Stent Graft Repair of the Primary Tear

Although percutaneous revascularization of ischemic vascular beds after aortic dissection can be achieved, the procedures are often technically complex and time consuming. An additional drawback of endovascular stenting and fenestration is that they do not address the primary tear and the potential for aneurysmal dilatation of the false lumen over time. Attention has now turned to placement of a stent graft over the primary tear as an alternative percutaneous treatment technique for aortic dissection. It is hoped that this approach will be effective in rapidly treating acute peripheral ischemic complications of aortic dissection as well as preventing chronic dilatation of the false lumen.

In patients with an acute dissection, indications for treatment with a stent graft include ischemia of multiple vascular beds, persistent back pain despite medical therapy, an entry tear in an atypical location or acute aortic rupture. The patients included 15 men and 4 women, with a mean age of 53.2 years (range 16-75 years). Fifteen patients had Type B dissection and 4 had Type A dissection. The primary tear was distal to the left subclavian artery in all patients, however in the 4 patients with Type A dissection there was retrograde extension to involve the ascending aorta. A distance of at least 1 cm between the left subclavian artery and the primary tear was necessary to be considered a candidate for stent graft treatment.

The primary tear was covered with a custom fabricated stent graft composed of a Z-stent endoskeleton covered with either woven polyester or balloon expanded polytetrafluoroethylene graft material. The device was delivered into the true lumen bridging the primary tear through a 22 French sheath (Keller-Timmerman sheath, Cook) which had been placed through the femoral artery. The stent grafts ranged in diameter from 20-38 mm (mean 29 mm) and ranged in length from 4.5-10 cm (mean 7.0 cm).

Device deployment was technically successful in all patients. The mean interval from the initial onset of symptoms to the stent graft procedure was 3.8 days (range 1-13 days). Restoration of flow to ischemic vessels was achieved with the stent-graft alone in 76% of the previously obstructed branches. The remaining vessels were revascularized after stent graft placement using bare endovascular stents. Thrombosis of the false lumen was complete in 15 patients (79%) and partial in 4 patients (21%). Three patients (16%) died within 30 days because of aortic rupture (1), sepsis (1) and pneumonia (1). There have been no late deaths, and no patient has had aneurysmal dilatation or rupture of the false lumen at a mean follow-up time of 10.5 months (range 1-26 months).

Treatment of patients with a sub-acute or chronic Type B dissection using a stent graft has been compared to surgical treatment of a similar group of patients. Although all patients were required to have at least one indication for elective surgical repair of the dissection, these indications were not specified. The 12 endovascular patients were treated with placement of a Talent endoprosthesis (World Medical/AVE, Sunrise, FL) over the primary tear. A minimum distance of 5 mm between the primary tear and left subclavian artery was necessary to be considered a candidate for stent

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