[Aortic dissection--when operative treatment, when endoluminal therapy?].
OBJECTIVE
To demonstrate the Heidelberg results of the previous 2 years in patients referred for acute aortic dissection.


METHODS
93 patients referred for acute aortic dissection were treated by cardiac surgery, vascular surgery and interventional radiology according to a novel therapeutic algorithm including stent-grafts and combined open and interventional procedures and conservative medical therapy when no malperfusion syndrome was present or patients were considered prohibitive for even minor surgical procedures. Stent-graft placements were done assisted by short term cardiac arrest to facilitate correct device deployment.


RESULTS
36 patients presented with type A and the other 57 with type B dissection. 32 of the A patients were operated and 20 of the B patients, respectively. 12 patients with B dissection were treated with stent-grafts. 3 required additional interventional therapy for organ malperfusion. The mortality was 0% in these 12 patients The overall mortality rate in the A group was close to 40% mainly as a result of postoperative organ malperfusion while it was 15% in the B group. In both groups mortality was highest in the respective untreated patient subgroup (3/4 and 8/37, respectively). The main mortality factor was visceral (mesenteric or liver) ischemia. Paraplegic complications occured in neither group. In 4 patients a combined approach applying cardiac surgery of the ascending aorta and endluminal stent-graft placement for the residual B dissection was successfully performed. In one patient this was done simultaneously.


CONCLUSIONS
Acute aortic dissection of type A with or without valve involvement, coronary artery ischemia can be treated with high technical success rates. However, remaining distal aortic dissection associated with true lumen collapse and organ malperfusion is the main causative factor for clinical failures. Successful combination of open proximal aortic surgery with endoluminal treatment of residual B dissection encourages further use of this novel approach. Acute B type dissection appears to be effectively and safely treated by endoluminal approach in selected cases. Unsolved questions of this less invasive therapeutic approach focus mainly on the design of the proximal anchoring part of the devices.
Richter
G M
GM
Radiologische Klinik, Abt. Radiodiagnostik, Ruprecht-Karls-Universität Heidelberg, Ruprecht-Karls-Universität, Kirschnerstrasse 1, 69120 Heidelberg.
Allenberg
J R
JR
Schumacher
H
H
Hansmann
J
J
Vahl
C
C
Hagl
S
S
D000208:Acute Disease; D000328:Adult; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D000800:Angioplasty, Balloon; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D002423:Cause of Death; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D015607:Stents; D016019:Survival Analysis