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.     

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.     

Type A dissection following endovascular thoracic aortic stent-graft repair.

PURPOSE: To describe our experience with endovascular stent-graft repairs in the thoracic aorta focusing on the secondary complication of type A dissection. METHODS: Between January 1996 and April 2004, 73 patients were treated for traumatic thoracic aortic rupture (n=15), type B dissection (n=22), or atherosclerotic descending thoracic aortic aneurysms (TAA, n=36). A retrospective review of the records found 5 (6.8%) patients (3 men; median age 64 years, range 43-87) who experienced a type A dissection at a median 20 days (range 2-124) after thoracic stent-graft repair for 3 type B dissections, 1 TAA, and a late type I endoleak that appeared 28 months after initial stent-graft repair of a traumatic dissection. RESULTS: In 3 patients (2 dissections, 1 endoleak), a tear in the aortic wall at the proximal stent-graft was responsible for a retrograde type A dissection. Underlying disease was the cause of the type A dissection in the 2 other patients (1 dissection, 1 TAA) and was unrelated to the stent-grafts. Three patients underwent open surgery at 3, 26, and 124 days after stent-graft placement; 2 procedures were successful, but the third patient died 3 months later due to multiorgan failure. Two type A dissections were untreated: one patient died from cardiac tamponade 14 days after successful stent-graft exclusion of the type I endoleak; the other patient refused further treatment and survived. The procedure-related mortality following acute retrograde type A dissection was 40%. CONCLUSIONS: Endovascular stent-graft repair of the thoracic aorta is associated with lower morbidity and mortality rates than surgical repair, although potentially lethal complications, acute or delayed, may occur.     

Stent-graft treatment of infected aortic and arterial aneurysms.

PURPOSE: To evaluate the feasibility and effectiveness of endovascular stent-graft repair of infected aortic and arterial aneurysms. METHODS: Eight patients (5 men; mean age 56.6 years, range 30-85) with infected saccular aneurysms in the brachiocephalic artery (n=1), proximal descending thoracic aorta (n=1), infrarenal abdominal aorta (n=3), common iliac artery (n=1), and common femoral artery (n=2) were treated with stent-graft placement and intravenous antibiotic treatment for at least 6 weeks followed by case-specific administration of oral suppressive antibiotics. All patients were considered to be in the high-surgical-risk group. RESULTS: Exclusion of the infected aneurysm was successful in all patients. However, 2 patients died within 30 days of uncontrolled sepsis, and 1 patient died at 6 months after rupture of a persistently infected aneurysm (37% mortality rate). Over a follow-up that ranged to 8 years, the 5 survivors showed complete resolution of the infected aneurysms; no stent-graft infection was observed during follow-up. CONCLUSION: The acceptable technical and clinical success of endovascular aneurysm repair makes this a promising treatment for infected aortic and arterial aneurysms. However, it is crucial that the infection is treated adequately prior to stent-graft placement.     

胸主动脉病变腔内修复术中“烟囱”技术的应用

目的:探讨胸主动脉病变腔内支架修复术"烟囱"技术的临床应用。方法:对2009年12月至2012年12月间,44例经"烟囱"技术治疗的胸主动脉病变患者临床资料,适应证及手术实施要点进行回顾性分析。结果:44例患者中,男性35例,女性9例,年龄49～76岁,平均(64.2±12.71)岁;其中胸主动脉瘤12例,Stanford B型胸主动脉夹层32例。44例胸主动脉病变患者因病变近端锚定区不足行左锁骨下动脉支架植入术即"烟囱"技术。所有患者手术均成功,最长随访时间12个月,无不良并发症发生。结论:腔内支架修复术"烟囱"技术扩展了胸主动脉病变腔内修复术的适应证范围,提高了治疗成功率,使更多的胸主动脉病变患者可以受益于这一微创、安全、有效的治疗方法。远期疗效尚需要进一步随访和观察。     

Underlying aortic pathology and clinical health status determine success of endovascular stent-grafting for descending thoracic aortic disease.

Despite advances in medical and surgical treatment, acute as well as chronic diseases of the thoracic aorta are still associated with a high mortality. For the descending thoracic aorta, endovascular stent-graft placement competes with surgical therapy for clinical outcome. From July 1999 till December 2004, a total of 84 patients (64 +/- 14 years) with aortic disease of the descending thoracic aorta were treated. Nine patients had acute (AAD) and 35 chronic aortic dissection (AD), 16 had thoracic aortic aneurysms (TAA), 21 had penetrating aortic ulcer (PAU), and 3 patients had traumatic dissection (trans). Initial clinical status was assessed using the American Society of Anesthesiologists (ASA) classification. Fifty-three patients were in class 2, 16 in class 3, 8 in class 4, and 7 in class 5. Stent-graft placement was performed in the cardiac catheterization laboratory with the patient under general anesthesia. Technical success was obtained in 81/84 patients (96%). Within 30 days, seven patients (8%) died, four of them due to aortic rupture. In 14 patients, additional stent-grafts had to be implanted due to type I endovascular leakage (n = 5) or additional entry site adding up to a total of 107 implanted stent-grafts. During a follow-up period of 21 +/- 18 months, 17 additional patients died (22%). In 10 patients, death was disease- or procedure-related (13%). This long-term mortality depended on the underlying disease and was highest in the group with TAA (45%) followed by AAD (38%) and AD (18%). Patients in ASA class 4 and 5 had a significantly worse outcome. No aortic-related death occurred among patients with PAU or traumatic transsections. Overall, there was only one transient neurological deficit. Endovascular stent-graft placement has acceptable results in the treatment of patients with disease of the descending thoracic aorta. The outcome strongly depends on the underlying aortic pathology and the clinical health status of the patients. Randomized trials are necessary in order to establish the exact value of this new therapeutic option.     

Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms

The stent-graft procedure is becoming an alternative to surgery for treatment of many diseases of the descending thoracic aorta. This study evaluated the role of transesophageal echocardiography (TEE), used in combination with fluoroscopy and angiography, in monitoring the outcome of stent-graft placement. Twenty-two consecutive patients were submitted to stent-graft positioning in the descending aorta for various pathologies (7 patients had type B aortic dissections, 6 had thoracic aneurysms, 2 had thoraco-abdominal aneurysms, and 7 had post-traumatic aortic aneurysms). Before stent-graft deployment, TEE changed the proximal site of stent positioning initially identified by angiography in 33% of patients (5 of 15) with aortic aneurysms because of calcifications or atheromas that could interfere with stent adhesion to the aortic wall and that were not seen on angiography. In 28% of patients (2 of 7) with aortic dissection, TEE showed the guidewire in the false lumen, allowing an immediate repositioning. After stent-graft deployment, color Doppler TEE showed a perigraft leak in 7 patients, whereas angiography detected a perigraft leak in only 2 patients (p = 0.02). In 4 of these patients, further balloon expansions resulted in resolution of the leak. In the remaining 3 patients, additional stent-graft positioning was necessary. Considering the total patient cohort, TEE yielded relevant information, resulting in procedure changes in 59% (13 of 22). In conclusion, TEE provided additional information with respect to angiography in all phases of stent-graft treatment, improving immediate outcome and reducing complications.     

Rapid progression of discrete type A intramural hematoma: prevention of a "procedure-related" complication by intraoperative transesophageal echocardiography.

PURPOSE: To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection. CASE REPORT: A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure. CONCLUSIONS: Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent "procedure-related" complications.     

Thoracic aorta endografts: variations in practice among medical specialists.

BACKGROUND: Endovascular stent-graft placement is emerging as a novel treatment option for patients with diseases of the descending thoracic aorta. However, currently no consensus guidelines exist to direct uniformity in stent-graft procedures as well as for pre- and postprocedural patient management, unlike that for the management of other cardiovascular disorder. Accordingly, the aim of the present survey was to assess variations in thoracic aortic stent-graft practice among different subspecialties in Germany. METHODS: An interdisciplinary questionnaire survey was conducted among 206 departments of vascular surgery, radiology, cardiology, and cardiothoracic surgery in Germany that actively performed aortic stent-graft placement. Data on preoperative procedure planning, logistics, practical/technical issues of stent-graft placement, and postoperative patient management were evaluated using a standardized, self-administered questionnaire comprising 29 items. Responses were tabulated for analysis. RESULTS: Of a total of 206 questionnaires, 184 (89.3%) were returned with 71 (38.5%) centers reporting to have performed thoracic aortic stent-graft placement (total number of procedures 2,267) through 1997 and 2003. The average number of stent-graft procedures per year was 7.4 (25-75% percentile, 2.05-10.75) at participating sites, with 49% of the respondents reporting <5 procedures per year. Treatment of thoracic aortic aneurysms was the predominant indication for stent-graft placement, followed by type B-dissection. As anticipated, marked variability existed among the different medical specialties performing stent-graft procedures with respect to all aspects of the procedures including indication for treatment, choice of preoperative and intraoperative imaging modalities, technical equipment and perioperative management. The only consistent agreement was on the need for lifelong follow-up after stent-graft placement, with CT being the preferred imaging technique (90% of centers). CONCLUSION: The present survey documents an increasing adoption of endovascular stent-graft placement for patients with diseases of the descending thoracic aorta in Germany. Despite this, there is a lack of consensus among the different medical specialties performing stent-graft placement with respect to indications and technical execution of stent-grafting. Our data supports the need for consensus practice guidelines endorsed by medical professional societies for stent-graft procedure to standardize the growing number of thoracic stent graft procedures.     

Stent-grafts in patients with marfan syndrome.

PURPOSE: To explore the safety and feasibility of stent-graft placement in the dissected descending thoracic aorta of patients with Marfan syndrome. METHODS: Six consecutive patients (4 men; mean age 33+/-15 years, range 24-61) with Marfan syndrome were offered endovascular repair for dissection after previous aortic root repair in 5 and solitary type B dissection in 1. RESULTS: Transluminal placement of customized Talent stent-grafts was technically successful in all patients, with no 30-day or 1-year intervention-related mortality. Complete abolition of the dissection and reconstruction of the entire dissected aorta was documented in 2 patients. Over a mean 51+/-22-month follow-up (range 12-74), elective conversion to surgical repair was necessary in 2 patients at 22 and 43 months after stent-graft implantation. In a third patient, conversion to surgery is being considered at 74 months after stent-grafting. One patient died suddenly 12 months after endovascular repair. CONCLUSIONS: Nonsurgical reconstruction of postsurgical distal aortic dissection in patients with Marfan syndrome is feasible and technically successful. Stent-graft placement may either avoid or bridge to repeat surgery of distal aortic dissections after previous aortic root repair. Technical expertise and close postinterventional surveillance appear mandatory and may limit the procedure to centers of competence for aortic diseases.     

Le traitement endovasculaire des lésions urgentes de l’aorte thoracique descendante est-il possible dans un centre ne disposant pas de circulation extracorporelle ?

OBJECTIVE: To determine whether access to extra-corporal circulation (ECC) is necessary to treat acute descending thoracic aorta disease. METHOD: From January 2004 to May 2006, 16 patients underwent endovascular stent-graft repair of the descending thoracic aorta, among them 13 (81%) were treated in an emergency setting (nine men, mean age: 75.4 years, range 30-94 years). The indication was traumatic aortic rupture (n=3, 23%), complicated acute type B dissection (n=4; 31%), symptomatic or ruptured thoracic aortic aneurysm (n=4; 31%), aorto-esophageal fistula (n=1; 7,5%) and aortic intramural haematoma (n=1; 7,5%). Computed tomography showed hemomediastin and/or hemothorax in five patients (38%). Transesophageal echocardiography and angiography were performed in two (15%) and one patients respectively. Cerebrospinal fluid drainage was performed for two patients (15%). RESULTS: Endovascular repair was successfully completed in 92.3% of cases. The 30-day mortality was 7.5% (n=1). There was one case (7.5%) of delayed paraplegia. Follow-up ranged between two and 24 months (mean 10.2), no rupture occurred. Three type I endoleaks were detected and only two were treated. Two none related additional mortalities were observed. None of these patients has needed ECC. CONCLUSION: The unavailability of ECC does not seem to be a compromising factor in the management of thoracic aorta disease, however a good experience in endovascular techniques is required.     

覆膜支架腔内治疗急性胸主动脉综合征

目的 评价覆膜支架腔内治疗急性胸主动脉综合征的有效性和安全性。方法 2001年5月至2005年12月应用覆膜支架治疗57例急性胸主动脉综合征患者,其中急性主动脉B型夹层45例,穿透性粥样硬化性溃疡（PAU）或假性动脉瘤9例,创伤性胸主动脉瘤3例。建立数据库,分析其临床特点、疗效及随访结果。结果 57例患者覆膜支架置入技术成功率100％。5例有近端内漏,1例术中出现升主动脉夹层,未予特殊处理,随访结果良好;1例术后7天出现升主动脉夹层并发心包填塞死亡。5例PAU或主动脉夹层合并冠心病患者,在应用覆膜支架成功完全封闭破口后立即行冠状动脉介入治疗成功。1例出现术后一过性双下肢无力,经静脉滴注山莨菪碱和甘露醇2天后痊愈。1例支架覆盖左锁骨下动脉开口导致左椎动脉缺血,嗜睡2天后自行好转。术后重症监护病房时间1～8（平均3．5）天,术后平均住院10天。术后30天内死亡2例,1例死于升主动脉夹层破裂,1例死于急性肾衰竭。术后30天内死亡率3．5％。术后平均随访（25．3±13．1）（13—55）个月。1例于术后3个月死于大咯血,1例死因不明。1例因近端内漏行二次腔内修复术。5例患者因降主动脉覆膜支架远端再发现破口,行二次腔内修复术。术后截瘫发生率为0,无支架移位、狭窄等并发症。术后住院及随访期内总死亡率为7．0％。与传统手术相比,腔内治疗急性胸主动脉综合征具有创伤小、严重并发症少、住院时间较短的优势。结论 覆膜支架是治疗急性胸主动脉综合征优良且有效的方法,也可用于外科手术高风险患者,近中期随访结果良好,远期结果有待于进一步随访。     

Endovascular stent-graft placement for acute and contained rupture of the descending thoracic aorta.

OBJECTIVES: To identify determinants of postinterventional death after endovascular stent-graft placement for acute rupture of the descending thoracic aorta, an emerging therapeutic modality for this highly life-threatening condition. METHODS: Between July 1999 and November 2004, 17 patients (14 males; mean age, 65+/-16 (25-83) years) underwent stent-graft repair of the descending thoracic aorta for acute rupture from a thoracic aneurysm (TAA, n=6), acute aortic dissection (AAD, n=6), penetrating aortic ulcer (PAU, n=3), or blunt chest trauma (n=2). Immediate, 30-day, 1-year, and 3-year mortality was assessed. Twenty-one clinical and procedural variables were evaluated in a post-hoc analysis regarding their influence on mortality. Of these, four preprocedural factors with the greatest impact were used to construct a rupture score with a scale from 0 (no adverse prognostic factors present) to 4 (all four adverse factors present). RESULTS: Stent-graft placement was technically feasible in all patients. Complete exclusion of the ruptured aortic pathology could be achieved in only 11 (65%) patients, despite implantation of 1.6+/-0.9 stent-grafts per patient, with a median length of 130 mm. There was one procedure-related early complication (bleeding at the access site). One patient died immediately following the procedure because of progressive mediastinal hematoma, although the rupture site was effectively sealed. Overall survival rates were (76.5+/-10.3)% at 30 days and (52.9+/-12.1)% at 1 year and remained at (52.9+/-12.1)% at 3 years. The four most important preprocedural denominators of death were (1) TAA or AAD as the underlying etiology of aortic rupture (P=0.024), (2) maximum aortic diameter>5 cm (P=0.024), (3) presence of mediastinal hematoma (P=0.056), and (4) an estimated lesion length requiring >1 stent-graft to be covered (P=0.009). Furthermore, residual leakage at the conclusion of the procedure (P=0.009), postprocedural need for dialysis (P=0.004), and prolonged ventilation (P=0.043) were significantly associated with postprocedural death. Using a threshold of >or=3, the rupture score constructed on the basis of the four preprocedural denominators of death was found to be well suited to discriminate postprocedural death (1-year survival: (20.0+/-12.7)% in patients with a rupture score>or=3 vs. 100% in patients with a rupture score<3, P=0.001). CONCLUSION: Endovascular stent-graft placement in patients with acute aortic rupture was technically feasible, albeit still associated with high mortality. A simple risk score constructed in retrospect, on the basis of preprocedural prognostic factors, appeared to provide a useful separation of candidates who are likely to benefit from a straightforward endovascular procedure and should be tested prospectively in future studies.     

Feasibility of real-time magnetic resonance-guided stent-graft placement in a swine model of descending aortic dissection.

AIMS: To evaluate the pre-clinical feasibility of real-time magnetic resonance imaging (rtMRI) to guide stent-graft placement for experimental aortic dissection (AD) and to alleviate disadvantages of ionising radiation and nephrotoxic contrast media. Endovascular stent-graft placement for thoracic aortic disease is usually performed under X-ray guidance. The feasibility of rtMRI-guided stent-graft placement is currently not known. METHODS AND RESULTS: By using a catheter-based technique, dissections of the descending thoracic aorta were successfully created in eight domestic pigs. Subsequent implantation of commercially available, nitinol-based stent-grafts was performed entirely under rtMRI guidance. By pre-interventional MRI, the mean minimal true-lumen diameter was 0.9 (0.825-0.975) cm. rtMRI permitted not only the successful and safe device navigation within the true lumen from the iliac arteries to the thoracic aorta, but also the precise positioning and deployment of the stent-graft and safe withdrawal of the delivery catheter in seven of eight pigs. This was achieved without any other complications. After the stent-graft placement, MRI demonstrated complete obliteration of the false lumen, which was confirmed at autopsy. All stent-grafts were well expanded resulting in an increase in the size of the true-lumen diameter to 2.05 (1.925-2.1) cm (P=0.066 vs. baseline). CONCLUSION: In experimental AD, rtMRI-guided endovascular stent-graft placement is feasible and safe and has the potential for mitigating radiation and contrast-related side effects. Additionally, it allows not only pre-interventional diagnosis and detailed anatomic diagnosis, but also permits immediate post-interventional, anatomical, and functional delineation of procedure success that may serve as a baseline for future comparison during follow-up.     

The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones

PURPOSE: To report an alternative to the fenestrated stent-graft for preserving blood flow to side branches in the sealing zones of aortic stent-grafts. TECHNIQUE: A covered stent is deployed parallel to the main aortic stent-graft, protruding somewhat proximally, like a chimney, to preserve flow to a vital side branch covered by the aortic stent-graft. Use of a chimney graft makes it possible to use standard off-the-shelf stent-grafts to instantly treat lesions with inadequate fixation zones, providing an alternative to fenestrated stent-grafts in urgent cases, in aneurysms with challenging neck morphology, and for reconstituting an aortic side branch unintentionally compromised during endovascular repair. This technique has been used successfully in 10 patients, combining chimney grafts in the renal, superior mesenteric, left subclavian, left common carotid, and innominate arteries with stent-grafts in the abdominal (n=6) or thoracic (n=4) aorta. There has been no late chimney graft-related endoleak on imaging studies up to 8 months. CONCLUSION: The use of chimney grafts is feasible in the renal and superior mesenteric arteries, as well as in the supra-aortic branches, to facilitate stent-graft repair of thoracic or abdominal aortic lesions with inadequate fixation zones.     

Endovascular stent-graft placement for complications of acute type B aortic dissection

PURPOSE OF REVIEW: To review the concepts and current clinical results of endovascular stent-graft placement for acute complicated type B aortic dissection. RECENT FINDINGS: The optimal treatment for patients with dissections confined to the descending aorta (Stanford type B-AD) remains a matter of debate. Usually, antihypertensive medical therapy with strict blood pressure lowering below 135/80 mm Hg represents the first choice for patients with uncomplicated type B-AD. Patients with acute complicated type B-AD remain a major therapeutic challenge because surgery of the descending aorta is still associated with high morbidity and mortality. In 1999, endovascular stent-graft placement was introduced as a novel, less invasive treatment option for patients with type B aortic dissection. Current indications include acute (contained) aortic rupture, symptomatic ischemic branch vessel involvement, early aortic expansion, or unrelenting pain. So far, few studies on stent-graft placement in patients with acute complicated aortic dissection have been published reporting an early mortality between 0 and approximately 20%. SUMMARY: To date, there is limited experience with endovascular stent-graft placement for acute complicated type B aortic dissection demonstrating its feasibility and life-saving potential. The endovascular approach can avoid the major trauma of open surgery and should help to get patients out of the acute life-threatening phase of the disease; however, long-term results are needed to assess the durability of this treatment.     

Self-Expanding Endovascular Stent-Graft Implant for Treatment of Descending Aortic Diseases

Abstract Background: Aneurysms and dissections involving the descending thoracic aorta and the distal portion of the aortic arch are difficult to resolve surgically. The introduction of endovascular self-expanding stent-grafts has simplified the operation. Given the complications associated with their peripheral placement, we explored the feasibility of surgical insertion. Methods: Thirteen patients underwent surgical insertion of a stent-graft into the aortic arch via longitudinal aortotomy. Six patients had aneurysms (ruptured in two, and seven dissections (acute in two, ruptured in one). Five patients also underwent associated procedures including aortic valve replacement (one), ascending aorta replacement (two), arch replacement (one), and coronary artery bypass (one). Results: There was one intraoperative death due to ascending aortic dissection, and two hospital deaths due to multiple complications. Of ten patients discharged, one died 3 months postoperatively. The remaining survivors are well, and imaging studies confirmed adequate correction of the aortic disease. Conclusions: The use of this technique simplifies the operation and treatment of particular cases of aortic disease. The observed morbidity and mortality are due to factors independent of the technique.     

Stenting Versus Surgery of the Thoracic Aorta

Aneurysms and dissections of the aorta represent a potentially life-threating situation. Surgical resection and interposition of vascular prostheses (Gortex or Dacron) has long been considered the only treatment option. Although there have been great strides during the past decades in the management of patients with thoracic aortic aneurysms and dissections by new surgical techniques, postoperative morbidity and mortality remain high. The afflicted population is usually of older age and present with a variety of comorbidities and significant impact on postsurgical outcome. Postoperative complications, such as paraplegia and renal insufficiency, contribute to prolonged hospital stays and higher medical costs. Conversely, interventional stent-graft placement may be a promising nonsurgical strategy for the treatment of thoracic aortic aneurysms and dissections. The endovascular stent-graft prostheses is based on the concept of a metal grid covered with vessel graft material. The initiation of the natural healing process by exclusion of an aneurysm or sealing of the proximal entry in dissection induces remodeling of the aortic wall and consolidation of the false lumen. Although the initial results of stent-graft treatment of thoracic aortic aneurysms and dissections are promising, the concept of nonsurgical reconstruction must be subjected to a randomized long-term study.     

Off-pump ascending to descending aorta bypass grafting with descending aneurysm exclusion

We performed an ascending to descending aorta bypass grafting with exclusion of the descending thoracic aortic aneurysm through a median sternotomy incision without cardiopulmonary bypass in a patient with severe chronic obstructive pulmonary disease. The patient was a 75-year-old man who had undergone endovascular stent-graft placement for a descending thoracic aortic aneurysm. The operation became necessary because the aneurysm continued to expand without evidence of endoleak. The postoperative course was uneventful, and without respiratory morbidity.     

Surgical experience with dissecting and nondissecting aneurysms of the ascending aorta

BACKGROUND: Patients who underwent replacement of the ascending aorta with a prosthetic graft for treatment of ascending aortic aneurysm and dissection between January 1992 and December 2000 were studied. METHODS AND RESULTS: Bentall's operation, using a composite aortic valve and prosthetic graft. was performed in 82 patients (70 males). Indications for the procedure included ascending aortic aneurysm (n=54 including 16 patients with Marfan's syndrome): DeBakey Type I or II aortic dissection (n=26 including 10 patients with Marfan's syndrome) and ascending aortic aneurysm with severe aortic stenosis (bicuspid aortic valve disease) (n=2). Bentall's procedure with the inclusion technique was performed in 72 patients and a Cabrol fistula created in 63 patients. In 10 other patients, coronary button transfer was done without a Cabrol fistula. There were 6 early deaths (7.3%) and 8 patients required re-exploration for excessive bleeding. Eighteen patients showed low cardiac output while the wound of 8 became infected. Postoperative arrhythmia and renal failure was seen in 26 and 6 patients, respectively. Four patients had pericardial effusion. Follow-up ranged from 1 month to 8 years. There were 8 late deaths, the causes of which include congestive heart failure (n=3). cerebral hemorrhage (n=3) and sudden cardiac death (n=2). Two patients reported back with dissection of the descending thoracic aorta and await surgery. CONCLUSIONS: Bentall's operation is a safe procedure with an acceptable mortality and morbidity.