Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections.
BACKGROUND
There is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection.


METHODS
In 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 +/- 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 +/- 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography.


RESULTS
In 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths.


CONCLUSIONS
Our experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.
Department of Cardiac Surgery, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.
Lennart F
LF
Duebener
Peter
P
Lorenzen
Gert
G
Richardt
Martin
M
Misfeld
Axel
A
Nötzold
Franz
F
Hartmann
Hans-Hinrich
HH
Sievers
Volker
V
Geist
D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000601:surgery*; D001014:Aortic Aneurysm / Q000150:complications / Q000601:surgery*; D001019:Aortic Rupture / Q000209:etiology / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D012422:Rupture, Spontaneous; D015607:Stents; D016896:Treatment Outcome