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Ann Thorac Surg 2002;74:S1815-S1817
© 2002 The Society of Thoracic Surgeons
a Federal University of São Paulo, Paulista School of Medicine and Affiliated Hospitals, São Paulo, SP, Brazil
* Address reprint requests to Dr Buffolo, R. Borges Lagoa, 1080-cj. 701, São Paulo, SP, Brazil, CEP 04038-002
e-mail: enio.buffolo{at}terra.com.br
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Acute aortic dissection is a life-threatening medical condition. It is associated with high morbidity and mortality. Type B dissections are usually managed clinically during the acute phase. Conventional surgery carries high mortality rates due to the presence of serious complications. We herein present treatment of this condition with a less invasive endovascular approach. Other clinical situations such as penetrating ulcers, intramural hematomas, and true aneurysms of descending aorta were similarly treated.
METHODS: From December 1996 to March 2002, 191 patients with type B dissections were treated with self-expandable, polyester-covered stents. There were 120 patients (62.8%) with type B dissections, 61 patients (31.9%) with true aneurysms, 6 patients (3.1%) with penetrating ulcers or intramural hematomas, and 4 patients (2.1%) with trauma. Patients with abdominal aneurysms (44) and stents introduced under direct vision through the aortic arch (70) were excluded. The stent graft was delivered in the catheterization laboratory under general anesthesia, with induced hypotension and heparinization. All stents used were made in Brazil (Braile Biomedics, Sao Jose do Rio Preto, SP).
RESULTS: The procedure was performed in 191 consecutive cases. The success rate was 91.1% (174/191). Success was defined as occlusion of the thoracic intimal tear, or exclusion of the aneurysm without leaks. Hospital mortality was 10.4% (20/191 patients), due to preoperative comorbidities. Six patients required conversion to surgery. No case of paraplegia was observed. An actuarial survival curve showed 87.4% ± 29% survival in the late follow-up period.
CONCLUSIONS: Stent grafts are an important development in the treatment of descending aortic aneurysms or dissections. This novel approach may replace conventional surgical treatment of these conditions, with earlier intervention and less morbidity.
Thoracic aortic aneurysms and dissections are associated with high morbidity and mortality rates both with medical and surgical management [1]. There is no doubt about the superiority of surgical therapy in the treatment of type A dissections. Type B dissection is usually treated medically, with surgery indicated for serious complications [2, 3]. The association of old age and comorbidities observed in this subset of patients justify medical management for this basically surgical condition. Our experience shows that some patients develop acquired pathologies such as reentry tears, visceral artery obstructions, or expansion of the false lumen [4], which lead to a thoracoabdominal surgical approach shortly after discharge. This was the main reason that led us to propose that the elephant trunk principle, described by Borst and associates to treat true aneurysms, should be applied to this condition [5, 6]. Having obtained satisfactory results in this initial series of complicated patients, we began to recommend surgery even for uncomplicated cases of type B dissection during the acute phase.
After our initial experience, we felt it necessary to simplify the surgical approach. To that end, we developed self-expandable stents that were placed through the aortic arch under conditions of deep hypothermia and circulatory arrest. This learning curve was fundamental to the subsequent development of self-expandable stents inserted through the femoral artery, as originally proposed by Parodi [7] for the treatment of abdominal aneurysms.
The endovascular approach for surgical pathologies of the descending thoracic aorta [8–12] is being employed with growing enthusiasm by other authors since the initial publications from Stanford [11, 13]. Recently, we presented a consecutive series of 70 patients with type B dissections who were treated by the endovascular approach with encouraging results [14]. A score to predict success has also been proposed based on this study [15].
The purpose of this paper is to present an overview of our total experience with self-expandable stent grafts in pathologies of the descending thoracic aorta.
Patients and methods
From December 1996 until March 2002, 191 consecutive patients with true aneurysms or dissections of the descending thoracic aorta were selected to undergo treatment by the endovascular approach. There were 120 patients (62.8%) with type B dissections, 61 patients (31.9%) with true aneurysms, 6 patients (3.1%) with penetrating ulcers or intramural hematoma, and 4 patients (2.1%) with trauma.
The self-expanding endoprosthesis used in all these cases is composed of a stainless steel cylindrical framework made of Z segments covered with polyester of various lengths and diameters (Braile Biomedics, Sao Jose do Rio Preto, SP, Brazil). Each device is compressed in a releasing sheet of polytetrafluorethylene varying in caliber from 20F to 24F. The selected prosthesis had a diameter exceeding that of the aorta by 10% to 20%, to increase the radial force.
The procedure was conducted in the catheterization laboratory under general anesthesia, with surgical backup by a team consisting of a cardiovascular surgeon, an interventional cardiologist, an anesthesiologist, a scrub-nurse and, if possible, echocardiographic monitoring. Antibiotic prophylaxis was with cephazolin for 48 hours, and heparin was given intravenously (5,000 U) only during catheter manipulation. In all cases, femoral access was achieved by surgical dissection of one of the femoral arteries chosen after contrast injection of the distal abdominal aorta to select the best side. Hypotension (mean arterial pressure, 50 to 60 mm Hg) was induced by nitroprusside just before the deployment of the stent. After placement of the stent(s), aortography was performed to confirm the adequacy of treatment. In patients with chronic renal failure (creatinine above 2 mg/dL), we tried to deploy the endoprosthesis using transesophageal echo monitoring alone.
Criteria for successful deployment included absence of death or surgical conversion, exclusion of the aneurysm, and occlusion of thoracic tears. Persistence of distal tears in the abdominal aorta was not considered a failure if the thoracic intimal tears were covered and there was no blood flow in the false lumen. The left subclavian artery was intentionally occluded in 14 patients. In 1 patient, a carotid shunt was necessary due to weakness in the left arm. The number of implanted stents varied from one to six. In 50% of the patients, more than one stent graft was necessary. In 38 patients, two-thirds of the entire descending aorta was covered by stents. In 34 patients, the region between T9 and T12 was treated.
Results
There was no paraplegia despite extensive repair of the entire descending aorta in many cases (Figs 1, 2). An actuarial survival curve shows a survival rate of 87.4% ± 2.9% in the late follow-up period, including hospital mortality (Fig 3).
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The endovascular approach for arterial pathologies was first suggested by Dotter [16] in 1969. However, it was Parodi [7] who pioneered the treatment of abdominal aortic aneurysms with a balloon-expandable endovascular prosthesis in 1995, demonstrating the feasibility of this new concept. Dake and colleagues [8] showed the possibility of treating descending aortic true aneurysms with an expandable endovascular prosthesis inserted through the femoral artery.
Since 1998 [6], we have been treating type B aortic dissections with the elephant trunk procedure described by Borst for the management in multiple stages of true aneurysms of the entire thoracic aorta. Experience with this approach made us begin to use auto-expandable stents introduced through the aortic arch under conditions of deep hypothermia and circulatory arrest. Two years later, we began utilizing stent grafts introduced through the femoral artery [14]. There was a dramatic change in morbidity and mortality, leading us to reassess the indications, results, and costs of the procedure. In 2001, of 135 patients with thoracic aortic aneurysms or dissections, we used the endovascular approach in 88 patients (65.2%).
As we gained experience with this technology, it was possible to predict success for the majority of patients depending upon the proximal and distal necks and the angle between the descending aorta and the aortic arch. In long aneurysms, more than one stent is needed because, with multiple short stents, curves are overcome, and more radial force is applied against the aortic wall. In our experience, we deliberately select the diameter of the endoprosthesis to exceed the predicted size of the aorta by about 20%. This provides fixation of the stent to the aortic wall, thereby avoiding migration of the stent.
In chronic type B dissections, it is common to detect distal reentry tears, usually around the left renal artery, iliac arteries, or in the transition between the thoracic and abdominal aorta. In this situation, we treat only the descending aorta tears. The fate of this incomplete correction is not known. It is possible that the pressure in the false lumen can be reduced by treating the proximal tears. The 87.4% actuarial survival curve in the late follow-up period, including the risk of death during hospitalization, permits us to continue to use this innovative approach to treat descending thoracic aortic pathologies.
References
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|
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|
 |
|
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|
|
|
|
 |
|
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|
|
|
|
 |
|
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|
|
|
|
|
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|
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|
|
 |
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|
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|
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|
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|
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