Treatment of aortic dissections with endovascular stent grafts

The management of aortic dissections remains controversial. Knowledge regarding the extent and specific pathophysiology of each dissection is critical prior to intervention. Cross-sectional imaging techniques coupled with intravascular ultrasound or hemodynamic measurements are vital. In the setting of ischemia with significant true lumen compromise, the placement of a proximal endovascular graft has a high likelihood of dramatically improving the diameter of the true lumen, alleviating distal ischemia. Caution must be taken when branch vessels are involved in the dissection. Adequate true lumen flow with persistent end-organ ischemia is best handled with branch vessel stenting. Combined true lumen compresssion and branch vessel dissection requires both visceral vessel stenting and proximal endovascular grafting. Using these techniques, we have been able to achieve a mortality rate of less than 35% in a patient population that previously suffered mortality rates in excess of 50%. However, application of these technologies to asymptomatic or nonischemic dissections is not warranted outside the context of investigational trials.