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Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement
C A Nienaber1, R Fattori, G Lund
1Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany. nienaber@uke.uni-hamburg.de
Insights
Endovascular stent-graft insertion offers a safe and effective alternative to surgery for thoracic aortic dissection. This minimally invasive approach demonstrated superior outcomes and reduced mortality compared to traditional surgical repair in a recent study.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Medicine
Background:
- Treatment for thoracic aortic dissection (TAD) relies on prognostic and anatomical factors.
- While proximal dissection necessitates surgery, optimal treatment for distal TAD remains unclear due to surgical limitations.
- Surgery for distal TAD has not shown significant improvement in patient prognosis.
Purpose of the Study:
- To evaluate the safety and efficacy of elective endovascular stent-graft insertion for descending (type B) aortic dissection.
- To compare outcomes of endovascular repair with traditional surgical treatment in matched patients.
Main Methods:
- Prospective evaluation of 12 patients undergoing elective transluminal endovascular stent-graft insertion.
- Comparison with 12 matched controls who underwent surgical resection.
- Diagnosis of aortic dissection confirmed by magnetic resonance angiography in all 24 patients.
Main Results:
- Endovascular stent-graft placement resulted in zero mortality or morbidity.
- Surgical repair was associated with 33% mortality and 42% adverse events within 12 months (P=0.04).
- Successful stent-graft deployment, sealing, and false lumen thrombosis were confirmed in all patients, with no major complications.
Conclusions:
- Elective, nonsurgical endovascular stent-graft insertion is a safe and effective option for select patients with thoracic aortic dissection.
- Endoluminal repair presents a promising approach for the interventional reconstruction of thoracic aortic dissections.
- This technique may offer improved outcomes for patients unsuitable for or who have failed surgical intervention.
Background:
The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis.
Methods:
We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent-graft was placed by unilateral arteriotomy.
Results:
Stent-graft placement resulted in no morbidity or mortality, whereas surgery for type B dissection was associated with four deaths (33 percent, P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 months. Transluminal placement of the stent-graft prosthesis was successful in all patients, with no leakage; full expansion of the stents was ensured by balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, and thrombosis of the false lumen was confirmed in all 12 patients after a mean of three months by magnetic resonance imaging. There were no deaths or instances of paraplegia, stroke, embolization, side-branch occlusion, or infection in the stent-graft group; nine patients had postimplantation syndrome, with transient elevation of C-reactive protein levels and body temperature plus mild leukocytosis. All the patients who received stent-grafts recovered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04).
Conclusions:
These preliminary observations suggest that elective, nonsurgical insertion of an endovascular stent-graft is safe and efficacious in selected patients who have thoracic aortic dissection and for whom surgery is indicated. Endoluminal repair may be useful for interventional reconstruction of thoracic aortic dissection.