, complete false lumen thrombosis was observed at the thoracic level in 70.4% and at the abdominal level in 13.5% of patients.

CONCLUSIONS

Combined proximal stent-grafting with distal bare stenting appears to be a feasible approach for the management of Type B aortic dissection. Although this approach clearly improved true lumen perfusion and diameter, it failed to completely suppress false lumen patency. However, it should be acknowledged that contemporary data on this approach is limited to small studies with variable results.

Prognostic factors in patients with uncomplicated acute type B aortic dissection

BACKGROUND

The benefit of thoracic endovascular aortic repair (TEVAR) for uncomplicated acute type B aortic dissection is unclear. Reliable prognostic factors are needed to identify candidates for prophylactic TEVAR. The aim of this study was to detect prognostic factors in patients with uncomplicated acute type B aortic dissection.

METHODS

From January 2003 to April 2012, a total of 228 patients with uncomplicated acute type B aortic dissection were admitted to our institute. Cox proportional hazards analysis was performed to identify risk factors for death, dissection-related death, and aortic events.

RESULTS

Independent predictors of mortality were age (hazard ratio [HR], 1.08; p < 0.001) and false lumen thickness (mm) (HR, 1.10; p = 0.013), and the risk factor for dissection-related death was false lumen thickness (mm) (HR, 1.14; p < 0.001). Independent risk factors for aortic events were diameter of the descending aorta (mm) (HR, 1.14; p < 0.001) and entry in a proximal site (HR, 2.90; p = 0.02). The actuarial freedom from aortic events in patients with a descending aortic diameter of less than 40 mm and no entry in a proximal site at 1, 3, and 5 years was 96.6%, 90.8%, and 82.5%, respectively, whereas in patients with 1 of these 2 factors, it was 80.1%, 66.8%, and 53.5%, respectively.

CONCLUSIONS

In uncomplicated acute type B aortic dissection, the diameter of the descending aorta and entry in a proximal site were independent prognostic factors for aortic events. Prophylactic TEVAR should be considered for patients with these risk factors.

Stented elephant trunk technique for retrograde type A aortic dissection after endovascular stent graft repair

BACKGROUND

Retrograde type A aortic dissection is a rare but deadly complication after thoracic endovascular aortic repair of type B aortic dissection. Total arch replacement combined with a modified stented elephant trunk technique (SET), was performed for these complicated dissections. We reviewed our results of the procedure for this serious complication, aiming to evaluate the feasibility of the technique.

METHODS

Between April 2005 and September 2012, 24 patients with retrograde type A aortic dissection after thoracic endovascular aortic repair underwent the SET procedure in our center. The mean age at operation was 44.1±8.8 years old. Postoperative mortality and morbidity were analyzed to evaluate the immediate and mid-term results.

RESULTS

Death at 30 days was 4.2% (1 of 24 patients). No patient suffered paraplegia or stroke after operation. Follow-up was completed with 23 survivors. The mean follow-up period was 32.2±13.1 months (range, 12 to 49 months). No late deaths occurred during follow-up. One patient underwent reoperation for replacement of the thoracoabdominal aorta and enjoyed an uneventful survival.

CONCLUSIONS

The stented elephant trunk technique could be an alternative for treatment of retrograde type A aortic dissection with acceptable surgical risks and satisfactory results.

Repeat endovascular repair for multiple intimal tears after endovascular stent grafting of Stanford type B aortic dissection

A 59-year-old man with hypertension was found to have a Stanford type B aortic dissection with a false lumen extending to the abdominal aorta. We placed a stent graft to the thoracic aorta covering the proximal entry and planned a second endovascular repair to cover the entries in the abdominal aorta. Five years later, computed tomography angiography revealed an extensive dissection to the right common iliac artery with multiple intimal tears. We placed stent grafts in the distal end of the primary stent graft and an abdominal stent graft to the aortic bifurcation to cover the entry tears. However, 3 months later it developed into a newly formed intimal tear in the right renal artery, leading to retrograde reperfusion into the false lumen. The patient was successfully treated with a third time endovascular repair and recovered smoothly during follow-up.

A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting

BACKGROUND

The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a systematic review to determine whether preoperative cerebrospinal fluid (CSF) drainage reduces SCI.

METHODS

PubMed, the Cochrane Library, and conference abstracts were searched using the keywords thoracic endovascular aortic repair, cerebrospinal fluid, spinal cord ischaemia, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. SCI rates across studies were pooled using random-effects modeling. Study quality was evaluated using the Downs and Black score.

RESULTS

Study quality was generally poor to moderate (median Downs and Black score, 9). The systematic review identified 46 eligible studies comprising 4936 patients; overall, SCI affected 3.89% (95% confidence interval, 2.95.05%-4.95%). Series reporting routine prophylactic drain placement or no prophylactic drain placement reported pooled SCI rates of 3.2% and 3.47%, respectively. The pooled SCI rate from 24 series stating that prophylactic drainage was used selectively was 5.6%.

CONCLUSIONS

Spinal chord injury is uncommon after TEVAR. The role of prophylactic CSF drainage is difficult to establish from the available literature. High-quality studies are required to determine the role of prophylactic CSF drainage in TEVAR.

Long-Term Outcome of Aortic Dissection With Patent False Lumen

Background—

Patent false lumen in aortic dissection has been associated with poor prognosis. We aimed to assess the natural evolution of this condition and predictive factors.

Methods and Results—

One hundred eighty-four consecutive patients, 108 surgically treated type A and 76 medically treated type B, were discharged after an acute aortic dissection with patent false lumen. Transesophageal echocardiography was performed before discharge, and computed tomography was performed at 3 months and yearly thereafter. Median follow-up was 6.42 years (quartile 1 to quartile 3: 3.31–10.49). Forty-nine patients died during follow-up (22 type A, 27 type B), 31 suddenly. Surgical or endovascular treatment was indicated in 10 type A and 25 type B cases. Survival free from sudden death and surgical-endovascular treatment was 0.90, 0.81, and 0.46 (95% CI, 0.36–0.55) at 3, 5, and 10 years, respectively. Multivariate analysis identified baseline maximum descending aorta diameter (hazard ratio [HR]: 1.32 [1.10–1.59]; P =0.003), proximal location (HR: 1.84 [1.06–3.19]; P =0.03), and entry tear size (HR: 1.13 [1.08–1.2]; P <0.001) as predictors of dissection-related adverse events, whereas mortality was predicted by baseline maximum descending aorta diameter (HR: 1.36 [1.08–1.70]; P =0.008), entry tear size (HR: 1.1 [1.04–1.16]; P =0.001), and Marfan syndrome (HR: 3.66 [1.65–8.13]; P =0.001).

Conclusions—

Aortic dissection with persistent patent false lumen carries a high risk of complications. In addition to Marfan syndrome and aorta diameter, a large entry tear located in the proximal part of the dissection identifies a high-risk subgroup of patients who may benefit from earlier and more aggressive therapy.

Acute ascending aortic intramural hematoma as a complication of the endovascular repair of a Type B aortic dissection

Endovascular aortic graft repair (EVAR) for patients with Type B aortic dissection is a less invasive surgical procedure (compared to traditional open surgical repair) that is associated with less morbidity and shortened recovery times. However, there are notable complications for the patients undergoing EVAR. We report a patient who was brought to our hospital with a Type B dissection and underwent a thoracic EVAR but suffered iatrogenic aortic injury resulting in cardiac tamponade. This case study highlights the importance of intraoperative transesophageal echocardiography to facilitate early detection of possible EVAR complications.

''Relining'' of thoracic aortic stent grafts for patients presenting with rupture/impending rupture

OBJECTIVES

To report a series of patients following thoracic endovascular aortic repair (TEVAR) presenting with rupture, who were effectively treated with TEVAR relining.

METHODS

Five patients who underwent repeat TEVAR in an urgent fashion were identified. Chart review was performed to identify demographics, device type, aneurysm characteristics, and postoperative course.

RESULTS

Mean time to relining procedure was 5.8 (range 2-10) years. All patients had ≥3 device components originally placed. Mean size of the original aneurysm was 7.2 cm (range 6.6-8). All patients underwent relining with proximal and distal extension with immediate technical success. At a mean follow-up of 1.3 years, there was no evidence of endoleak and no patients required repeat intervention.

CONCLUSIONS

Complete relining with proximal and distal extension was effective in treating patients presenting with rupture. These findings suggest that proximal and distal landing zones provided, relining should be considered the initial management strategy in patients s/p TEVAR re-presenting with rupture.

[Chronic aortic syndrome: how to follow patients, which complications and when to treat?]

After the acute phase, if patient survives, the disease is still present. Chronic stage is defined as the period after the first month following the acute phase. Follow-up of the thoracic aorta is mandatory and even at the abdominal level to check the risk of rupture. In case of aortic dissection, late complications such as chronic malperfusion syndrome, but also secondary localisation of the disease, the risk factor indicate a role for the global management of the patient. The main objective of this article is to insist on the necessity to a close follow-up.

Midterm results after endovascular treatment of acute, complicated type B aortic dissection

BACKGROUND

The purpose of this study was to assess the efficacy and midterm results of endovascular treatment of acute, complicated type B aortic dissection.

METHODS

Between January 2001 and February 2010, 32 patients (7 women, 25 men) with acute, complicated type B aortic dissection (mean age, 56 years; range, 35 to 83 years), defined as either aortic rupture, malperfusion, intractable pain, or uncontrolled hypertension, underwent endovascular stent graft placement with either the Gore Excluder/TAG device (n = 11), Medtronic Talent/Valiant device (n = 16), Bolton Relay (n = 2), or a combination of these stents (n = 3). Follow-up was 94% complete and averaged 26 ± 23 months.

RESULTS

Technical feasibility and success with deployment proximal to the entry tear was 87%, requiring partial or total coverage of the left subclavian artery (LSA) in 9 patients (28%). Hospital mortality was 12% ± 11% (95% confidence limit) with 2 late deaths (17 and 98 months after implant). Causes of hospital death included rupture in 2, retrograde type A dissection in 1, and multiorgan failure in 1 patient. Three patients (11%) experienced new neurologic complications (2 paraparesis and 1 hemiparesis). Six patients with malperfusion required branch vessel stenting. Furthermore, 2 had an early type Ia endoleak. Actuarial survival at 1 and 5 years was 81% and 76%, respectively. Freedom from treatment failure at 1 and 5 years (including reintervention, aortic rupture, device-related complication, and aortic related death) was 78% and 61%, respectively.

CONCLUSIONS

Endovascular stent-graft placement in acute, complicated type B aortic dissection proves to be a promising alternative therapeutic treatment modality in this relatively difficult patient cohort. Refinements, especially in stent design and application, may further improve the prognosis of patients in this life-threatening situation.

Importance of Refractory Pain and Hypertension in Acute Type B Aortic Dissection

Background—

In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection.

Methods and Results—

Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P =0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P =0.0003). Mortality rates after surgical (20% versus 28%; P =0.74) or endovascular management (3.7% versus 9.1%; P =0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P =0.041).

Conclusions—

Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.

Emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset in 30 cases

OBJECTIVE

To investigate the results of emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset.

METHODS

A retrospective analysis of the clinical data of 30 patients with complicated Stanford type B aortic dissections who underwent emergency endovascular repair between June 2007 and October 2008. Endovascular repairs were performed within 24 hours of symptom onset. Stent-grafts were deployed at the first entry tear through the femoral artery under fluoroscopic guidance. Follow-up computed tomography scans were performed at 1, 3, 6, 12, and 18 months after treatment.

RESULTS

The mean patient age was 64 years (range, 43-83 years). There were 3 cases associated with rupture, 6 cases associated with refractory hypertension, 15 cases associated with persistent pain, 2 cases associated with retrograde dissection, and 4 cases associated with malperfusion. The technical success rate was 100%, and the incidence of immediate postoperative endoleaks was 13.4%. One patient died of dissection rupture within 30 days. The mean follow-up period was 12 ± 8 months. A small, persistent endoleak (<10%) occurred in 1 patient, and 1 patient died of acute liver failure 2 months after the operation. No stent dislocation, false lumen expansion, or paraplegia occurred. The false lumen was completely thrombosed in 6 patients and partially thrombosed in 19 patients. The mortality rate was 6.67%.

CONCLUSIONS

Our results suggest that emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset is associated with good outcomes and can decrease mortality.