Endovascular stent-graft treatment of thoracic aortic syndromes: a 7-year experience

Thoracic aortic diseases (TAD) are relatively frequent conditions associated with high mortality. Recently, several reports have demonstrated the safety and efficacy of endovascular stent-graft (EVG) placement for TAD as an alternative to open surgery. We report our experience in management of thoracic aortic syndrome on 56 consecutive patients with TAD that underwent endovascular stent-graft repair. MDCT angiography was used in all patients to provide preprocedure evaluation and measurements. In particular it is necessary to evaluate the proximal and distal landing zones of the stent-graft. All EVGs in our series were placed successfully. Conversion to open surgery was never required. Six patients (10.7%) died early after the stent-graft deployment. During follow-up four more patients died. The endoleak rate was 16.7% (no. 10 pt). We did not observe any case of paraplegia. The present study shows the efficacy of EVG in the long-term follow-up, with an overall survival of 82.1%, which is comparable to that reported in recent studies. In conclusion this technique is emerging as an alternative approach in the treatment of TAD because this approach offers a less invasive therapeutic option to standard surgical techniques, even in patients who have associated diseases that make them poor surgical candidates.

Endovascular Repair of Symptomatic Penetrating Atherosclerotic Ulcer of the Thoracic Aorta

BACKGROUND

In this study we evaluate published and personal experience of Endovascular Repair (EVAR) of penetrating atherosclerotic ulcers (PAU).

PATIENTS AND METHOD

In 12 patients (mean 74 years, 58-87 years) PAU was diagnosed with computer tomography (CT). Symptomatic ulcers were treated by vascular surgeons using stentgrafts via a femoral access route. Patients were followed up clinically and with CT for an average of 849 days (186-1968 days).

RESULTS

11 patients had severe acute thoracic pain, one patient presented with hemoptysis. CT showed well outlined ulcer, intramural hematoma, and contrast enhancement of the aortic wall (n=12), pseudoaneurysm (n=11), intimal calcification adjoining the ulcer (n=10), pleural (n=9) and mediastinal fluid (n=4). Mean duration of surgery was 68min (32-120min). Primary technical success was achieved in all patients. There was no perioperative complications except one acute hemorrhage from an intercostal artery and one iliac dissection. 3 months after stentgraft application owing to a severe stenosis of the right common femoral artery, an iliofemoral bypass was performed in one patient. All patients were free of symptoms after the procedure. There was incomplete sealing of PAU in 2 of 12 patients, but no re-intervention was needed. All patients were alive during follow-up.

CONCLUSION

Symptomatic PAU is a potentially fatal lesion. Considering the low morbidity and mortality of EVAR, this option might be first choice.

Endovascular Treatment of Ruptured Penetrating Aortic Ulcers

Penetrating aortic ulcer (PAU) is a potentially lethal lesion that should be promptly diagnosed and treated. Because of the older age and serious comorbidity of these patients, outcome with rupture of the ulcer is often ominous, even when appropriate conventional surgical treatment is given. In this study we report our experience with two cases of endovascular treatment of ruptured PAU in two elderly female patients who had evident signs of intrathoracic bleeding. Endovascular treatment was performed with a stent-graft device advanced through a 24-F sheath. The graft successfully covered the PAU in both cases and the postoperative course was uneventful. Both patients were alive and well at follow-up, with regression of the hematomas and correct positioning of the grafts. Because of the reduced invasiveness of endovascular stent-graft repair, it is an alternative therapeutic option to conventional surgery in the treatment of ruptured PAU.

Penetrating Atherosclerotic Ulcers of the Infrarenal Aorta: Life-threatening Lesions

OBJECTIVES

To analyze the incidence, clinical features, natural history, and treatment of penetrating atherosclerotic ulcers (PAU) of the abdominal aorta.

MATERIAL AND METHODS

From January 2000 to June 2003, an abdominal PAU was diagnosed at our institution in eight patients (seven men, one woman; mean age 70 year). These eight cases were analyzed together with 38 additional cases found in a review of the literature (total 46 cases).

RESULTS

Occurring at an incidence of approximately 1%, abdominal PAU are less common than thoracic PAU. Seventy percent of cases are symptomatic: pain 52.5% (n =21), acute lower limb ischemia due to distal embolism 12.5% (n =5), shock 5% (n =2). Diagnosis is usually made by CT (66%) (n =26) that demonstrates a PAU in 35% (n =16) of cases, a subadventitial pseudoaneurysm in 28% (n =13), and rupture in 37% (n =17). An intramural hematoma (IMH) is observed in 9% (n =4) of cases. There were no cases of aortic dissection in this series. Calcifications of the abdominal aorta were frequent (56%) (n =26); while intra-aortic mural thrombus was found in 24% of cases (n =11), and 46% of patients (n =21) had an associated aneurysm. Twelve patients were treated medically while 34 underwent surgery (one postoperative death).

CONCLUSION

Review of the literature and this series suggests that PAU of the abdominal aorta is a life-threatening lesion, the main risk being rupture. Surgical management is recommended owing to its low morbidity and mortality.

Endovascular stent-graft repair of a complicated penetrating ulcer of the descending thoracic aorta: a word of caution

PURPOSE

To report a pitfall encountered during stenting of a complicated penetrating ulcer of the descending thoracic aorta.

CASE REPORT

A 65-year-old man was diagnosed with a complicated penetrating ulcer of the thoracic aorta. A 38-mm Talent endograft was implanted. On balloon dilation of the distal end of the endoprosthesis, the terminal bare stent became distorted and penetrated the aortic wall. A 42-mm endoprosthesis was immediately placed to exclude the aortic perforation. Control aortography demonstrated exclusion of the original proximal aortic ulcer and the distal iatrogenic aortic tear.

CONCLUSIONS

Endoprostheses may present some drawbacks in terms of elasticity and adaptability to tortuous and angulated diseased aortas. Caution is advised in the treatment of penetrating aortic ulcers where the aortic wall is diffusely friable. In this condition, balloon dilation should be limited to the covered portion of the stent-graft to prevent stent distortion and erosion through the aortic wall.

Penetrating atherosclerotic ulcer of the aorta: treatment by endovascular stent-graft placement

PURPOSE OF THE REVIEW

To summarize the current clinical experience with endovascular stent-graft repair in patients presenting with penetrating atherosclerotic ulcer of the descending thoracic aorta.

RECENT FINDINGS

Penetrating atherosclerotic ulcer is increasingly acknowledged as a pathologic variant of classic false lumen aortic dissection with a high incidence of bleeding complications and rupture in up to 40% of patients. So far, no generally accepted therapeutic regimen has been established, as the natural history of penetrating atherosclerotic ulcer is not yet fully understood. Recently, however, penetrating atherosclerotic ulcer is increasingly considered to be treated more aggressively (preferentially surgically). Given the high morbidity and mortality of aortic surgery, endovascular stent-graft repair may be an attractive, less invasive alternative in selected patients with penetrating atherosclerotic ulcer. Sealing of a penetrating ulcer by the stent-graft reduces wall stress and thus provides stabilization of the diseased aortic segment.

SUMMARY

To date, there is limited experience with endovascular repair in penetrating atherosclerotic ulcer, suggesting that endovascular stent-graft repair is safe and effective. Long-term results are, however, required to fully establish the efficacy of endovascular repair in penetrating atherosclerotic ulcer.

Endovascular stent-graft repair for penetrating atherosclerotic ulcer in the infrarenal abdominal aorta

PURPOSE

Penetrating atherosclerotic ulcer (PAU) is an ulceration of an atherosclerotic plaque penetrating through the intima, which may lead to intramural hematoma, aneurysm formation, or rupture. This disease is predominantly found in the thoracic aorta and is uncommon in the infrarenal aorta. The effectiveness of endovascular repair of PAU in the infrarenal aorta was retrospectively investigated.

METHODS

From 1999 to 2002, PAU was diagnosed with computed tomography and magnetic resonance imaging in the abdominal aorta in four patients. All patients were men; their average age was 78 years. All four patients had hypertension, and two patients had concomitant coronary artery disease. Three patients had abdominal pain or lumbago.

RESULTS

All patients underwent endovascular grafting with a Gianturco Z-stent covered with thin-wall woven Dacron graft. Indications for endovascular intervention were aneurysm formation with or without intramural hematoma in two patients and contained rupture with extraaortic hematoma in two patients. The postoperative course was uneventful in all cases, and no endoleak or aneurysm expansion was recognized during follow-up (4-32 months; average, 14 months).

CONCLUSIONS

Infrarenal aortic lesions caused by PAU were generally localized, and endovascular grafting appears to be a feasible alternative to surgical repair.