Extension of Dissection in Stent-Graft Treatment of Type B Aortic Dissection:Lessons Learned from Endovascular Experience

Abstract

Endovascular treatment is becoming the most important treatment modality in the complex management of type B dissection, providing benefits to both acute and chronic patients. Growing technical experience and improving stent-graft devices have resulted in better patient outcome and expanded clinical indications. Nevertheless, similar to any treatment option, this less invasive method has its inherent risks. Several cases of iatrogenic dissection have been reported in the literature, underlying the need for guidelines to minimize this risk and improve procedural safety. Extension of the dissection after endovascular repair of type B dissection does not appear to be device-specific, but related primarily to aortic wall alterations or adverse anatomy that arise most frequently in hypertensive patients or those with challenging aortic configuration. An accurate examination of the aortic wall and dissection anatomy and careful intraprocedural device manipulation and balloon molding may help avoid this potentially life-threatening complication.

Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement

“…10,11 Indeed, in 40 of the 48 (83%) patients of our series stent grafts with proximal bare springs were used. Moreover, in patients in whom rAAD was classified as being stent graftinduced, proximal bare spring stent grafts were used in 27 of 29 patients (93%).…”

“…10,11 Previous reports have estimated the risk of rAAD after TEVAR to range between 1.9% and 2.4% 1,10,11 to as high as 6.8% 9 in a single-center experience involving a relatively small number of procedures. The incidence of TEVAR-related dissection was low in the current study and perhaps represents a much more stable estimate of this event due to the large number of patients evaluated.…”

“…9,10 In fact, of the total of 48 patients with rAAD, 40 (83%) had TEVAR performed either for acute or chronic aortic dissection. This is not surprising, given that the aortic wall is particularly friable in patients presenting with spontaneous aortic dissection and even minor injury during guide wire manipulation, or, stent graft deployment or subtle movement during the cardiac cycle of the semirigid stent graft may ultimately result in retrograde ascending aortic dissection.…”

Thoracic endovascular repair for acute type A aortic dissection: operative technique

“…Injury of the aortic wall in this part of aorta may have fatal consequences such as a retrograde type A aortic dissection (RAAD) or aortic rupture. The incidence of RAAD following TEVAR has been reported to be between 1.3% and 6.8% (9)(10)(11).…”

Management of aorto-esophageal fistula secondary after thoracic endovascular aortic repair: a review of literature

“…In the past, TEVAR was positioned as the main treatment strategy for TAA or traumatic aortic transection after its clinical introduction in 1994 [16]. Various studies demonstrated that the minimally invasive procedure of TEVAR might allow rapid control of blood loss even in patients with hemodynamic instability [17,18], and that the perioperative morbidity of TEVAR during an urgent condition was significantly better than that of emergency open surgery [19]. After the usefulness of TEVAR in closing a fistula between the aorta and an adjacent organ was reported in 1996 [20], numerous promising results in its short-term effectiveness have encouraged its clinical use, and the indications of TEVAR have expanded to AEF.…”