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Interventional management of aortic dissection
Holger Eggebrecht1, Dietrich Baumgart, Ulf Herold
1Department of Cardiology, University Hospital, Essen, Germany.
Insights
Advancements in imaging and catheter-based interventions are improving outcomes for aortic dissection patients. New techniques like percutaneous balloon fenestration and stent-graft placement offer lower complication rates than traditional surgery.
Area of Science:
- Cardiovascular Surgery
- Vascular Imaging
- Interventional Cardiology
Background:
- High-resolution imaging reveals aortic dissection precursors like intramural hematoma.
- Novel classifications (e.g., Svensson) aid in understanding aortic dissection.
- Despite diagnostic advances, aortic dissection mortality remains high due to complications.
Purpose of the Study:
- To review current diagnostic imaging modalities for aortic dissection.
- To explore novel catheter-based interventional techniques for aortic dissection.
- To assess the impact of new techniques on patient morbidity and mortality.
Main Methods:
- Utilizing advanced imaging: transesophageal echocardiography, MRI, CT, intravascular ultrasound.
- Implementing percutaneous balloon fenestration (PTF) for ischemia.
- Employing aortic stent-graft placement to occlude entry tears.
Main Results:
- Interventional techniques demonstrate low complication rates compared to surgery.
- PTF effectively improves perfusion in cases of branch vessel ischemia.
- Stent-grafts promote false lumen thrombosis, aiding in disease management.
Conclusions:
- Catheter-based interventions represent a significant advancement in aortic dissection treatment.
- These minimally invasive techniques have the potential to further reduce patient morbidity and mortality.
- Continued development of interventional strategies is crucial for improving aortic dissection prognosis.
Background:
Modern high-resolution imaging techniques have provided new insights into the pathogenesis of aortic dissection during recent years. Distinct pathologic entities or potential precursors of classic false-lumen aortic dissection such as intramural hematoma or penetrating atherosclerotic ulcer have been identified. As a result, a novel classification according to Svensson used in addition to the standard differentiation according to DeBakey or Stanford has been introduced. Due to improved diagnostic imaging, preoperative mortality has decreased but mortality remains substantial (up to 1.4% per hour within the first 2 days) related to complications of aortic dissection such as aortic rupture, bleeding, pericardial tamponade, critical branch vessel ischemia, multiorgan failure, and myocardial infarction.
Examinations:
Transesophageal echocardiography, angiography, magnetic resonance imaging or computed tomography as well as intravascular ultrasound are used for a complete vascular "staging" of patients with aortic dissection after initial stabilization (with or without surgery). New catheter-based interventional techniques have been developed to improve the poor prognosis of aortic dissection: 1 Percutaneous balloon fenestration (PTF) of the intimal flap improves perfusion in case of bowel, limb, or renal ischemia. 2. Aortic stent-graft placement allows for occlusion of the intimal entry tear by implantation of a membrane-covered, self-expanding stent-graft to initiate progressive thrombus formation within the false lumen. Compared to the traditional surgical approaches, both techniques have a low complication rate. The development of these techniques may help to further improve to decrease patients' morbidity and mortality.