Stent-Graft Treatment of Dissecting Aneurysm in Association with Aortic Intramural Hematoma: When Should the Procedure Be Performed?

Endovascular Treatment of Ruptured Penetrating Aortic Ulcers

Penetrating aortic ulcer (PAU) is a potentially lethal lesion that should be promptly diagnosed and treated. Because of the older age and serious comorbidity of these patients, outcome with rupture of the ulcer is often ominous, even when appropriate conventional surgical treatment is given. In this study we report our experience with two cases of endovascular treatment of ruptured PAU in two elderly female patients who had evident signs of intrathoracic bleeding. Endovascular treatment was performed with a stent-graft device advanced through a 24-F sheath. The graft successfully covered the PAU in both cases and the postoperative course was uneventful. Both patients were alive and well at follow-up, with regression of the hematomas and correct positioning of the grafts. Because of the reduced invasiveness of endovascular stent-graft repair, it is an alternative therapeutic option to conventional surgery in the treatment of ruptured PAU.

Acute aortic syndrome: a case presentation and review of the literature

Aortic disease can present as an acute chest pain syndrome. Although aortic dissection is the most common etiology, other processes such as intramural hematoma (IMH) and penetrating atherosclerotic ulcers are being increasingly recognized. They can all be accurately identified by computed tomography (CT) imaging or transesophageal echocardiography. The overlap between these processes regarding definition and mechanism is controversial. Treatment for all three conditions has thus far been dictated by location, wherein ascending or arch involvement (Stanford type A) necessitates surgery and descending disease (type B) is treated medically. Small studies suggest that subgroups of type A IMH may be treated medically with good outcomes.

Type A aortic dissection developing during endovascular repair of an acute type B dissection

PURPOSE

To describe an extension of type B dissection into type A during endoluminal treatment of acute type B dissection.

CASE REPORT

A 57-year-old man with acute type B dissection underwent endovascular repair using 2 Excluder stent-grafts. Before releasing the second stent-graft, the patient complained of mild central chest pain, headache, and visual flashes, but no hemodynamic changes were noticed. An angiogram, performed soon afterwards, showed a retrograde extension of the dissection through the aortic arch involving both the left carotid artery and the ascending aorta. The procedure was completed, and the patient was transported to the operating room where the proximal ascending aorta was replaced. Spiral computed tomographic angiography performed 2 weeks after the procedure showed complete exclusion of the primary entry tear. At 6-month follow-up, the patient was asymptomatic; the left carotid artery dissection had disappeared.

CONCLUSIONS

Endovascular repair of acute type B dissection is technically feasible, but longer experience will help prevent technical complications.