Endovascular stent-graft placement for the treatment of acute aortic dissection

Validated Computational Model to Compute Re-apposition Pressures for Treating Type-B Aortic Dissections

The use of endovascular treatment in the thoracic aorta has revolutionized the clinical approach for treating Stanford type B aortic dissection. The endograft procedure is a minimally invasive alternative to traditional surgery for the management of complicated type-B patients. The endograft is first deployed to exclude the proximal entry tear to redirect blood flow toward the true lumen and then a stent graft is used to push the intimal flap against the false lumen (FL) wall such that the aorta is reconstituted by sealing the FL. Although endovascular treatment has reduced the mortality rate in patients compared to those undergoing surgical repair, more than 30% of patients who were initially successfully treated require a new endovascular or surgical intervention in the aortic segments distal to the endograft. One reason for failure of the repair is persistent FL perfusion from distal entry tears. This creates a patent FL channel which can be associated with FL growth. Thus, it is necessary to develop stents that can promote full re-apposition of the flap leading to complete closure of the FL. In the current study, we determine the radial pressures required to re-appose the mid and distal ends of a dissected porcine thoracic aorta using a balloon catheter under static inflation pressure. The same analysis is simulated using finite element analysis (FEA) models by incorporating the hyperelastic properties of porcine aortic tissues. It is shown that the FEA models capture the change in the radial pressures required to re-appose the intimal flap as a function of pressure. The predictions from the simulation models match closely the results from the bench experiments. The use of validated computational models can support development of better stents by calculating the proper radial pressures required for complete re-apposition of the intimal flap.

Collapsed stent graft and severe malperfusion 2 years after endovascular aortic repair

Late collapsing of a stent graft is an extremely rare event, with one existing report describing this phenomenon. A 65-year-old man with a history of endovascular aortic repair for an abdominal aortic aneurysm presented with paraplegia and bilateral lower limb ischaemia. Contrast-enhanced computed tomography showed a dissection of the descending thoracic aorta and a collapsed stent graft, resulting in bilateral lower limb ischaemia. Subsequent axillo-bifemoral bypass resolved his lower extremity functions. The patient required haemodialysis due to acute kidney failure. The follow-up computed tomography scan demonstrated re-expansion of the collapsed stent graft, and his renal function recovered. The case highlights the rare manifestation of late stent collapse and subsequent re-expansion of the collapsed stent and restoration of visceral and lower extremity perfusions following axillo-bifemoral bypass.

Thoracic endovascular aortic repair to treat uncomplicated Stanford type B aortic dissection: The surgeon's dilemma to preventing future complications

Uncomplicated type B aortic dissections have traditionally been managed non-operatively with aggressive blood pressure control. However, the best medical treatment is associated with a considerable risk of disease progression to complicated dissection or aneurysmal degeneration of the affected aortic segment. Thoracic endovascular aortic repair could prevent long-term complications but, because the dissected aorta is vulnerable, it is a high-risk procedure performed in asymptomatic patient. Therefore, endovascular treatment is not a solution for all patients and it should be performed only in the subgroup prone to developing progression of the disease and future complications. A number of studies have suggested several prognostic factors of early or late adverse events such as the patency of the false lumen in the follow-up, an initial aortic diameter ≥4 cm with a patent false lumen, an initial false lumen diameter ≥22 mm in the proximal descending aorta, visceral involvement and recurrent or refractory pain or hypertension. Partial false lumen thrombosis and a proximal entry tear size >10 mm have also been suggested to be associated with an increased rate of aortic growth. We need randomised trials focused on these prognostic factors to reach level 1, class A recommendation for the optimal timing of intervention. Meanwhile, we have to discuss with the patient the pro and cons of this prophylactic, low-invasive but high-risk treatment to personalise medical care and provide the optimal risk-to-benefit ratio.

Aortic remodelling after thoracic endovascular aortic repair for acute and subacute type B aortic dissection

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) in the current era has gained widespread acceptance as the modality of choice for the treatment of complicated aortic dissection (AD). However, reports on clinical results of TEVAR treatment of AD patients are mainly comparisons and analyses of results between patients in the acute and chronic phases, few reports have described the postoperative aortic remodelling of patients with subacute AD after TEVAR. The aim of this study was to investigate aortic remodelling after TEVAR in acute and subacute Stanford type B AD patients.

METHODS

The clinical data of 38 Stanford type B AD patients who received TEVAR treatment in our hospital between July 2012 and December 2017 were retrospectively analysed. The maximum diameters of the aorta, the mean diameters of the true lumens (TLs) and the false lumens (FLs) of the aorta in the dissection range before and after TEVAR treatment were measured. All diameters between different groups or in the same group before and after therapy were compared using nonparametric tests. Count data were examined using the χ² test.

RESULTS

The 38 patients were 31.0-82.0 years old with a mean age of 57.0±11.0 years, including 31 men and 7 women, with 22 patients in the acute phase and 16 patients in the subacute phase. Among the 38 patients included in this study, 7 (18.4%) patients had endoleaks after treatment. No perioperative deaths occurred. Analyses of computed tomography angiography measurement results showed that the baseline maximum diameters of the aorta, TLs and FLs before TEVAR between the acute and subacute groups were not significantly different (P=0.193, P=0.301 and P=0.067, respectively). After TEVAR treatment, the maximum diameters of the aorta and the diameters of the FLs were different between the two groups (P=0.005 and P=0.012), but the diameters of the TLs were not (P=0.069). The diameters of the TLs increased, and those of FLs decreased significantly in the acute and subacute groups after TEVAR (P<0.001, P<0.001, P<0.001 and P=0.007, respectively); the maximum diameters of the aorta decreased significantly in the acute group (P<0.001), but they did not change obviously in the subacute group (P=0.121).

CONCLUSIONS

TEVAR offers satisfactory results for the treatment of type B AD. Acute AD may be associated with better aortic remodelling compared to subacute AD after TEVAR.

Experimental evaluation of homemade distal stent graft fenestration for thoracic endovascular aortic repair of type A dissection by a transapical approach

OBJECTIVE

The use of off-the-shelf stent grafts for thoracic endovascular aortic repair of type A dissections is limited by variability in both the length of the ascending aorta and the location of the proximal intimal tear. This experimental study aimed to assess the feasibility of using a physician-modified thoracic aortic stent graft to treat acute type A dissection by a transapical cardiac approach.

METHODS

The experiments were performed on six cadaveric human heart, ascending aorta, aortic arch, and descending aorta specimens. Fenestration was fashioned in each standard tubular Valiant thoracic stent graft (Valiant Captivia; Medtronic Vascular, Santa Rosa, Calif) to match the anatomy of each specimen. Stent grafts of sufficient length were selected to cover the entire ascending aorta and aortic arch. Stent graft diameters in proximal sealing zones were oversized by 5% to 10%. The length of the fenestration was the distance between the left subclavian artery and the proximal edge of the origin of the brachiocephalic trunk with an additional 10 mm. The diameter of the scallop was that of the brachiocephalic trunk with an additional 5 mm on all sides. The length of the covered portion of the stent graft was the distance between coronary arteries and the proximal edge of the origin of the brachiocephalic trunk. Two lateral radiopaque markers were positioned to delineate the distal and lateral edge of the scallop. Another 3-cm radiopaque marker was sutured onto the sheath to ensure accurate radiologic positioning of the scallop on the outer curve of the aorta. The left ventricle and the thoracic aorta were connected to a benchtop aortic pulsatile flow model. A 5-mm 30-degree lens was introduced through the left subclavian artery to monitor the procedure. The customized stent graft was deployed by a transapical approach under fluoroscopic control.

RESULTS

Median duration of stent graft modification was 21 minutes (range, 17-40 minutes). All attempts to deploy the homemade proximal scalloped stent graft by a transapical approach were successful. Completion angiography demonstrated patency of the supra-aortic trunks and of the coronary arteries in all cases. Macroscopic evaluation did not identify any deterioration of the customized stent graft.

CONCLUSIONS

The use of physician-modified stent grafts is feasible for thoracic endovascular aortic repair of type A dissection by a transapical approach in this model.

Application of thoracic endovascular aortic repair (TEVAR) in treating dwarfism with Stanford B aortic dissection: A case report

RATIONALE

To apply thoracic endovascular aortic repair (TEVAR) to treat dwarfism complicated with Stanford B aortic dissection.

PATIENT CONCERNS

In this report, we presented a 63-year-old male patient of dwarfism complicated with Stanford B aortic dissection successfully treated with TEVAR.

DIAGNOSES

He was diagnosed with dwarfism complicated with Stanford B aortic dissection.

INTERVENTIONS

After conservative treatment, the male patient underwent TEVAR at 1 week after hospitalization. After operation, he presented with numbness and weakness of his bilateral lower extremities, and these symptoms were significantly mitigated after effective treatment. At 1- and 3-week after TEVAR, the aorta status was maintained stable and restored.

OUTCOMES

The patient obtained favorable clinical prognosis and was smoothly discharged. During subsequent follow-up, he remained physically stable.

LESSONS

TEVAR is probably an option for treating dwarfism complicated with Stanford B aortic dissection, which remains to be validated by subsequent studies with larger sample size.

A simple patient-tailored aortic arch tangential angle measuring method to achieve better clinical results for thoracic endovascular repair of type B aortic dissection

Background

To report a simple individual tailored aortic arch tangential angle (θ-AATA) measuring method and its clinical application efficacy in the endovascular treatment of type B aortic dissection (AD).

Methods

From January 2013 to December 2014, acute type B AD patients were prospectively enrolled and treated with endovascular therapy in our center. Among these patients, a specific method was applied to measure θ-AATA based on the axial images of the CT scan. The length of proximal landing zone (PLZ) of each patient was measured at the routinely applied left-anterior oblique (LAO) 45-degree and θ-AATA. Respective treatment strategies based on the length of the PLZ were planned accordingly, and the stent-graft was deployed under the fluoroscopy at θ-AATA. The occurrence of immediate type I endoleak was recorded during the completion angiogram, while the alignment of the proximal marks was determined under fluoroscopy at θ-AATA and at LAO-45-degree as well.

Results

Totally 76 patients with type B AD were prospectively enrolled. The average value of θ-AATA was 58.3±5.2 degrees, which was significantly larger than the routine 45 degrees (P<0.01). The mean landing zone length measured under θ-AATA (18.4±3.9 mm) was longer than that (15.9±3.1 mm) obtained at the routine LAO-45 degrees (P<0.05). Stent-grafts' deployment strategies were substantially changed accordingly. Alignment of the proximal marks was achieved in 72 patients (93.4%) under θ-AATA and only in two patients (2.7%) at LAO-45 degrees (P<0.01). All stent-grafts' implantation was successfully completed. No major type I endoleak was found in the immediate post-deployment angiography.

Conclusions

It is easy to apply this patient-tailored θ-AATA measuring method in clinical practice. This more precise measurement is benefit for more reasonable treatment strategy planning, more precise deployment, and therefore a better outcome.

Hybrid Reconstruction of the Aortic Arch Using a Double-Branched Stent-Graft in a Canine Model

Purpose: To report the results of a hybrid approach to aortic arch repair using an innovative unibody double-branched stent graft in a canine model.Materials and methods: The stent-graft system consists of two parts: the main body and two branches for reconstruction of the supra-arch branches. There is a 2-cm-long suturing portion at the proximal end of the main body. Twenty adult German sheep dogs underwent a hybrid surgical treatment to place the stent-grafts into the proximal descending aorta and the supra-arch branches. Outcomes were assessed by operative mortality, complications, imaging studies, and histomorphometric analyses.Results: Placement of the stent-graft was performed successfully in all dogs without complications. One dog died of respiratory failure due to early extubation. The other dogs survived to 6 months without complications, at which time they were sacrificed. The mean cardiopulmonary bypass time was 80.3 ± 7.3 mins and hypothermic circulatory arrest time was 10.7 ± 1.9 min. The average blood loss was 373.5 mL. At 6 months, postoperative aortic imaging indicated that the main body and branches of the stent-graft were fully open and in satisfactory position. No migration, deformation, or endovascular leakage was observed. Histomorphometric results showed normal arrangement of medial and adventitial elastic fibers, moderately proliferated intima, with or without neo-microvessels, and microscopic morphological changes in internal elastic lamina.Conclusions: These results demonstrate that it is possible and safe to reconstruct the aortic arch with the novel open-branched stent-graft placement.

Geometric Deformations of the Thoracic Aorta and Supra-Aortic Arch Branch Vessels Following Thoracic Endovascular Aortic Repair

Objective:

To utilize 3-D modeling techniques to better characterize geometric deformations of the supra-aortic arch branch vessels and descending thoracic aorta after thoracic endovascular aortic repair.

Methods:

Eighteen patients underwent endovascular repair of either type B aortic dissection (n = 10) or thoracic aortic aneurysm (n = 8). Computed tomography angiography was obtained pre- and postprocedure, and 3-D geometric models of the aorta and supra-aortic branch vessels were constructed. Branch angle of the supra-aortic branch vessels and curvature metrics of the ascending aorta, aortic arch, and stented thoracic aortic lumen were calculated both at pre- and postintervention.

Results:

The left common carotid artery branch angle was lower than the left subclavian artery angles preintervention ( P < .005) and lower than both the left subclavian and brachiocephalic branch angles postintervention ( P < .05). From pre- to postoperative, no significant change in branch angle was found in any of the great vessels. Maximum curvature change of the stented lumen from pre- to postprocedure was greater than those of the ascending aorta and aortic arch ( P < .05).

Conclusion:

Thoracic endovascular aortic repair results in relative straightening of the stented aortic region and also accentuates the native curvature of the ascending aorta when the endograft has a more proximal landing zone. Supra-aortic branch vessel angulation remains relatively static when proximal landing zones are distal to the left common carotid artery.

Protocol for the ROBUST (Registry Of type B aortic dissection with the Utility of STent graft) study: an ambispective, multicentre, open cohort study

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) is widely used for type B aortic dissection, although with satisfactory outcome in a limited proportion of patients. To better inform patient prognostication, the Registry Of type B aortic dissection with the Utility of STent graft (ROBUST) study aims to identify imaging-based predictors of post-TEVAR adverse outcomes up to 10-year follow-up.

METHODS AND ANALYSIS

ROBUST is designed as an ambispective, multicentre, open cohort study. All patients undergoing TEVAR from 1 January 2008 to 1 July 2027 at participating centres will be invited to join the study. It is conservatively estimated that over 2000 patients will join the study. Data on demographics, disease history, procedural details, imaging features and follow-up will be collected after discharge. Cox proportional-hazards analysis will be used to identify independent predictors of primary outcomes. Stratification analysis will be performed to identify which subgroup of patients would benefit the most from TEVAR.

ETHICS AND DISSEMINATION

The protocol has been approved by the ethics committee of the coordinating centre. Findings will be disseminated in professional peer-reviewed journals to promote understanding of the rehabilitation process.

TRIAL REGISTRATION NUMBER

ChiCTR-POC-17011726; Pre-results.

Retrograde Ascending Dissection After Thoracic Endovascular Aortic Repair Combined With the Chimney Technique and Successful Open Repair Using the Frozen Elephant Trunk Technique

The chimney technique can be combined with thoracic endovascular aortic repair (TEVAR) to both obtain an appropriate landing zone and maintain blood flow of the arch vessels. However, surgical repair becomes more complicated if retrograde type A aortic dissection occurs after TEVAR with the chimney technique. We herein report a case involving a 73-year-old woman who developed a retrograde ascending dissection 3 months after TEVAR for acute type B aortic dissection. To ensure an adequate proximal sealing distance, the proximal edge of the stent graft was located at the zone 2 level and an additional bare stent was placed at the left subclavian artery (the chimney technique) at the time of TEVAR. Enhanced computed tomography revealed an aortic dissection involving the ascending aorta and aortic arch. Surgical aortic repair using the frozen elephant trunk technique was urgently performed. The patient survived without stroke, paraplegia, renal failure, or other major complications. Retrograde ascending dissection can occur after TEVAR combined with the chimney technique. The frozen elephant trunk technique is useful for surgical repair in such complicated cases.

Incidence and risk factors for retrograde type A dissection and stent graft-induced new entry after thoracic endovascular aortic repair

OBJECTIVE

Stent graft (SG)-induced new entry (SINE) and retrograde type A dissection (RTAD) are serious device-related complications occurring after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) and may lead to endograft-related complications including retrograde dissection and death. The purpose of this study was to investigate the incidence and risk factors for the development of RTAD and SINE after TEVAR for TBAD and to identify the complications associated with this.

METHODS

From April 2005 to October 2013, there were 997 patients who underwent TEVAR for TBAD; 852 were followed up (0-6 years; mean, 2.6 years), and 59 SINEs developed in 53 patients. The oversizing ratio and incidence of RTAD and SINE were compared between proximal bare stent (PBS) and non-PBS groups and RTAD and SINE and non-RTAD and non-SINE groups. The baseline characteristics and SG configurational factors potentially affecting both RTAD and distal SINE were analyzed.

RESULTS

There was no significant difference between PBS and non-PBS groups in the incidence of RTAD. A greater oversizing ratio was related to a higher distal SINE rate. SINE was seen more frequently in smokers and in patients with hypertension, Marfan syndrome, and TEVAR in the chronic phase and less frequently in complicated dissection cases. Device-related factors for SINE were SG with a connecting bar and SG length <165 mm. The SG length <165 mm increased the overall proximal and distal SINE incidence in multivariate analysis.

CONCLUSIONS

The presence of a PBS is not associated with a higher RTAD rate, whereas the use of an SG with a connecting bar and length <165 mm increases the risk of RTAD and SINE after TEVAR.

Comparison of thoracic endovascular aortic repair, open surgery and best medical treatment for type B aortic dissection: A meta-analysis

BACKGROUND

Treatments of type B aortic dissection (TBAD) include thoracic endovascular aortic repair (TEVAR), best medical treatment (BMT) and open surgery (OS). This meta-analysis was to compare these three strategies to evaluate which provides best outcomes.

METHODS

We searched clinical trials that compared treatment strategies for TBAD. The outcomes measures were 30-day/in-hospital mortality, long-term survival rate, paraplegia or paraparesis, renal failure, rupture, stroke, late re-intervention, late rupture and aneurismal dilatation/expansion.

RESULTS

Sixteen control trials covering 10,307 patients were evaluated. Meta-analysis showed that TEVAR provides preferable long-term survival rate (HR=0.71; 95% CI: 0.52-0.95), lower rate of late re-intervention (OR=0.33; 95% CI: 0.13-0.85), late rupture (OR=0.21; 95% CI: 0.10-0.43) and late aneurismal dilatation/expansion (OR=0.15; 95% CI: 0.04-0.63) compared with BMT. However, TEVAR seemed to be associated with higher stroke rate than BMT (OR=1.65; 95% CI: 1.21-2.23). 30-day/in-hospital mortality appeared to be lower in TEVAR (OR=0.49; 95% CI: 0.29-0.81) when compared with OS. In addition, OS induced higher 30-day/in-hospital mortality compared with BMT (OR=3.95, 95% CI: 1.56-10.02).

CONCLUSIONS

Our study shows that TEVAR may be favorable in long-term outcomes and effectively provide morphologic advantages compared to BMT. However, there is a need for prophylactic measures against stroke in TEVAR. OS seems to be inferior to TEVAR both in short-term and long-term outcomes. Further studies especially randomized clinical trials are needed to comprehensively compare the efficacy between TEVAR and BMT.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults

Objectives

Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients.

Methods

We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n  = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n  = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery.

Results

The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P  = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P  = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P  = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P  = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P  = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P  = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P  = 0.12).

Conclusions

Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Circulating microRNAs: a novel potential biomarker for diagnosing acute aortic dissection

Acute aortic dissection (AAD) is a catastrophic emergency with high mortality and misdiagnosis rate. We aimed to determine whether circulating microRNAs allow to distinguish AAD from healthy controls and chest pain patients without AAD (CP). Plasma microRNAs expression were determined in 103 participants, including 37 AAD patients, 26 chronic aortic dissection patients, 17 healthy volunteers, 23 patients without AAD. We selected 16 microRNAs from microarray screening as candidates for further testing via qRT-PCR. The results showed that plasma miR-15a in patients with AAD (n = 37) had significantly higher expression levels than it from control group (n = 40; P = 0.008). By receiver operating characteristic curve analysis, the sensitivity was 75.7%; the specificity was 82.5%; and the AUC was 0.761 for detection of AAD. Furthermore, 37 patients with AAD had significantly higher plasma expression levels of let-7b, miR-15a, miR-23a and hcmv-miR-US33-5p compared with 14 CP patients of 40 controls (P = 0.000, 0.000, 0.026 and 0.011, respectively). The corresponding sensitivity were 79.4%, 75.7%, 91.9% and 73.5%, respectively; the specificity were 92.9%, 100%, 85.7% and 85.7%, respectively; and the AUCs of these microRNAs were 0.887, 0.855, 0.925 and 0.815, respectively. These data indicate that plasma miR-15a and miR-23a have promising clinical value in diagnosing AAD.

How should we manage type B aortic dissections?

Dissection of the descending aorta is a serious and potentially lethal event. Treatment options consist of medical therapy, open surgical replacement of the affected aorta and thoracic endovascular repair. In acute cases, medical treatment is started initially. When complicated, endovascular repair is generally considered as first choice treatment, except for connective tissue disorders where open surgery remains the standard. In stable, uncomplicated patients with risk factors for future aortic growth pre-emptive endovascular repair should be considered in the sub-acute phase of the dissection. The treatment strategy in chronic dissections is somewhat debated. Long-term results and aortic remodeling of endovascular repair are disappointing and open surgery remains the standard.

A Novel Reverse Branch Technique for Reconstruction of a Renal Artery Perfused by the False Lumen After Thoracic Endovascular Aortic Repair

PURPOSE

To describe an innovative endovascular technique that successfully reconstructs a renal artery completely perfused by the false lumen after thoracic endovascular aortic repair (TEVAR).

CASE REPORT

A 65-year-old patient diagnosed with acute Stanford type B aortic dissection underwent successful TEVAR 4 years ago. Regular follow-up found that the thoracic aorta was well repaired, but the false lumen in the abdominal aorta had enlarged year by year. The left renal artery was supplied entirely by the false lumen, which caused kidney hypoperfusion. The abdominal aorta was successfully remodeled using endovascular aneurysm repair with reconstruction of the left renal artery using Viabahn stent-grafts inserted through the patent false lumen. At 6 months, computed tomography showed false lumen thrombosis and patent Viabahn stent-grafts in the false lumen.

CONCLUSION

The false lumen reverse branch technique was feasible in our case, which provides a new idea for dealing with distal dissection involving the renovisceral arteries after TEVAR.

Restrictive bare stent prevents distal stent graft-induced new entry in endovascular repair of type B aortic dissection

OBJECTIVE

Distal stent graft-induced new entry (SINE) can occur after thoracic endovascular aortic repair (TEVAR) of type B aortic dissection. This study investigated the mechanism of distal SINE and its prevention using a restrictive bare stent (RBS) technique.

METHODS

From January 2013 to December 2014, 68 consecutive type B aortic dissection patients received endovascular repair at our center. The RBS technique was used with distal oversizing (between the diameter of the thoracic stent graft and the descending aorta true lumen diameter at the level of the intended distal edge of the thoracic stent graft) >20%.

RESULTS

Twenty-three patients received TEVAR with a single thoracic stent graft (TEVAR group, n = 23); the rest received TEVAR combined with the RBS technique (TEVAR + RBS group, n = 45). Four distal SINEs occurred in the TEVAR group. Distal oversizing (69.7% ± 35.5% vs 31.2% ± 24.5%; P = .005) and expansion mismatch ratio (132.2% ± 16.9% vs 106.5% ± 11.6%; P < .05) were significantly higher in the SINE patients. Compared with standard TEVAR, TEVAR + RBS was associated with significantly lower distal oversizing (TEVAR vs TEVAR + RBS group, 59.8% ± 24.7% vs 16.7% ± 7.6%; P < .05), lower expansion mismatch ratio (113.8% ± 14.6% vs 103.8% ± 11.7%; P = .012), and lower distal SINE rate (4/23 [17.4%] vs 0/45 [0%]; P = .011). Compared with the TEVAR group, the false lumen was reduced significantly at the level of the RBS distal edge (P = .029).

CONCLUSIONS

Excessive distal oversizing and distal expansion mismatch ratio may contribute to the occurrence of distal SINE. The RBS technique reduced the incidence of distal SINE. Based on our midterm and long-term observations, implantation of an RBS may improve aortic remodeling.

Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection

Objective

This study aimed to describe treatment of serious complications after primary thoracic endovascular aortic repair (TEVAR) in type B aortic dissection.

Methods

From June 2008 to March 2016, serious complications occurred in 58 patients without Marfan syndrome who received TEVAR for type B aortic dissection.

Results

Complications included endoleak, distal true lumen collapse, retrograde dissection, stroke, stent–graft (SG) migration and mistaken deployment, lower limb ischaemia, and SG fracture. Treatment included endovascular repair, surgical procedures, or conservative medication. Forty-six patients recovered from complications. Twelve patients were not cured. The median follow-up time was 29.5 months (2–61 months). The overall 30-day mortality rate was 1.7% (1/58) and the total mortality rate following secondary complications was 8.6% (5/58). The causes of death were stroke and aortic rupture.

Conclusion

Some treatments need to be performed after TEVAR because of severe complications. A reduction in these complications can be achieved by optimal evaluation of patients, selection of SGs, and specialized endovascular manipulation.

A History of Thoracic Aortic Surgery

Ancient historical texts describe the presence of aortic pathology conditions, although the surgical treatment of thoracic aortic disease remained insurmountable until the 19th century. Surgical treatment of thoracic aortic disease then progressed along with advances in surgical technique, conduit production, cardiopulmonary bypass, and endovascular technology. Despite radical advances in aortic surgery, principles established by surgical pioneers of the 19th century hold firm to this day.

Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection

Thoracic endovascular aortic repair (TEVAR) in the current era has been chosen as a dominant and minimally invasive treatment for complicated aorta dissection. This study aimed to assess safety and feasibility of TEVAR in acute and chronic type B aortic dissection.Between January 2011 and December 2013, 85 patients with complicated type B aortic dissection undergoing TEVAR were divided into acute aortic dissection (AAD) (n = 60) group and chronic aortic dissection (CAD) group (n = 25). Computed tomography was used to evaluate postoperative changes in maximal aortic diameter and true and false lumen diameters at 3 levels during a mean follow-up period of 26.4 ± 15.6 months.The technical success rate was 100%. In-hospital and 30-day rates of death were 3.3% in acute group and 0 in chronic group. Postdischarge rates of type I leak, type II leak, and retrograde type A dissection were 6.7%, 5.2%, and 3.4% (acute) and 0%, 4.0%, and 4.0% (chronic), respectively. The maximal aorta diameter remained stable in all the 3 levels in both acute and chronic group. The cumulative freedom from all-cause mortality at 3 years was similar in acute and chronic groups (89.5% vs 95.5%, P = .308). The cumulative freedom from aortic-related mortality was also not significantly different in the acute and chronic groups (92.8% vs 95.2%, P = .531). In the thoracic aorta, TEVAR treatment resulted in a significant increase in true lumen (TL) diameter and decrease in false lumen (FL). However, in the abdominal aorta, TEVAR did not lead to significant change in TL and FL diameters. The rates of complete thrombosis thoracic false lumens were better than that in the abdominal false lumen.TEVAR was a safe and effect therapy for complicated acute and chronic type B dissection with low early and mid-term mortality and morbidity.

Treatment of patients with aortic disease during pregnancy and after delivery

Objective

This study aimed to review treatment of patients with aortic disease during pregnancy and after delivery in Beijing Anzhen Hospital.

Methods

A retrospective study was conducted using data from 12 patients with aortic disease during pregnancy and after delivery in our institution from May 2005 to December 2014. Patients were provided different treatments based on the type of aortic disease and clinical characteristics.

Results

The mean age was 29.83 ± 4.17 years, mean height was 171.7 ± 8.22 cm, mean weight was 68.55 ± 10.62 kg, and mean body mass index was 23.18 ± 2.93 kg/m². Two patients with Stanford type A aortic dissection died of renal failure after surgery. All of the other patients were discharged. Six foetuses survived. One patient continued her pregnancy after an aortic operation. The gestational age of the remaining five patients was less than 28 weeks at the time of the operation and all foetuses of these five patients died.

Conclusions

A suitable treatment strategy for aortic disease during pregnancy and after delivery should be chosen based on an individual’s comprehensive clinical condition. Foetal management should be chosen based on gestational age and severity of aortic disease.

Endovascular Repair in Acute Complicated Type B Aortic Dissection: 3-Year Results from the Valiant US Investigational Device Exemption Study

Acute complicated type B aortic dissection (TBAD) is a potentially catastrophic, life-threatening condition. If left untreated, there is a high risk of aortic rupture, irreversible organ or limb damage, or death. Several risk factors have been associated with acute complicated TBAD, including age and refractory hypertension. In the acute phase, even uncomplicated patients are more prone to develop complications if hypertension and pain are left medically untreated. Innovations in stent graft technologies have incrementally improved outcomes since their first use for this condition in 1999, though improvement is needed in mitigating periprocedural complications, adverse events, and mortality. In the past decade, endovascular repair has become the preferred treatment because of its superior outcomes to open repair and medical therapy. The Valiant Captivia Thoracic Stent Graft System is a third-generation endovascular stent graft with advancements in minimally invasive delivery, conformability to the anatomy, and the minimization of adverse sequelae. Herein, this stent graft is briefly reviewed and its 3-year outcomes are presented. Freedom from all-cause and dissection-related mortality was 79.1% and 90.0%, respectively. The Valiant Captivia Stent Graft represents a safe, effective intervention for acute complicated TBAD. Continued surveillance is needed to verify its longer-term durability.

Type B Aortic Dissections: Current Guidelines for Treatment

Stanford type B aortic dissections (TBADs) involve the descending aorta and can present with complications, including malperfusion syndrome or aortic rupture, which are associated with significant morbidity and mortality if left untreated. Clinical diagnosis is straightforward, typically confirmed using CT angiography. Treatment begins with immediate anti-impulse medical therapy. Acute TBAD with complications should be repaired with emergent thoracic endovascular aortic repair (TEVAR). Uncomplicated TBAD with high-risk features should undergo TEVAR in the subacute phase. Open surgical repair is seldom required and reserved only for select cases. It is critical to follow these patients clinically and radiographically in the outpatient setting.

An unusual case of aortic rupture after deployment of a bare stent in the treatment of aortic dissection in a patient with giant-cell arteritis

Giant-cell arteritis is associated with a higher risk of aortic aneurysm and aortic dissection formation. We present a women with aortic dissection type B treated with a stent graft and bare-metal stent implantation. After the stent deployment we noticed aortic rupture, which was successfully treated with implantation of an additional stent graft. This report highlights the difficulty of endovascular therapy in patients with giant-cell arteritis. We have to bear in mind that chronic inflammation of the aorta leads to a more fragile aortic wall than normal. We recommend the use of a stent graft over a bare-metal stent and gentle use of a balloon catheter.

Safety and Efficacy of an Aortic Arch Stent Graft with Window-Shaped Fenestration for Supra-Aortic Arch Vessels: an Experimental Study in Swine

Background and Objectives

Thoracic endovascular aortic repair exhibits limitations in cases where the aortic pathology involves the aortic arch. We had already developed a fenestrated aortic stent graft (FASG) with a preloaded catheter for aortic pathology involving the aortic arch. FASG was suitable for elective cases.

Materials and Methods

An aortic arch stent graft with a window-shaped fenestration (FASG-W) for supra-aortic arch vessels is suitable for emergent cases. This study aims to test a FASG-W for supra-aortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASG-Ws with 1 preloaded catheter were advanced through the iliac artery in 6 swine. The presence of endoleak and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for FASG-W was 27.15±4.02 minutes. The mean time for the selection of the right carotid artery was 5.72±0.72 minutes.

Results

Major adverse events were not observed in any of the 6 pigs who survived for 8 weeks. For the FASG-W, no endoleaks, no disconnection, and no occlusion of the stent grafts were observed in the CT findings or the postmortem gross findings.

Conclusion

The procedure with the FASG-W was able to be performed safely in a relatively short procedure time and involved an easy technique. The FASG-W was found to be safe and convenient for use in this preclinical study of swine.

Diagnostic implication of fibrin degradation products and D-dimer in aortic dissection

Fibrin degradation products (FDP) and D-dimer have been considered to be involved in many vascular diseases. In this study we aimed to explore the diagnostic implication of FDP and D-dimer in aortic dissection patients. 202 aortic dissection patients were collected as the case group, 150 patients with other cardiovascular diseases, including myocardial infarction (MI, n = 45), pulmonary infarction (n = 51) and abdominal aortic aneurysm (n = 54) were collected as non-dissection group, and 27 healthy people were in the blank control group. The FDP and D-dimer levels were detected with immune nephelometry. Logist regression analysis was performed to evaluate the influence of FDP and D-dimer for the aortic dissection patients. ROC curve was used to determine the diagnostic value of FDP and D-dimer. The FDP and D-dimer levels were significantly higher in aortic dissection patients than in non-dissection patients and the healthy controls. FDP and D-dimer were both the risk factors for patients with aortic dissection. From the ROC analysis, diagnostic value of FDP and D-dimer were not high to distinguish aortic dissection patients from the non-dissection patients. However FDP and D-dimer could be valuable diagnostic marker to differentiate aortic dissection patients and healthy controls with both AUC 0.863.

Thoracoabdominal aortic replacement for Crawford extent II aneurysm after thoracic endovascular aortic repair

BACKGROUND

The surgical treatment of Crawford extent II aneurysms after thoracic endovascular aortic repair (TEVAR) remains challenging, because of the need to remove the failed endograft and the complexity of the aortic reconstruction. We retrospectively reviewed our experience with surgical management of Crawford extent II aneurysms after TEVAR using thoracoabdominal aortic replacement (TAAR).

METHODS

Eleven patients (10 males, 1 female) with Crawford extent II aneurysm after TEVAR were treated with TAAR between August 2012 and May 2015. The indications included: diameter >5.0 cm; persistent pain; size increase >0.5 cm/year; and no suitable landing zone for re-TEVAR. Five patients underwent surgery under deep hypothermic cardiac arrest, two under mild hypothermic cardiopulmonary bypass, and four under direct aortic cross-clamping under normothermia. Two patients had Marfan syndrome.

RESULTS

There were no in-hospital deaths. Continuous renal replacement therapy was required in three patients. One patient needed re-intubation, and two patients had prolonged intubation (>72 h). One patient sustained paraplegia after surgery but recovered during follow-up. Cerebrospinal fluid drainage were used in four patients (3 immediately in the operation room, and 1 in the intensive care unit when the patient suffered paraplegia). One patient died during follow-up.

CONCLUSIONS

TAAR represents a feasible option for the treatment of Crawford extent II aneurysms after TEVAR, with acceptable surgical risks and favorable results.

Heparin and rosuvastatin calcium-loaded poly(l-lactide-co-caprolactone) nanofiber-covered stent-grafts for aneurysm treatment

Heparin and rosuvastatin calcium cause P(LLA-CL) nanofibers to exhibit good cell viability and anticoagulation ability.

Stent-Graft Placement in Atherosclerotic Descending Thoracic Aortic Aneurysms: Midterm Results

Purpose:

To determine midterm durability and need for reinterventions after stent-graft placement in atherosclerotic descending thoracic aortic aneurysms.

Methods:

Fifty-four patients (38 men; mean age 68 years, range 33–87) underwent stent-graft repair of chronic atherosclerotic aneurysms of the descending thoracic aorta between November 1996 and December 2002. Acute aortic syndromes (type B aortic dissections, perforating ulcers, and traumatic dissections) were excluded from analysis. Two types of commercially available stent-grafts were used (Talent and Excluder).

Results:

The primary technical success rate was 94.4%. In-hospital mortality was 3.7% (2/54). No adverse neurological events were encountered. Of 3 (5.6%) early type I endoleaks, 2 (3.7%) required reintervention; the other type I endoleak closed spontaneously. Mean follow-up was 38 months (range 1–72) in the 52 surviving patients. Four (7.7%) type I, 7 (13.5%) type II, and 4 (7.7%) type III endoleaks were seen. Three 3 patients had additional treatment for endoleaks (proximal stenting [type Ia], open thoracoabdominal repair [type Ib], and embolization [type II]). Two of the 3 reinterventions were performed in the first year of follow-up. One additional patient with a type Ia endoleak not suitable for reintervention is under close observation. There were no differences in the number of endoleaks between the 2 types of stent-grafts. Three-year event-free survival was 63%.

Conclusions:

Midterm durability of endovascular stent-graft placement in atherosclerotic descending aortic aneurysms seems promising, as the rate of endoleaks requiring reintervention is acceptably low. In our series, endoleak formation occurred during the first year after stent-graft placement, so close follow-up of patients after aortic aneurysm repair is crucial. Further studies are warranted to evaluate long-term durability of this new treatment modality.

A Decade of Thoracic Endografting: Planning the Next 10 Years…

Endovascular repair has emerged as a very important treatment modality in the management of a host of serious and relatively frequent thoracic aortic diseases. This minimally invasive approach is certain to revolutionize the entire field of thoracic aortic surgery in the near future. The technologies, however, can still be considered as a “work in progress.” Future refinements, which should be available within the next 1 to 2 years, will address some of the most important needs as yet unmet today: lower profile (<22 F) delivery systems, greater device flexibility, no longitudinal metal bars, and precise deliverability and deployment characteristics that will be conducive to optimal success and safety, especially in the region of the aortic arch.

Serial CT Volume and Thrombus Length Measurements after Endovascular Repair of Stanford Type B Aortic Dissection

Purpose:

To evaluate the outcome of stent-graft placement in Stanford type B aortic dissection using contrast-enhanced spiral computed tomographic (CT) measurements of true and false lumen volumes and thrombus length.

Methods:

Among 18 consecutive patients (13 men; mean age 60 years, range 44–79) who underwent endovascular repair of Stanford type B dissection, 12 completed at least a 12-month follow-up, which included CT measurements of true and false lumen volumes and thrombus lengths prior to discharge and at 6 and 12 months postimplantation. Volumes were assessed in 3 different aortic segments (A1, A2, A3) extending from the proximal attachment site of the prosthesis to the aortic bifurcation. In addition, thrombus length was measured to evaluate the influence of clot formation on outcome of the false lumen volume.

Results:

Mean follow-up was 27 months (range 12–60). Within 12 months, mean true lumen volumes showed statistically significant increases in the A1 (p<0.001) and A2 (p=0.003) segments; false lumen volumes showed a significant decrease in the A1 segment (p=0.002) but an insignificant increase in the A2 segment. No substantial volume changes were observed in the A3 segment. Extension of clot formation in the false lumen varied among patients and over time. Length of stent-grafts, percentage of stented dissection length, or visceral arteries originating from the false lumen did not significantly influence thrombus development, nor did these parameters or thrombus formation distal to the prosthesis have a relationship to false lumen volumes.

Conclusions:

Volumetric analysis after endovascular repair of Stanford type B dissection shows optimal technical outcome in the stented segment, whereas the false lumen in the segment immediately adjacent to the stent-graft seems to be a vulnerable area. Extension of clot formation beyond the endograft seems to be no reliable predictor of outcome.

Endografting of the Aortic Arch

In recent years, endovascular repair with stent-grafts has made great advances as a minimally invasive alternative to conventional open surgery in the treatment of aortic aneurysm and dissection. Although many commercial endograft systems are now used worldwide for the treatment of these pathologies in the abdominal aorta, only a few dedicated stent-grafts have been developed for use in the thoracic aorta. However, these second-generation commercial endografts have almost identical specifications and performance profiles in terms of structure, function, and delivery mechanism as stent-graft systems employed in the abdominal aorta. Thus, endografts have been used in the thoracic aorta with little consideration to the morphological and hemodynamic characteristics specific to the aortic arch and the deployment techniques needed to navigate this curved region of the thoracic aorta. This review will survey the literature on aortic arch stent-graft repair and identify key elements critical to the successful design of an endograft to treat lesions in the aortic arch.

Management of type A dissection with malperfusion

Malperfusion is a common lethal complication of acute aortic dissection following rupture, for which the optimal management strategy has yet to be clearly established. The objective of this study was to reassess the management of acute type A aortic dissection (Type A-AAD) with malperfusion. We retrospectively analyzed the outcomes of all patients with Type A-AAD with malperfusion at the University of Michigan and compared the results from patients that directly underwent open surgical repair versus those who had percutaneous reperfusion prior to open surgical repair. Based on the results, we developed a patient care protocol for the treatment of all patients with acute type A dissection. We later re-analyzed the long-term outcomes for patients using the protocol. The present study demonstrated that, although the outcomes for patients with acute type A aortic dissection with malperfusion syndrome treated with initial percutaneous reperfusion and delayed open surgical intervention are not as good as the results for patients with uncomplicated Type A-AAD that undergo immediate surgical repair, their outcomes continue the long-term outcomes of the former group are superior. To outdo patients with acute type A aortic dissection with malperfusion syndrome treated with immediate open surgical intervention. In conclusion, at the University of Michigan we continue to use our patient care protocol to treat patients with Type A-AAD.

Custom-made Stent-Grafts for Aortic Aneurysm Repair Using Gianturco Z Stents and Woven Polyester: Healing in an Animal Model

The purpose of this study was to evaluate the healing at 6 months of aortic stent-grafts custom-made by using Z stents and woven polyester in an animal model. Stent-grafts were built by a published method using autoexpandable stainless steel stents continuously compiled with polyester sutures and covered with a woven polyester membrane. Fourteen stent-grafts of 3 different designs were deployed under fluoroscopic control into the thoracic and the abdominal aorta of 7 adult sheep. At 6 months, all the implants of the sheep that survived the implantation were angiographed and harvested for macroscopy and microscopy. All stentgrafts were implanted successfully and remained patent from then to the explantation procedure. All stent-grafts implanted among the 6 of 7 (86%) animals that survived after the implantation remained patent, stayed free from local complications, and did not migrate during more than 6 months. In all these cases during this period, the implant functioned as a satisfactory aortic substitute while the aortic segment containing the graft kept a normal structure. There was no adverse effects of the presence of the implant upon the aorta or the animal. Stent-grafts home-made according to the described methods gave results at 6 months in this animal model compatible with a safe clinical application among humans.

Aortic dissection

Aortic dissection is a life-threatening condition caused by a tear in the intimal layer of the aorta or bleeding within the aortic wall, resulting in the separation (dissection) of the layers of the aortic wall. Aortic dissection is most common in those 65-75 years of age, with an incidence of 35 cases per 100,000 people per year in this population. Other risk factors include hypertension, dyslipidaemia and genetic disorders that involve the connective tissue, such as Marfan syndrome. Swift diagnostic confirmation and adequate treatment are crucial in managing affected patients. Contemporary management is multidisciplinary and includes serial non-invasive imaging, biomarker testing and genetic risk profiling for aortopathy. The choice of approach for repairing or replacing the damaged region of the aorta depends on the severity and the location of the dissection and the risks of complication from surgery. Open surgical repair is most commonly used for dissections involving the ascending aorta and the aortic arch, whereas minimally invasive endovascular intervention is appropriate for descending aorta dissections that are complicated by rupture, malperfusion, ongoing pain, hypotension or imaging features of high risk. Recent advances in the understanding of the underlying pathophysiology of aortic dissection have led to more patients being considered at substantial risk of complications and, therefore, in need of endovascular intervention rather than only medical or surgical intervention.

Aneurysmal Degeneration in Patients with Type B Aortic Dissection

BACKGROUND

The optimal management of type B aortic dissection (TBAD) remains controversial in the era of endovascular therapies. This study reports the outcomes and complication rates of different treatment paradigms for TBAD.

METHODS

A retrospective review was undertaken of all patients with TBAD from June 2006 to June 2012. Demographics, hospital course, and follow-up visits were analyzed. Patients who underwent surgical interventions were compared to those with medical therapy. Survival rates and predictors of outcome were determined using the Kaplan-Meier method with Cox proportional hazards.

RESULTS

Of 261 consecutive patients who were hospitalized during this period with a confirmed thoracic dissection, 134 (51%) had TBAD. Sixty-two (46%) were women, and the mean age was 66.4 ± 14.9. Median follow-up was 22.4 (0, 184) months. Thirty-five patients underwent surgical intervention with 20 thoracic endovascular aortic repair (TEVAR) and open surgery in 15. The overall 30-day mortality was 7%, and cumulative survival rates at 1, 3, and 5 years were 85% (95% confidence interval [CI], 79-91), 68% (95% CI, 59-78), and 57% (95% CI, 47-69) with no difference between medical versus surgical groups (P = 0.8) and TEVAR versus open surgery group (P = 1.0). Sixty-six (50%) patients developed aneurysmal expansion, which required surgical intervention in 26 (hazard ratios [HR], 0.99; P = 0.96). Malperfusion and rupture only occurred in 5 (HR, 1.57; P = 0.54) and 5 (HR, 3.64; P = 0.01) patients, respectively. Multivariate analysis for overall survival found renal insufficiency (HR, 2.6; P = 0.004) and age (HR, 1.06; P < 0.0001) and rupture (HR 3.3, P = 0.04) were independent predictors of mortality. Intramural hematoma was not a significant predictor of survival (HR, 0.49; P = 0.11).

CONCLUSIONS

Medical therapy remains the mainstay of treating TBAD with low morbidity. Surgical interventions are indicated in selected patients with malperfusion or aneurysmal expansion with comparable survival rates.

Diagnosis and treatment of uncomplicated type B aortic dissection

A type B dissection involves the aorta distal to the subclavian artery, and accounts for 25–40% of aortic dissections. Approximately 75% of these are uncomplicated with no malperfusion or ischemia. Multiple consensus statements recommend thoracic endovascular aortic repair (TEVAR) as the treatment of choice for acute complicated type B aortic dissections, while uncomplicated type B dissections are traditionally treated with medical management alone, including strict blood pressure control, as open repairs have a prohibitively high morbidity of up to 31%. However, with medical treatment alone, the morbidity, including aneurysm degeneration of the affected segment, is 30%, and mortality is 10% over 5 years. For both chronic and acute uncomplicated type B aortic dissections, emerging evidence supports the use of both best medical therapy and TEVAR. This paper reviews the current diagnosis and treatment of uncomplicated type B aortic dissections.

Contemporary endovascular treatment of type B aortic dissection in China

OBJECTIVE

Endovascular stent-grafts have been used in China to treat type B aortic dissection since 1999, and there is a plethora of cohort studies in the contemporary literature. The aim of this review was to analyse the published results of endovascular treatment for type B aortic dissection in China.

METHOD

A systematic literature review of all published literature from January 1999 to October 2014 on endovascular treatment of type B aortic dissection in China was undertaken using PubMed, Medline, and the Chinese National Knowledge Infrastructure databases.

RESULTS

Seventy papers were retrieved (4 English, 66 Chinese) with a total of 4208 patients; 3396 (80.7%) were male, and the mean age ranged from 43 to 65 years. Procedural success was reported in 99.4% ± 1.7%. Complications were reported in 14.6% ± 11.1%, with major complications in 1.7% ± 2.9%, and the most devastating neurologic complications in 1.1% ± 2.2% (stroke 0.9% ± 2.4%, paraplegia 1.5% ± 0.7%). Postoperative endoleak occurred in 8.1% ± 7.6%. The 30-day postoperative mortality was 2.4% ± 3.3%. During follow-up, false-lumen thrombosis occurred in 92.1% ± 11.7%. Reintervention was performed in 1.3% ± 3.3%. The incidence of proximal and distal stent-graft-induced new entry was 0.5% ± 1.3% and 0.9% ± 2.7%, respectively, with endoleak in 2.7% ± 4.4% and mortality of 2.2% ± 3.2%.

CONCLUSIONS

Current evidence suggests that use of endovascular stent-grafts for type B aortic dissection in China is feasible and safe with low rates of perioperative complications and short-term mortality. However, a standardised reporting system and long-term follow-up data are lacking.

Aortic Dissection: A Dreaded Disease with Many Faces

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.