Use of endovascular stents for acute aortic dissection: an experimental study

Surgical strategy for acute type A aortic dissection in octogenarian

With the progressive aging of Western populations, cardiac surgeons are increasingly faced with octogenarians. In these high-risk patients, owing to high mortality, the surgical strategy has to be adapted to the patient's age. We describe a method by which the cross-clamping technique is associated with a safe and simple maneuver, consisting of stenting the aortic arch and reducing the aortic cross-clamping damages.

Multiple Overlapped Conical Endoprostheses in a Patient With Aneurysmatic Right Aortic Arch and Aortic Coarctation

An aortic neck with a nonconstant diameter represents a challenge for endovascular treatment. We report our experience in a patient with right aortic arch, aneurysmatic aberrant subclavian artery, aortic coarctation, and a precoarctation aneurysm that was treated with surgery and endoprothestic procedures in two stages.

Intraluminal rotatory device: a hypothesized new approach for the treatment of type B aortic dissections

Acute dissection is the most common and frequently fatal catastrophic event to effect the aorta. Current treatments are unsatisfactory, particularly for Type B dissections where the mortality is excessive (approaching 33%) yet the late complication rate is high. It is hypothesized that an alternative approach would be to introduce an intraluminal freely rotating device via the femoral artery to lie adjacent to the site of the initial intimal tear. As a result it is predicted that the local shear stress would become zero, effectively arresting the dissection process. At the same time, the centrifugal force developed by the device would oppose the layers of the dissection, increasing the likelihood of false lumen obliteration. Such an approach may result in less short-term mortality and a lower long-term complication rate than current treatments.

Treatment of Stanford type B aortic dissection with stent-grafts: preliminary results

PURPOSE

To evaluate the feasibility and safety of endovascular stent-graft placement in treating Stanford type B aortic dissection.

MATERIALS AND METHODS

Seven patients underwent endovascular stent-graft placement for type B aortic dissection. Five patients had acute and two had chronic dissection. In five patients, the proximal entry tear was within 2 cm of the origin of the left subclavian artery, and in two patients it was beyond this site. In three patients, the noncovered proximal portion of the stent-graft was placed across the origin of the left subclavian artery. The efficacy of the procedure was assessed at follow-up studies 3, 6, 12, and 24 months after intervention.

RESULTS

The procedure was technically and clinically successful in six patients (86%). The left subclavian artery remained patent in all patients. In two patients with involvement of aortic branches, endovascular stent-graft placement restored adequate blood flow to the compromised branches. One patient was readmitted 1 month later because the dissection extended into the ascending aorta. In all but this patient, closure of the entry tear and thrombosis of the false lumen along the stent-graft were achieved. All false lumina shrank considerably. The mean follow-up time was 14 months (range, 1-25 months).

CONCLUSION

Type B aortic dissections within and beyond 2 cm of the origin of the left subclavian artery can be treated safely and effectively by means of endovascular stent-graft placement.

Endovascular treatment of descending thoracic aortic aneurysms and dissections

Various endovascular techniques have become viable therapeutic alternatives in the treatment of patients with many types of descending thoracic aortic pathology and aortic dissections. Descending thoracic aortic aneurysms can be successfully treated using stent grafts. This technique is less invasive and is associated with acceptable morbidity and mortality rates. Patients who are particularly likely to benefit include the very elderly population; those with markedly compromised cardiac, pulmonary, or renal status; and individuals who have previously undergone complex operations on the thoracic aorta. Other endovascular methods, such as aortic flap fenestration, stent, or covering of the primary intimal tear in the descending thoracic aorta with a stent graft, have also been effectively employed in the treatment of peripheral arterial complications of aortic dissection. Despite the reported early success of these endovascular percutaneous methods, true assessment of the effectiveness of these various techniques awaits long-term follow-up evaluation in large patient populations.

Endovascular management of traumatic infrarenal abdominal aortic dissection

Dissection is a recognized finding after blunt trauma to the abdominal aorta. Immediate and long-term prognosis is poor without surgical treatment especially since most patients present severe associated injuries. On the basis of encouraging results using endovascular techniques to treat experimental dissection of the descending thoracic aorta, we treated three patients with traumatic infrarenal abdominal aortic dissection by percutaneous stent placement. There were two men 34 and 41 years of age and one 89-year-old woman. In all patients, dissection began in the infrarenal portion of the aorta and extended into the iliac arteries. All patients had multiple associated injuries. The main symptoms were acute abdominal pain (two patients) and ischemia of the lower extremities (two patients). Diagnosis was missed in one patient despite exploratory laparotomy for an associated injury. Two patients were treated in the acute phase by placement of a self-expanding endovascular prosthesis at the aortoiliac level. The third patient was treated in the chronic phase by placement of a balloon-expandable endovascular stent. All procedures were performed uneventfully by femoral route. Success of treatment was confirmed by arteriography and computed tomography (CT) scan demonstrating obliteration of the dissection. Upon late follow-up examination, all patients were in satisfactory condition, with normal Doppler ultrasound findings. These findings confirm experimental studies using endovascular treatment for dissection of the descending thoracic aorta and are promising for future clinical management.

Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration

PURPOSE

The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection.

METHODS

Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections.

RESULTS

Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia. Sixteen patients were treated with EVS including 11 with renal, 6 with lower extremity, 2 with superior mesenteric artery, and 2 with aortic stents. Three patients had BF of the intimal flap, and three had BF in combination with EVS. Revascularization with clinical success was achieved in all 22 patients. Two patients died 3 days and 13.4 months after the procedure was performed, respectively. Of the remaining 20 patients, 1 is lost to follow-up, and 19 have persistent relief of clinical symptoms. Mean follow-up time is 13.7 months (range 1.1 to 46.5 months). One case was complicated by guidewire-induced perinephric hematoma.

CONCLUSION

EVS and BF provide a safe and effective percutaneous method for managing peripheral ischemic complications of aortic dissection.

Intravascular stenting of traumatic abdominal aortic dissection

PURPOSE

We describe the case of a 34-year-old man with blunt abdominal trauma. Initial abdominal computed tomography scan showed retroperitoneal hematoma, pancreatic contusion, multiple fractures of the transverse process in the thoraco-lumbar spine, and infrarenal aortic dissection.

METHOD

Angiography revealed that the aortic dissection originated proximal to the inferior mesenteric artery and extended down to the left common iliac artery without vascular obliteration. The pancreatic trauma was managed without operation, and the dissection was treated with aortic and left iliac endovascular self-expanding Schneider Wall Stents.

RESULT

Immediate angiographic and computed tomography scan examination showed the obliteration of the greater part of the dissection with persistence of a short dissected segment at the level of the aortic bifurcation. Examination a week later showed thrombosis of this false lumen and complete obliteration of the dissection.

CONCLUSION

Intravascular stenting allowed treatment of the dissection without open surgical procedures requiring laparotomy and aortic operation.