Endovascular stenting of descending aorta for retrograde type A dissection

Surgical interposition graft replacement of the ascending aorta, irrespective of antegrade or retrograde type, has traditionally been the standard treatment of all type A aortic dissection. However, open aortic repair carries high surgical risks and mortality. Recent studies showed that endovascular stenting for retrograde type of aortic dissection might have a high success rate and is considered to be less invasive. We report a case of type A aortic dissection, who was diagnosed to be retrograde type according to a 3‐D reconstruction computed tomography scan and was managed successfully with endovascular stenting in the proximal descending aorta. Complete resolution of the false lumen in the ascending and descending aorta was achieved 2 years after the stenting.     

Treatment of chronic aortic type A dissection with a new designed hybridprosthesis.

This report describes the use of a new combined surgical and endovascular treatment for chronic type A aortic dissection after Cabrol operation. Intraoperative antegrade stenting of the descending aorta combined with distal ascending aorta and aortic arch repair was performed using the E-vita open endoluminal stentgraft. The stentgraft was deployed under direct vision into the true lumen. Postperative CT scan revealed a partially thrombosed false lumen. This report shows that a combined surgical and endovascular approach of chronic type A aortic dissection in a single stage procedure is a feasible option and extends aortic repair without increase of risk.     

Delayed retrograde aortic dissection after endovascular stenting of the descending thoracic aorta

A 66-year-old patient underwent emergency endovascular repair of a descending thoracic aneurysm because of suspected aortic rupture. Two weeks later, a small saccular aneurysm of the aortic arch was treated with open surgery. An unexpected intraoperative finding was retrograde dissection of the aortic arch and of the ascending aorta that was not seen on the postprocedural computed tomographic scans after endografting. The ascending aorta, the aortic arch, and the proximal part of the descending thoracic aorta were successfully replaced with a Dacron graft with deep hypothermia, circulatory arrest, and retrograde cerebral perfusion. Awareness that this life-threatening complication that necessitates extensive cardiovascular surgery can occur not only during or immediately after endovascular stenting of the thoracic aorta but also as much as several days or perhaps even weeks after the procedure is important.     

Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.     

Graft-to-endograft anastomosis for emergency treatment of distal aortic arch aneurysm after endovascular stenting of thoracoabdominal type B dissection

Emergency aortic arch surgery still remains a challenge, especially in elderly patients. We report a case about the open surgical management by graft-to-endograft anastomosis of a complicated aortic arch aneurysm because of a type I endoleak after thoracic endovascular aortic repair of a chronic type B aortic dissection.     

Stanford B型主动脉夹层的诊断治疗

Stanford B型夹层是一种严重威胁人类生命健康的主动脉疾病.随着临床分类的细化及诊断方法的改进,Stanford B型主动脉夹层病死率逐渐降低.治疗上,腔内修复因其微创优势逐渐取代传统开放手术成为复杂性Stanford B型主动脉夹层治疗的首选.对于非复杂性夹层,腔内修复也逐渐取代药物治疗,并显示出良好疗效.开放手术仅适用于不适用腔内修复,修复失败或合并结缔组织病患者.     

Endovascular repair of a ruptured chronic type B aortic dissection

Aneurysm formation is a common sequel of chronic type B aortic dissection. Ruptured false lumen aneurysms have traditionally been treated with open repair. These procedures are associated with high morbidity and mortality rates. We report the first successful endovascular repair of a ruptured chronic type B aortic dissection in a patient who had been turned down for elective surgery. The endovascular management of chronic dissection with rupture is difficult and may necessitate stenting of both entry and reentry points to induce false channel thrombosis. The long-term efficacy of this technique is unknown.     

Indication of endovascular treatment of type B aortic dissection - Literature review

Aortic dissection is a cardiovascular event of high mortality if not early diagnosed and properly treated. In Stanford type A aortic dissection, there is the involvement of the ascending aorta, whereas in type B the ascending aorta is not affected. The treatment of type A aortic dissection is mainly surgical. The hospital mortality of type B aortic dissection surgical treatment is approximately 20%, while medical therapy is 10%. However, half the patients who are discharged from hospital after medical treatment, progress to aortic complications in the following years, and the mortality in three to five years may reach 25-50%. In addition, the surgical treatment of aortic complications after medical treatment, has also a significant mortality. This way, the endovascular treatment comes up as an interesting alternative of a less invasive treatment for this disease. They presented a mortality rate lower than 10% with more than 80% success rate of occlusion and thrombosis of the false lumen. The INSTEAD TRIAL, which randomized patients with uncomplicated type B aortic dissection for optimal medical therapy and endovascular treatment in addition to optimal medical therapy, showed that after three years of follow up, patients who underwent endovascular treatment had lower mortality and aorta-related complications. Therefore, there is a current tendency to recommend the endovascular treatment as a standard for the treatment of type B aortic dissection     

Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection.

OBJECTIVE: To describe our experience with endovascular stent-graft repairs in type B aortic dissection focusing on serious secondary complications resulting in immediate or late conversion to open repair. METHODS: From November 1997 to May 2007, 28 patients underwent a thoracic endovascular stent-graft procedure for acute symptomatic type B dissection at our institution. Indication for endovascular repair at our department is a complicated course of type B dissection, including thoracic aortic rupture, suspicion of impending rupture, visceral and/or peripheral ischemia, uncontrollable hypertension, and severe therapy-resistant pain. Median follow-up time was 48.3 months (range 2-97 months). RESULTS: Secondary complications with indication for a secondary intervention occurred in 5/28 patients, resulting in additional procedures in 4 patients. One patient declined any further therapy. Conversion to an open procedure was performed in four patients, one due to type I endoleak followed by retrograde type A dissection, and three due to retrograde type A dissection. One of these patients had an additional stent-graft procedure performed due to a type III endoleak 20 months post stent grafting. Retrograde type A dissection occurred 39 months later, finally leading to conversion to an open procedure. Open surgery was performed in four patients after 3, 26, 29, and 1170 days post stent-graft placement and was successful in three patients. The fourth patient died 3 months post-surgically due to multi-organ failure. The procedure-related mortality rate following secondary complications was (1/5) 20%. CONCLUSIONS: Endovascular stent-graft repair of the thoracic aorta is an alternative to surgical repair, however not without significant morbidity and mortality. Potentially lethal complications, acute or delayed, may occur.     

The first endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta

Endovascular repair has emerged as a potential alternative to emergency open surgical repair for type A dissection in selected patients, with isolated reports describing the results obtained with a range of devices designed originally for the descending aorta. We believe that we present the first reported repair of an acute ascending aortic dissection using an endovascular stent graft manufactured specifically for the ascending aorta.     

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.     

Sudden endograft collapse due to type B aortic dissection after open conversion of endovascular aortic repair

A 58-year-old man was admitted for sudden numbness of the right leg and abdominal pain 6 months following late open conversion for endotension after endovascular aortic repair. Computed tomography demonstrated residual endograft collapse due to Stanford type B dissection. Emergent right axillobifemoral bypass was performed to perfuse the lower extremities. We performed subsequent total arch replacement with secondary thoracic endovascular aortic repair.     

穿透性主动脉溃疡的外科治疗

目的 总结经开放手术或腔内修复穿透性主动脉溃疡(PAU)的外科治疗经验.方法 回顾性分析10例PAU患者的临床资料,其中6例病灶位于降主动脉,4例位于腹主动脉;并发主动脉瘤1例、间壁血肿2例、溃疡破溃2例及夹层6例.结果 4例采用开放手术治疗,1例术后出现右胸腔积液,但经处理后基本痊愈;6例采用腔内治疗,1例腔内治疗后发生轻微的内漏,1个月后该内漏自发消失.10例患者获得随访,平均随访时间为(17.8±11.53)个月,1例在随访12个月后失访.开放手术者无一例发生与血管手术相关的并发症;腔内治疗患者无一例发生支架移位.结论 PAU经正确选择外科治疗方案并进行处理后的效果是理想、安全的,而且其短期及中期效果是稳定的.     

Outcomes of emergency in situ laser fenestration-assisted thoracic endovascular aortic repair in patients with acute Stanford type A aortic dissection unfit for open surgery

ObjectiveThis study investigated the outcomes of emergency in situ laser fenestration (ISLF)-assisted thoracic endovascular aortic repair (TEVAR) for patients with acute Stanford type A aortic dissection unfit for open surgery.MethodsTwenty patients with acute Stanford type A aortic dissection who were found to be unfit for open surgery, underwent emergency ISLF-assisted TEVAR in our center between March 2016 and December 2018. Anatomic criteria for endovascular repair: coronary artery and aortic valve was not involved, proximal landing zone diameter of 45 mm or less, and proximal landing zone length of 20 mm or greater. Their clinical outcomes were reviewed retrospectively.ResultsTwenty patients achieved a procedural success of 100.0%. The 30-day mortality was 10%; two patients died, one of severe pneumonia and the other from cerebral hemorrhage after the operation. Rate of stroke at 30 days was 5%. The average follow-up time was 16 months (range, 3-26 months). One death owing to heart failure occurred at 23 months postoperatively. Kaplan-Meier curve analysis revealed that the 24-month survival rate was 77.1%. Two patients had type Ia endoleaks and one had a type II endoleak. There was no stent graft migration or fenestration-related endoleak and all patients had a thrombosed false lumen in the covered section of the stent grafts. No reintervention, myocardial infarction, transient ischemic attacks, cerebral infarction, or other complications occurred during the follow-up period.ConclusionsEmergency ISLF-assisted TEVAR is a safe and effective alternative method for treating acute Stanford type A aortic dissection unfit for open surgery.     

Total endovascular repair of thoracoabdominal aortic aneurysms

BackgroundEndovascular graft designs incorporating sidebranches, fenestrations and scallops offer a minimally-invasive alternative to open surgery and hybrid approaches for thoracoabdominal aortic aneurysms (TAAA). Our unit has offered total endovascular TAAA repair to selected higher-risk patients since 2008. We report the largest UK series to date of total endovascular TAAA repair.MethodsRetrospective analysis of a prospectively-maintained operative database.Results31 patients (21 male, 10 female) median age 71 years (range 58–84), with TAAA (12 Crawford type I, 13 type III, 6 type IV), median diameter 6.4 (4.3 (mycotic)- 9.9) underwent endovascular TAAA repair (total 48 sidebranches, 26 fenestrations, 13 scallops) between July 2008 and January 2011. Median operating time 225 min (65–540 min), X-ray screening time 58 min (4–212 min), contrast dose 175 ml (70–500 ml), blood loss 325 ml (100–400 ml). Median post-operative length of hospital stay 6 days (2–22 days). Three patients (3/31, 9.7%) died within 30 days of operation: multisystem organ failure (1) acute renal failure and paraplegia (1) and paraplegia (1). There were no other cases of in-hospital organ failure, paraplegia or major complications. The median change in pre-discharge from pre-operative renal function was 3.4% deterioration in eGFR (range: 32.7% deterioration to 73.0% improvement) One patient presented with late-onset paraparesis, a second developed acute renal failure 8 months after repair. One early high-pressure endoleak (type 3) required correction. Three patients had died by median follow-up 12 months (1–36), 2 from heart disease and one from haemopericardium secondary to acute dissection of the ascending aorta (the dissection did not involve, nor extend close to, the endovascular graft).ConclusionsTotal endovascular repair of TAAA offers patients a minimally-invasive alternative to open surgery with early results at least comparable to those seen with open or hybrid surgical approaches.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

胸主动脉B型夹层腔内修复术后逆向撕裂的外科治疗

目的 回顾分析11例胸主动脉Stanford B型夹层分离行腔内修复术后逆向撕裂为StanfordA型夹层病例,总结其特点及外科治疗经验.方法 2005年4月至2008年3月,手术治疗11例腔内修复术后逆向夹层病人.7例发生于支架术3个月内,夹层破口均位于支架附着处,人工血管远端均与支架吻合;4例发生于支架术3个月后,夹层破口与支架距离较远,人工血管远端吻合口与支架无关.结果 所有病人均康复出院,随访7～40个月,均生存,无严重并发症.结论 发生于腔内修复术后近期(＜3个月)的A型夹层可能与腔内修复术有关,术中人工血管可与支架直接吻合.发生于术后较长时间的A型夹层是否与腔内修复术有关尚需探讨.外科手术治疗可获良好疗效,术中良好的脑保护与远端吻合口处理是手术成功的关键.     

Deployment of endograft in the ascending aorta to reverse type A aortic dissection

Current surgery to treat acute type A aortic dissection involving an intimal tear in the ascending aorta consists of resection and replacement, but mortality is high. We report the case of a 46-year-old female patient with Marfan syndrome who presented with excruciating retrosternal pain and breathing distress after a bowel movement with stress. Magnetic resonance imaging and multicolour sonography showed type A aortic dissection extending from the aortic root to the right iliac artery, with intimal tears in the ascending aorta above the sinotubular junction, the distal arch beyond the left subclavian artery and the isthmic region. We adapted the endoluminal stenting technique to this case of type A aortic dissection by sealing the intimal tears in the ascending aorta using endovascular introduction of one endoluminal graft, as confirmed on angiography. The patient was discharged after 10 days. Follow-up examination by computed tomography after more than 1 year revealed no sign of dissection at any level of the aorta.     

Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections

PURPOSE: The advent of endovascular prostheses to treat descending thoracic aortic lesions offers an alternative approach in patients who are poor candidates for surgery. The development of this approach includes complications that are common to the endovascular treatment of abdominal aortic aneurysms and some that are unique to thoracic endografting. METHODS: We conducted a retrospective review of 60 emergent and high-risk patients with thoracic aortic aneurysms (TAAs) and dissections treated with endovascular prostheses over 4 years under existing investigational protocols or on an emergent compassionate use basis. RESULTS: Fifty-nine of the 60 patients received treatment, with one access failure. Thirty-five patients received treatment of TAAs. Four of these procedures were performed emergently because of active hemorrhage. Twenty-four patients with aortic dissections (16 acute, 8 chronic) also received treatment. Eight of the patients with acute dissection had active hemorrhage at the time of treatment. Three devices were used: AneuRx (Medtronic; n = 31), Talent (Medtronic; n = 27), and Excluder (Gore; n = 1). Nineteen secondary endovascular procedures were performed in 14 patients. Most were secondary to endoleak (14 of 19), most commonly caused by modular separation of overlapping devices (n = 8). Other endoleaks included 4 proximal or distal type I leaks and 2 undefined endoleaks. The remaining secondary procedures were performed to treat recurrent dissection (n = 1), pseudoaneurysm enlargement (n = 3), and endovascular abdominal aortic aneurysm repair (n = 1). One patient underwent surgical repair of a retrograde ascending aortic dissection after endograft placement. Procedure-related mortality was 17% in the TAA group and 13% in the dissection group, including 2 acute retrograde dissections that resulted in death from cardiac tamponade. Overall mortality was 28% at 2-year follow-up. CONCLUSION: Although significant morbidity and mortality remain, endovascular repair of descending TAAs and dissections in patients at high-risk patients can be accomplished with acceptable outcomes compared with traditional open repair. The major cause for repeat intervention in these patients was endoleak, most commonly caused by device separation. Improved understanding of these complications may result in a decrease in secondary procedures, morbidity, and mortality in these patients. The need for secondary interventions in a significant number of patients underscores the necessity for continued surveillance.     

Acute type B aortic dissection

Aortic dissection is infrequent in everyday practice; however, it can result in life-threatening complications and causes more deaths each year in the UK than road traffic collisions. It is one of the family of acute aortic syndromes, which includes penetrating aortic ulcer (PAU) and intramural haematoma (IMH). Type A aortic dissections involve the ascending aorta and arch and almost invariably require prompt surgical treatment due to exceptionally high early 48-hour mortality without surgery. Many type B aortic dissections (TBAD) are not complicated at presentation and can be treated conservatively in high dependency and discharged without intervention. Complicated aortic dissection requires intervention, often with a thoracic endovascular aortic repair (TEVAR). The survival after TBAD is higher than type A dissection that invariably requires emergency operative intervention, with 65% of patients surviving to 1 year. Following acute aortic syndrome, best medical therapy involves tight blood pressure and heart rate control using beta-blockers or calcium channel blockers. Statin therapy may be of benefit. Regular cross-sectional imaging surveillance is important to detect late complications such as aortic dilatation. In type B aortic dissection, aortic dilatation is a common cause of late rupture with only 50% of patients surviving after 5 years without intervention. One of the most important questions at present is whether people at high risk of further aortic dilatation can be identified and intervened on early to prevent these late complications?