Extended total arch replacement by means of the open stent-grafting method to treat intimal tears after transluminal stent-graft placement for a ruptured acute type B aortic dissection

Emergency Endovascular Stent-Grafting for Life-Threatening Acute Type B Aortic Dissections

BACKGROUND

There is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection.

METHODS

In 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 +/- 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 +/- 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography.

RESULTS

In 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths.

CONCLUSIONS

Our experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.

Endovascular treatment of complicated type-B aortic dissection with stent-grafts:: midterm results

PURPOSE

To report the midterm results of the endovascular treatment of complicated type-B aortic dissection with use of stent-grafts.

MATERIALS AND METHODS

Ten patients with acute (n = 4) or chronic (n = 6) complicated type-B dissection were treated with custom-made stent-grafts. Indications for treatment included uncontrollable hypertension with dissection extension (n = 3), renal ischemia (n = 1), and false lumen aneurysm (n = 6). Stainless-steel Z-stents covered with polyester grafts were placed in the initial six patients. Nitinol stents covered with ultrathin polytetrafluoroethylene were used in the remaining four patients. The patients were followed-up with helical computed tomography for a maximum of 30 months (mean, 20 mo).

RESULTS

There was one technical failure related to the access site. Early complications included deep venous thrombosis (n = 1) and embolic stroke (n = 1). Complete thrombosis of the thoracic false lumen was achieved in six patients and partial thrombosis was achieved in three. Aneurysms developed at the ends of the stainless-steel stents in two patients, requiring additional stent-graft placement. Despite successful remodeling of the thoracic aorta, three of four patients with distal reentry into the abdominal aorta experienced progressive abdominal aortic aneurysm (AAA). AAA rupture developed in two patients; one rupture was fatal and the other was treated with emergency surgery.

CONCLUSIONS

Endovascular treatment of complicated type-B aortic dissection is technically feasible and effective. Closely monitoring the treated aorta is essential to detect early aneurysm formation at the ends of rigid stents. Despite adequate sealing of the tears in the thoracic aorta, dissection with distal reentry phenomenon into the abdominal aorta may evolve into AAA with late rupture.