Endovascular Management of Acute Aortic Syndromes

Abstract

The term "acute aortic syndrome" (AAS) refers to a spectrum of life-threatening thoracic aortic pathologies including intramural hematoma, penetrating atherosclerotic ulcer, and aortic dissection. Clinically, patients often present with characteristic aortic pain. AAS often leads to aortic rupture. Therefore, recognition of this condition, its prompt diagnosis, and timely treatment is crucial to obtain clinical success and improved overall survival. The management of AAS, however, remains a therapeutic challenge. Endovascular strategies have gained wide acceptance and now represent a minimally invasive alternative to traditional open surgery. Several studies have shown endovascular repair of varying thoracic aortic pathologies to be technically feasible with fewer complications than open surgery. In this review, the authors discuss AAS pathology and its management, with particular attention to the current role of endovascular aortic repair and its treatment.

Endovascular management of acute aortic dissection

“…The ultimate objective is to reduce aortic wall sheer stress by regulating the patient's cardiac output (14). Beta-blockers are the principal medications utilized in initial medical management, with esmolol the most common intravenous agent utilized in the United States.…”

“…General guidelines stipulate a target systolic blood pressure of 100-120 mmHg (except in patients presenting with paraplegia, where a systolic range of 120-130 is generally employed) and a heart rate of 60-80 beats per minute (15,16 an entry tear distal to the left subclavian origin, in which the false lumen extends retrograde into the ascending aorta. The objective of taking this course would be to cover the primary dissection entry point to prevent further retrograde propagation or re-entry (14).…”

“…If true lumen collapse persists, a 16 or 18 mm self-expanding stent is then deployed exclusively in the true lumen above the fenestration after pulling the wire back into the true lumen and advancing above the tear (Figures 5,6). A potential limitation of dissection flap fenestration is persistent flow into the false lumen, but vulnerability to future aneurysmal degeneration and risk of rupture is considered an acceptable trade-off in the setting of malperfusion (14).…”

Art of operative techniques: treatment options in arch penetrating aortic ulcer

“…The natural history of PAU is not completely clear, being potentially associated with intramural hematoma (IMH) and aortic dissection or leading to aortic wall rupture (2). Typically, PAUs develop as isolated lesions and are mainly located in the descending thoracic aorta (3), with only 7% of PAUs in the aortic arch (4). Up to 38% of PAUs have abrupt onset with rupture-those presenting with pain have been associated with morphologic progression and complication (5).…”

“…In contrast, the solitary nature and focal extent of these lesions makes them adequate anatomic targets for thoracic endovascular aortic repair (TEVAR). Although several series have reported favorable short and mid-term outcomes (3,(6)(7)(8), PAUs developed in the arch are the most challenging to treat endovascularly. The anatomic constraints presented by the supra-aortic vessels pose either clinical or technical challenges that increase with more proximal arch PAU.…”