Midterm results of aortic diameter outcomes after thoracic stent-graft implantation for aortic dissection: a multicenter study.

PURPOSE: To evaluate aortic diameter outcomes after stent-graft implantation for aortic dissection in the descending thoracic aorta. METHODS: Fifty patients with type A dissection after ascending aortic surgery (n = 10), type B dissection (n = 34), or intramural hematoma (n = 6) underwent stent-graft repair in 3 centers. Thrombosis and aortic diameter were analyzed by computed tomographic angiography at different levels of the aorta before stent-graft implantation, at discharge, and at follow-up. Measurements were standardized. RESULTS: In all, 67 stent-grafts were implanted for acute (n = 18) and chronic (n = 32) dissection. Stent-graft placement was successfully performed with high technical success (100%) despite 4 major complications (iliac thrombosis in 2 cases, aortic rupture, and a type A dissection) in 3 (6%) patients. Complete thrombosis of the thoracic false lumen was observed in 42% and 63% of cases at discharge and at follow-up (mean 15 months), respectively. At follow-up, the diameters of the entire aorta (mean 5 mm, p < 0.05) and the false lumen (mean 11 mm, p < 0.0001) decreased. Diameters of the abdominal aorta remained stable in association with persistent false lumen perfusion at this level. Aortic diameter results were better in the subgroup of patients with intramural hematoma compared to patients with Marfan syndrome. Three early deaths unrelated to the stent-graft procedure occurred; 2 patients with partial thrombosis of the false lumen died in follow-up secondary to aortic diameter growth. CONCLUSION: Complete thrombosis of the false lumen by stent-graft coverage of the entry tear results in decreased diameter of the entire aorta. In patients with partial thrombosis of the false lumen, the aneurysm continues to enlarge.     

Aortic dissection surgery: experience of 78 cases.

From May 1990 to January 2001, 78 patients underwent surgery for aortic dissection, 68 (87%) of type A. Presentation was acute in 55 patients (71%). For type A dissection, in-hospital mortality was 13% (9 patients) and late mortality was 16%. For type B dissection, in-hospital and late mortality were both 30% (3 patients). The follow-up was complete and medical and imaging controls were performed periodically. Computerized axial tomography has shown persistence of distal aortic dissection in 18 patients, one of whom maintained dissection of the supraaortic trunks with false lumen thrombosis. Six patients maintained signs of dissection in the thoracic and abdominal aorta with patent false lumen. In another eight patients the false lumen was thrombosed. In 3 cases the dissection was located in the abdominal aorta. Two patients developed pseudoaneurysms of the thoracic aorta, one of whom was reoperated due to symptoms of dysphagia and chest pain, with angiographic signs of probable rupture of the aorta. Periodic imaging monitoring is essential, as it allows assessment of the extent of residual aortic disease and its evolution, with early detection of possible complications. This will enable prompt and safe action in those patients who may benefit from reoperation.     

Prognosis of postoperative aortic dissection. Assessment with magnetic resonance]

OBJECTIVE: To evaluate operated type A aortic dissection by Magnetic Resonance Imaging (MRI), in order to detect long-term complications and identify prognostic indexes of evolution. DESIGN: Prospective study with a three-year period of follow-up. Prognosis evaluation. SETTINGS: Outpatient Clinic at Hospital de Santa Maria and Magnetic Resonance Imaging Center at Hospital da Cruz Vermelha. PATIENTS: A sample of 37 patients submitted to type A aortic dissection surgery, included sequentially, after exclusion of those with contraindication to MRI. METHODS: Initial evaluation (clinical and MRI study) at 3 to 4 months and at 1, 2 and 3 years after surgery. The mean follow-up time was 39.3 +/- 2.9 months. We evaluated the following complications over the aorta (aortic graft and five segments of residual aorta) and the aortic valve: aneurysm, pseudoaneurysm, rupture, re-dissection, progressive aortic valve regurgitation, reoperation and death. The prognostic indexes analysed were: presence of residual flap; false lumen patency; presence of re-entry points; false lumen to aorta dimension ratio; initial aortic dimension; increase of aortic dimension. RESULTS: All patients, with the exception of three that died, remained asymptomatic. COMPLICATIONS: Aneurysm was detected in 45.9% of patients, located in one or more segments; rupture occurred in three patients, preceded by aneurysm and pseudoaneurysm development; moderate or severe aortic regurgitation was detected in 47.8% of patients. Prognostic indexes: 1. Aneurysm development in each segment yeilded a significant association with: presence of residual flap in the same and other segments; higher initial dimension of the same and other segments, with the exception of the abdominal segment; higher increase in dimension of the same and other segments, with the exception of the abdominal segment; 2. Moderate or severe aortic regurgitation development showed a tendency to association with higher increase in dimension of proximal ascending aorta. 3. No association was found between aneurysm and aortic regurgitation development. CONCLUSIONS: Patients operated for type A aortic dissection had a high incidence of late complications which lead to reoperation and in some cases death. The presence of a residual flap, increased aortic dimensions and higher increase rate of aortic dimensions were associated with a complicated evolution. MRI was a very useful technique for long-term monitoring and to identify prognostic indexes of evolution.     

Fate of the native aorta after repair of acute type A dissection: a magnetic resonance imaging study.

OBJECTIVE--To determine late patency of the aortic false lumen and propensity for aneurysm formation after repair of type A dissection. DESIGN--Retrospective follow up study. SETTING--Regional cardiac surgical unit. PATIENTS--28 patients after repair of type A dissection. METHODS--Magnetic resonance imaging (MRI) was performed between 6 weeks and 12 months after operation. RESULTS--A patent distal false lumen with demonstrable blood flow was found in 22 patients (78%). Only six patients had complete obliteration of the false lumen by thrombus. The conduct of operation did not influence this. Nine patients (32%) showed aneurysmal dilatation of the false lumen and three had a repeat operation. CONCLUSIONS--So-called "successful repair" of aortic dissection does not obliterate the distal false lumen. MRI is a safe and effective radiological procedure for determining patency and dilatation in the false lumen. Patients with type A dissection with blood flow in the false lumen should be studied every 6 months to look for aneurysmal dilatation.     

Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept.

PURPOSE: To report the use of a technique (PETTICOAT: provisional extension to induce complete attachment) to obliterate sustained abdominal false lumen flow and pressurization despite successful stent-graft sealing of the thoracic entry tear in patients with complicated type B aortic dissection. METHODS: Of 100 initial patients subjected to stent-graft repair for complex type B aortic dissection with thoracoabdominal extension, 12 patients (10 men; mean age 58.7 years, range 44-76) demonstrated distal true lumen collapse and a perfused abdominal false lumen despite successful sealing of the proximal tears. As an adjunctive or staged procedure, a scaffolding stent was placed for distal extension of the previously implanted stent-graft. In each case, a Sinus aortic stent, Fortress stent, or a Z-stent system was customized with maximum 2-mm oversizing versus the original stent-graft diameter. Magnetic resonance or computed tomographic angiography was performed at discharge, at 3 months, and then annually to determine false channel thrombosis, true and false lumen dimensions, and re-entry flow. RESULTS: Delivery was successful in all cases (100%). The compressed distal true lumen (mean 4+/-3 mm) was reconstructed to a mean width of 21+/-3 mm, and malperfusion was abolished without any obstruction of the abdominal side branches. At up to 1-year follow-up, there were no signs of expansion or distal progression of the scaffolded dissected aorta. All patients with complete thoracic thrombosis showed evidence of improved aortic remodeling; 1 patient with no false lumen thrombosis died at 11 months from thoracoabdominal aortic rupture. CONCLUSION: The PETTICOAT technique may offer a safe and promising adjunctive endovascular maneuver for patients with distal malapposition of the dissecting membrane and false lumen flow. The technique can both abolish distal true lumen collapse and enhance the remodeling process of the entire dissected aorta.     

Postoperative follow-up of type A aortic dissectionexperience with 67 patients]

BACKGROUND: The surgical treatment of type A aortic dissection is usually palliative and most surviving patients remain at considerable risk to develop late postoperative complications; consequently, there is the need for careful long-term follow-up. The present study reports on our experience in the postoperative follow-up of a consecutive series of patients with type A aortic dissection. METHODS: Between January 1986 and December 1996, 89 patients underwent emergency surgery for type A acute aortic dissection; the overall hospital mortality rate was 22% (20/89). This study includes the 69 hospital survivors (49 men and 20 women). Forty-six patients had ascending aortic graft replacement, 13 patients underwent replacement of aortic valve and ascending aorta by a composite graft. The surgical repair was extended to the aortic arch in 5 patients. All patients were serially evaluated by clinical examination and imaging techniques (transthoracic echocardiography in all patients, magnetic resonance imaging in 40, transesophageal echocardiography in 33 and computed tomography in 25). Follow-up was complete in 97% of patients (two patients were lost to follow-up and excluded from the study) and extended to a maximum of 152 months (mean 74 +/- 39 months). The postoperative quality of life was assessed by a questionnaire in 51 current survivors. Risk factors for cardiovascular death, reoperation and poor quality of life were investigated with univariate and multivariate analysis. RESULTS: During the follow-up period 15 patients (22%) died; in 13 cases death was due to cardiovascular causes and in 6 of them it was related to aortic disease. The Kaplan-Meier survival was 92 +/- 3%, 87 +/- 5%, 78 +/- 6% and 70 +/- 8% at 2, 4, 6 and 8 years, respectively. A persistent aortic dissection was demonstrated in 50 patients (75%) and 42 of them showed the presence of flow in the false lumen. A dilatation of one or more aortic segments was found in 59 patients (88%), with a diameter > or = 50 mm in 17 and > or = 60 mm in 8. In 30 patients who underwent transesophageal echocardiography the relation between aortic dimensions and flow pattern in the false lumen was examined; the presence of aneurysmal dilatation with a diameter > or = 50 mm was significantly correlated with a "high flow" pattern. Ten patients (15%) underwent reoperation from 13 to 83 months postoperatively. Reoperation was indicated for: sinus of Valsalva aneurysm and severe aortic regurgitation (2 patients), severe aortic regurgitation (2 patients), aneurysm of the arch (1 patient), thoracoabdominal aneurysm (1 patient), periprosthetic pseudoaneurysm (4 patients). The hospital mortality rate was 20% (2 patients). Sixty-two% of current survivors are asymptomatic; 30 patients returned to their predissection status. Quality of live is judged "good" by 23 patients, "fairly good" by 21 patients and "poor" by 7 patients. No significant independent risk factor for cardiovascular death, reoperation and poor quality of life was identified. CONCLUSIONS: The long-term prognosis after surgical treatment of type A aortic dissection is not satisfactory because of a significant risk of late complications. However, the results of our study can be judged fairly good, particularly if we consider the natural history of the disease.     

Percutaneous coronary intervention following repair of type B aortic dissection:a report of 8 cases

Objective Patients with aortic dissection have a significant incidence of coronary artery disease.The purpose of this study is to evaluate the safety and feasibility of percutaneous coronary stent in patients who have undergone endovascular stent,and to assess the effect of anti-coagulant and anti-platelet treatment on patients' thrombosis process.Methods From January 2005 to July 2007,8 patients who had undergone endovascular stent-graft during the past 1 to 7 months for type B aortic dissection repair,underwent percutaneous coronary intervention (PCI) because of coexisting coronary artery disease.Anti-coagulant and anti-platelet treatments were administrated after PCI according to the standard protocol.Patients were followed up for a mean period of 23 months.Clinical and false lumen status data were collected during the follow-up.Results PCI were technically successful in all 8 patients and no severe complications such as death,paraplegia,renal failure occurred during hospitalization.Complete false lumen thrombosis was observed in 5 patients and incomplete false lumen thrombosis in the remained 3 patients at the end of follow up.There were no major complications such as death,dissection rupture or aneurysm development occurred during the follow-up period.Conclusion Our data implied that PCI can be safely performed in patients with type B aortic dissection who have undergone endovascular stent-graft,without interrupting the thrombosis process.     

Type "A" aortic dissection. Surgical technique, caseload, and follow-up

BACKGROUND: The authors analyse the indications for the various surgical strategies through a retrospective study of the morbility and mortality rates in their own series of cases and during follow-up. METHODS: 107 patients were operated for type A aortic dissection between 1978 and 1998: 69 using a technique performed under moderate hypothermia (Group A) and 38 in deep hypothermia (Group B). All patients who survived from 1978 to 1994 underwent an accurate follow-up. RESULTS: The mortality rate in Group A was 21.7% and 26.3% in Group B. 61.9% patients in Group B presented thrombosis of the false lumen, compared to 30.6% in Group A. Patients with a false perfused lumen underwent re-do surgery in 9.5% compared to 3.5% in those with thrombosed false lumen, and 16.6% showed an aortic dilatation rate of over 5 cm compared to 7.1%. CONCLUSIONS: From an analysis of these data, and in line with the data reported in the literature, although it is impossible lo indicate an ideal surgical strategy for this severe pathology, it is extremely important to achieve thrombosis of the false lumen.     

主动脉腔内修复术治疗75例DeBakey Ⅲ型主动脉夹层

目的 总结主动脉腔内修复术(EVAR)治疗DeBakey Ⅲ型主动脉夹层适应证的选择、临床疗效以及探讨并发症的防治原则.方法 2002年12月至2007年6月采用TALENT带膜支架施行EVAR治疗75例DeBakeyⅢ型主动脉夹层患者,男65例,女10例,平均年龄54.4±12.6(29～83)岁.1例29岁女性病因考虑为埃-当综合征,2例年青男性分别继发于原发性醛固酮增多症和外伤车祸.全部患者均经螺旋CT或磁共振血管造影检查确诊.全身麻醉下经股动脉置入带膜血管内支架,封堵原发破口,重复造影检查.结果 75例患者共置入81枚带膜支架.其中2例因近端破口接近左锁骨下动脉,先行颈总动脉-锁骨下动脉旁路移植术,再置入支架,支架近段覆盖左锁骨下动脉.25例支架置入后出现明显内漏,20例予球囊扩张,6例置入1枚短支架后内漏消失.支架置入技术成功率为100％.1例埃-当综合征女性患者术中出现股动脉、髂外动脉、髂总动脉广泛血管撕裂,失血性休克,经抢救好转恢复.2例术后早期死于夹层破裂.术后随访1～24个月,2例(包括1例埃-当综合征患者)术后半年发生猝死,1例术后1年复查CT发现支架远端出现破口,经外科手术治疗后恢复良好;其余存活者复查螺旋CT示假腔径缩小并见腔内血栓形成,真腔径增大,无瘤体破裂、内漏及支架移位等并发症发生.结论 EVAR治疗DeBakeyⅢ型主动脉夹层具有技术可靠、创伤小、术后恢复快、成功率高等优点,尤其适用于不能耐受传统开胸手术的老年高危患者.而对于年轻的主动脉夹层患者要注意排除埃-当综合征等遗传性疾病,用EVAR治疗埃-当综合征的血管并发症,目前尚未见报道,其手术并发症及疗效有待进一步观察.     

Endovascular treatment of thoracic aortic disease: mid-term follow-up.

OBJECTIVE: The aim of this study was to evaluate the mid-term follow-up in a cohort of patients with acute or chronic descending aortic disease treated by stent-graft repair. BACKGROUND: Since 1999, endovascular stent-graft placement has been reported as an alternative treatment to surgical approach for a variety of thoracic aortic diseases; however, results beyond initial short-term follow-up are not widely available for the broad range of applications. METHODS: From March 2001, 43 consecutive patients with traumatic aortic transection (group A = 16) and complicated type B aortic dissection or aneurysm (group B = 27) underwent stent-graft implantation. All patients underwent computed tomography (CT) scan as preoperative assessment and in 26 a transesophageal echo (TEE) exam was performed. RESULTS: Technically successful stent-graft deployment was achieved in all patients. No patient required surgical conversion and no cases of paraplegia occurred. The overall in-hospital mortality was 9.3%. A residual endoleak (type II) was detected in one group B patient who was managed conservatively. The mean follow-up was 29 +/- 8 months (range 10-48 months). No patient died during late follow-up after hospital discharge. At 12 months, one patient (2.5%) who had stent graft repair of an aortic dissection developed an asymptomatic type I endoleak. Three asymptomatic patients with chronic dissection had a persistent retrograde perfusion of the thoracic false lumen via a distal tear(s) in the dissection septum. CONCLUSION: Our results of stent-graft treatment of complicated and uncomplicated diseases of the descending aorta confirms that this alternative to open repair is a safe, less invasive, and relatively low risk approach. Medium-term follow-up results suggest that it is effective and durable therapy with low associated mortality and morbidity rates.     

腔内隔绝术治疗112例Stanford B型主动脉夹层动脉瘤患者疗效观察

目的评价主动脉夹层腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤的院内及长期临床疗效。方法选择行主动脉腔内隔绝术治疗Stanford B型主动脉夹层患者112例。经股动脉切开置入覆膜支架封堵胸主动脉破裂口,置入后冠状动脉造影检查证实疗效,术后随访平均(39±18)个月。分析其临床特点及疗效。结果手术成功112例,共置入覆膜支架119枚。左锁骨下动脉完全被封闭8例,合并严重狭窄病变的冠心病患者完成PCI 16例,主动脉腔内隔绝术后综合征19例,术后1个月内夹层破裂死亡3例。随访3个月,所有患者内膜破裂口封闭,胸降主动脉和腹主动脉真腔扩大,假腔内血栓形成,支架位置、形态正常。术后明显残余内漏10例,3个月自行封闭。术后6个月,再发升主动脉夹层3例,其中行升主动脉外科手术1例,截瘫1例,胃癌多器官转移死亡1例。术后1年迟发性内漏1例。结论腔内隔绝术治疗Stanford B型主动脉夹层动脉瘤的院内及长期疗效满意。     

Endovascular stent-graft repair of aortic dissection

Between October 2000 and January 2002, 9 consecutive male patients with subacute or chronic aortic dissection underwent stent-graft placement. The indication for surgery was continuous pain or aneurysm development. One patient had a type A dissecting aortic aneurysm with a primary tear in the ascending thoracic aorta; the other 8 had type B dissection. Placement of an endovascular stent-graft was technically successful in 8 patients, and one underwent an open procedure for abdominal aortic fenestration. The entry site was sealed and the false lumen disappeared in 8 cases, and thrombosis of the false lumen was obtained. Rupture of an iliac artery dissecting aneurysm occurred in one patient 2 days after stent-graft placement; abdominal aortic fenestration with prosthetic replacement of the distal abdominal aorta was performed. One patient died of myocardial infarction 3 days after the stent-graft procedure. During a mean follow-up period of 7 months (1-16 months), one patient died of acute myocardial infarction at 11 months. It was concluded on the basis of these short-term results that endovascular repair of aortic dissection is a promising treatment, and abdominal aortic fenestration is a useful adjuvant procedure.     

Case Report of an Endovascular Repair of a Residual Type A Dissection Using a Not CE Not FDA-Approved Najuta Thoracic Stent Graft System

This report describes an endovascular repair of a residual type A dissection using a medical device that is not marked by european conformity (CE) or Food and Drug Administration (FDA).The patient underwent ascending aortic surgery for acute type A dissection. The 2-year angio–computed tomography demonstrated patency of the residual false lumen with evolution into a 6 cm aneurysm, the extension of the dissection from the aortic arch to the aortic bifurcation with thrombosis of the right common iliac artery. There was no CE- or FDA-marked medical device indicated for this case or any other acceptable therapeutic alternative.We used the Najuta thoracic stent graft and successfully handled the pathology in a multiple-phase treatment.Technology is evolving with specific grafts for the ascending and fenestrated grafts for the aortic arch. In this single case the Najuta endograft, in spite of the periprocedural problems, was a valid therapeutic option.     

国产覆膜支架治疗Stanford B型主动脉夹层

目的评价国产主动脉覆膜支架治疗Stanford B型主动脉夹层患者的院内及中期临床疗效。方法应用国产覆膜支架行主动脉腔内隔绝术治疗B型主动脉夹层患者34例,经股动脉置入覆膜支架封堵胸主动脉破裂口,置入Aegis或Hercules国产支架后,造影检查证实疗效。术后平均随访(19±17)个月。结果34例手术均获成功。32例置入1枚支架,2例分别置入主体和短支架各1枚,平均支架直径(33.5±3.5)mm,平均支架长度(96.5±17.6)mm。1例术后2h死于夹层破裂。3例术后存在原发性内漏。2例肾功能不全。出院后随访,2例分别于术后5个月和9个月发生继发性内漏,1例1年时升主动脉再次发现夹层,1例6个月后发生截瘫,2例死亡。结论国产主动脉覆膜支架治疗Stanford B型主动脉夹层患者具有良好的临床疗效。     

Value of echocardiography in patient follow-up after surgically corrected type A aortic dissection.

BACKGROUND: To identify patients (pts) at risk of late complications, follow-up after surgery for type A aortic dissection is essential. We assessed the value of echocardiography to monitor patients after surgery for type A aortic dissection. METHODS: 80 out of 108 pts operated between 1989 and 1999 for type A aortic dissection survived surgery. 62 pts with at least one TEE, CT or MRI examinations during follow-up were included in this study. All pts had transthoracic echocardiography (TTE), 53 transesophageal echocardiography (TEE), 51 had CT, and 39 had MRI. RESULTS: At the first follow-up, 12 of 48 pts with aortic valve sparing surgery presented with aortic insufficiency >I degrees detected using echocardiography. 16 pts evolved a distal aortic aneurysm of over 5 cm, all seen in TEE, CT and MRI. A distal intimal flap was present in 39 pts and could be seen in TEE, CT and MRI in all patients. A new proximal aortic root dissection took place in 5 pts. Progressive aortic pathology led to reoperation in 9 pts. TEE was especially useful in 2 pts to confirm redissection, in 1 pt to rule out redissection assumed by CT, and in 1 with paraprosthetic blood flow after ascending aortic replacement. MRI led to additional information in 1 patient with false aneurysm of the distal anastomosis and 1 with redissection not seen in TEE 6 month before. CT and MRI were superior to TEE in demonstrating aortic arch pathology, whereas TEE was more effective in showing the flow pattern and residual entry sites. CONCLUSIONS: Echocardiography is an effective and cost-saving diagnostic tool to monitor pts after surgery for type A aortic dissection, and should be the method of choice to ascertain aortic pathology initially after surgery. Follow-up intervals and need for additional CT or MRI should be determined afterwards according to specific pathologies.     

Results of video-assisted mitral surgery in a non-selected population

A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.     

Value of transesophageal echocardiography combined with computed tomography for assessing repaired type A aortic dissection.

Thirty-two patients with repaired type A aortic dissection were examined by transthoracic echocardiography (TTE) (n = 32), transesophageal echocardiography (TEE) (n = 30), computed tomography (CT) (n = 29), or a combination of all 3, to assess course and complications as a function of the surgical procedure. The mean follow-up period was 55.7 months (range 3 to 132). Surgery consisted of a replacement of the ascending aorta in 25 patients (group 1) with extension to the transverse aorta in 7 (group 2). The transverse diameter of the aorta, the persistence of the false lumen, thrombus formation and flow dynamics in the false lumen were evaluated by TEE. Ten patients (31%) had a dilation in the initial ascending aorta (sinus of Valsalva aneurysm in 6 patients, and a false aneurysm in the other 4). Three of 4 patients with a proximal pseudoaneurysm underwent operation after TEE and CT evaluation. In the descending thoracic aorta, there was good agreement between TEE and CT scan determinations of transverse vessel diameter. Persistence of flow within the false lumen was significantly more frequent in patients with a dilated aorta (p < 0.05), whereas thrombosis was seen more often and false lumen less often in patients with nondilated aorta. No significant differences in vessel status or outcome were observed between the 2 groups, although this may have been due to the small size of group 2. TEE is thus a well-tolerated method for postoperative follow-up of type A aortic dissection whatever the type of surgery. For the upper ascending aorta, CT provided sufficient data.     

Restoration of the thoracic aorta in Type A dissection with hybrid prosthesis

Following successful repair of Type A dissection, late morbidity and mortality depend on the progression of residual chronic Type B dissection. To avoid the development of late aneurysms of the descending thoracic aorta, a persistent aortic false lumen around the stent-graft can be prevented by remodeling the thoracic aorta. Ten consecutive patients (mean age: 56 years) with acute Type A dissection underwent a "frozen elephant trunk operation" with the E-vita hybrid prosthesis, under deep hypothermic circulatory arrest, between October 2009 and April 2010. The thoracic aorta was restored to its original size. Computed tomography was used to size the aortic diameter. All patients survived and were routinely discharged. Postoperative computed tomography showed no remaining false lumen and no distal organ ischemia in any patient. No new neurological complication was recorded. Two patients suffered postoperative pulmonary arterial embolism; one underwent embolectomy. Restoration of the thoracic aorta is a safe procedure to close the false lumen during the primary operation for acute Type A dissection. However, the diameter of the stent should reflect the overall aortic size, independent of the diameter of the true lumen.     

Comparison of a percutaneous separate stent endograft and a conventional thoracic stent-graft for endovascular repair of type B aortic dissection.

PURPOSE: To compare the immediate and midterm outcomes of aortic dissection repair with a separate stent endograft (SSE) versus a conventionally constructed thoracic stent-graft. METHODS: The records of 35 patients treated for type B aortic dissection from September 1997 to April 2003 were reviewed. Seventeen patients (12 men; mean age 58.8+/-11.6 years) underwent endovascular repair with a separate stent endograft (SSE), a custom-made device with a reduced profile suitable for percutaneous introduction through a 12-F sheath. Eighteen patients (10 men; mean age 56.1+/-12.8 years) underwent treatment with a conventional custom-made stent-graft. RESULTS: Angiographic success was achieved in 13/17 (76.5%) of the SSE-treated patients and 12/18 (66.7%) for the conventional device group (p=0.521). Clinical success (complete obliteration/thrombosis of the false lumen) was achieved in 12/17 (70.6%) and 11/18 (61.1%), respectively (p=0.555). There were 2 cases of stent-graft movement during deployment and 2 access site complications in the conventional stent-graft group, whereas the SSE patients had no complications. Except for 2 conventional stent-graft patients who were lost to follow-up, all patients are alive at a mean 19.5+/-11.6 months for the SSE group and 34.2+/-21.5 months for the conventional stent-graft patients. CONCLUSIONS: The separate stent endograft can be deployed percutaneously without the need for blood pressure reduction, achieving accurate deployment without migration. In this small clinical experience, patients treated with the SSE had no access site complications and demonstrated midterm results comparable to the conventional stent-graft cohort, suggesting the possible usefulness of this device for the treatment of thoracic aortic dissection.     

Aiming at One-Stage Corrective Surgery for Extended Thoracic Aortic Dilatation

Definitive treatment of extended thoracic aortic dilatation is a major surgical challenge. Histopathology of resected thoracic aortic wall may reveal undiagnosed aortitis affecting outcome. We sought to investigate the benefit of thorough histopathology after one-stage corrective surgery for the treatment of extended thoracic aortic dilatation. Five patients underwent one-stage corrective surgery using the hybrid open arch repair by the frozen elephant trunk together with endovascular aortic grafting. A representative sample of the resected aortic arch was procured for histology. T- and B-lymphocytes, plasma cells, macrophages, and immunoglobulin G4 (IgG4) positivity were evaluated by immunohistochemistry. The mean preoperative maximum aortic diameter was 54 mm (range, 41–79 mm). The mean follow-up was 18 months (range, 1–24 months). As confirmed by computed tomography (CT) upon follow-up, complete thrombosis of the false lumen at the level of the frozen elephant trunk was achieved in all patients with dissection. One patient was operated due to atherosclerotic dilatation of the thoracic aorta, and postoperative CT showed successful exclusion of the atherosclerotic dilatation; this 75-year-old man was diagnosed with IgG4-positive aortitis and experienced unexpected blindness after surgery without evidence of emboli or long-term neurological impairment upon repeated brain CT. The hybrid open arch repair by the frozen elephant trunk and simultaneous endovascular repair is a feasible choice for one-stage surgery through sternotomy aiming at definitive treatment of extended thoracic aortic pathology. However, systematic evaluation of inflammation may reveal concealed aortitis affecting postoperative outcome and need for long-term surveillance.