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[Aortic dissection--when operative treatment, when endoluminal therapy?]
G M Richter1, J R Allenberg, H Schumacher
1Radiologische Klinik, Abt. Radiodiagnostik, Ruprecht-Karls-Universität Heidelberg, Ruprecht-Karls-Universität, Kirschnerstrasse 1, 69120 Heidelberg.
Insights
This study shows that a novel therapeutic algorithm combining open surgery and endovascular stent-grafts for acute aortic dissection (AAD) achieved a 0% mortality in type B dissections treated with stent-grafts. This approach offers a promising alternative for selected patients.
Area of Science:
- Cardiovascular Surgery
- Interventional Radiology
- Vascular Medicine
Background:
- Acute aortic dissection (AAD) is a life-threatening condition requiring timely and effective treatment.
- Traditional management strategies have limitations, particularly in complex cases involving malperfusion.
- A novel therapeutic algorithm integrating surgical, endovascular, and medical approaches has been developed.
Purpose of the Study:
- To evaluate the outcomes of a novel therapeutic algorithm for acute aortic dissection (AAD) at Heidelberg over two years.
- To assess the efficacy and safety of stent-graft placement, including during short-term cardiac arrest.
- To compare outcomes between different types of AAD and treatment modalities.
Main Methods:
- A cohort of 93 patients with AAD were treated using a multidisciplinary algorithm.
- Treatment options included cardiac and vascular surgery, interventional radiology with stent-grafts, and conservative medical therapy.
- Stent-graft placement was facilitated by short-term cardiac arrest for precise device deployment.
Main Results:
- 36 patients had Type A AAD and 57 had Type B AAD.
- Mortality was 0% in 12 Type B patients treated with stent-grafts, with 3 requiring additional intervention for malperfusion.
- Overall mortality was ~40% in Type A and 15% in Type B dissections, highest in untreated subgroups. Visceral ischemia was the primary mortality factor.
Conclusions:
- High technical success rates are achievable for Type A AAD, but organ malperfusion remains a challenge.
- Combining open repair of the ascending aorta with endovascular treatment for residual Type B dissection is effective.
- Endovascular treatment is a safe and effective option for selected Type B AAD cases, though device design requires further refinement.
Goal:
To demonstrate the Heidelberg results of the previous 2 years in patients referred for acute aortic dissection.
Material And 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.
Discussion:
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.