Background-Thoracic endovascular aortic repair (TEVAR) represents a novel concept for type B aortic dissection.Although life-saving in acute emergencies, outcomes and survival of TEVAR in stable dissection are unknown. Methods and Results-One hundred forty patients in stable clinical condition at least 2 weeks after index dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (nϭ72) or to optimal medical therapy alone (nϭ68) with surveillance (arterial pressure according to World Health Organization guidelines Յ120/ 80 mm Hg). The primary end point was all-cause death at 2 years, whereas aorta-related death, progression (with need for conversion or additional endovascular or open surgery), and aortic remodeling were secondary end points. There was no difference in all-cause deaths, with a 2-year cumulative survival rate of 95.6Ϯ2.5% with optimal medical therapy versus 88.9Ϯ3.7% with TEVAR (Pϭ0.15); the trial, however, turned out to be underpowered. Moreover, the aorta-related death rate was not different (Pϭ0.44), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgery) was similar (Pϭ0.65). Three neurological adverse events occurred in the TEVAR group (1 paraplegia, 1 stroke, and 1 transient paraparesis), versus 1 case of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% of patients with TEVAR versus 19.4% of those who received medical treatment (PϽ0.001), which suggests ongoing aortic remodeling. Conclusions-In the first randomized study on elective stent-graft placement in survivors of uncomplicated type B aortic dissection, TEVAR failed to improve 2-year survival and adverse event rates despite favorable aortic remodeling. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00525356.
Use of EndoAnchors to treat existing and acute type Ia endoleaks and endograft migration was successful in most cases. Prophylactic use of EndoAnchors in patients with hostile aortic neck anatomy appears promising, but definitive conclusions must await longer term follow-up data.
Objective: Endoluminal aortic stent grafting offers a potentially less invasive alternative to open chest surgery, especially in patients with polytrauma. We compare the results of conventional surgical repair and endovascular treatment of traumatic aortic rupture. Methods: Retrospectively, 74 patients with acute traumatic aortic rupture were analyzed. Most of the patients had a rupture limited to the isthmus, and severe associated injuries. Thirty-five patients (6 female, 29 male, mean age 36 years) underwent surgical repair. Two patients were operated upon without cardiopulmonary bypass. In 39 patients (5 female, 34 male, mean age 36 years) thoracic endografts were implanted. The delay between trauma and treatment was comparable in the two groups. Results: Hospital mortality was 20% (7 of 35 patients) in the surgical group and 7.7% (3 of 39 patients) in the endovascular group. The most common cause of death in the surgical group was brain death in severe traumatic patients. Ten surgical complications occurred in 5 patients: respiratory insufficiency (n = 3), pulmonary infection (n = 2), recurrent nerve palsy (n = 2), repeat thoracotomy (n = 2), and compartment syndrome (n = 1). No patient in this group had paraplegia. Except for one case, which required conversion to conventional surgery, stent-graft implantation was successful in all cases, without peri-interventional complications or procedure-induced paraplegia. In 9 patients the left subclavian artery was covered with the device. Two patients underwent surgical repair 15 days and 4 months after endografting because of injury of the aortic wall by the stent and development of a spurious aneurysm, respectively. Conclusions: In the treatment of traumatic thoracic aortic rupture, the early outcome of patients treated with endovascular stent grafts appears to be better than that with conventional surgical repair. The new technique allows safe and successful repair of this life-threatening injury in the early phase of trauma management. How far this potential benefit is sustained in the long term remains unclear at present. #
Background-Thoracic endovascular aortic repair (TEVAR) represents a therapeutic concept for type B aortic dissection.Long-term outcomes and morphology after TEVAR for uncomplicated dissection are unknown. Methods and Results-A total of 140 patients with stable type B aortic dissection previously randomized to optimal medical treatment and TEVAR (n=72) versus optimal medical treatment alone (n=68) were analyzed retrospectively for aortaspecific, all-cause outcomes, and disease progression using landmark statistical analysis of years 2 to 5 after index procedure. Cox regression was used to compare outcomes between groups; all analyses are based on intention to treat. From the University of Rostock, Heart Center and Institute for Biostatistics, Rostock, Germany (C.A.N., S.K., T.C.R., G.K., A.G., T.K., H.I.); CCB Heart Center Frankfurt, Frankfurt, Germany (H.E.); University Heart Center Leipzig, Leipzig, Germany (D.S.); German Heart Institute Berlin, Berlin, Germany (B.Z.); the Centre Hospitalière Universitaire, Hôpital de Rangueil, Toulouse, France (H.R.); the Universitá St. Orsola Malpighi, Bologna, Italy (R.F.); the Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland (M.C.); and Bordeaux Heart University Hospital, Bordeaux, France (L.L.).All members of the Investigation of Stent grafts in Aortic Dissection with extended length of follow-up (INSTEAD-XL) study group are listed in the Appendix in the online-only Data Supplement.The online-only Data Supplement is available at http://circinterventions.ahajournals.org/lookup/suppl
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