Interventional techniques in the treatment of aortic dissection

Abstract

Acute aortic dissection continues to be one of the most catastrophic cardiovascular events. While there is a general consensus on immediate surgical repair when the ascending aorta is involved, the optimal treatment strategy for type B aortic dissection (B-AD) remains controversial. Recently, endovascular treatment with percutaneous stent-graft implantation, originally used for aortic aneurysm exclusion, has acquired an important role in the treatment of B-AD. Imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and angiography have a fundamental role in the search for the anatomic details necessary to tailor the stent graft and in evaluating the most suitable anatomy for stent graft. Transesophageal echocardiography is fundamental during the procedure to monitor the correct release of the stent graft and evaluate the result of the procedure expressed by immediate thrombosis out of the stent-graft. Again, imaging techniques, more notably CT, have a fundamental role in the postoperative followup after stent-graft placement. The risk of endoleaks may compromise the result of endovascular repair and increase the risk of aortic rupture. Several reports and a few trials attesting to technical feasibility and safety of stent-graft implantation procedures for B-AD have been reported so far. Also, a randomised trial comparing type B aortic stent-graft placement with medical therapy is currently underway. According to the investigators, new therapeutic indications are likely to emerge also in uncomplicated B-AD.

Emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset in 30 cases

“…9 The 1-year mortality and incidence of complications with endovascular stent-graft repair are significantly lower than those of conventional open surgery, and the thrombosis rate of the false lumen is significantly higher. 10,11 Although the safety and efficacy of endovascular repair of AD have been reported by many studies, 11,12 it is still controversial whether endovascular repair can be performed during the acute stage of ADs. Most scholars believe that stent-graft repair should not be used during the early stage of Stanford type B ADs because congestion and edema of the artery wall prevent effective support of the stent.…”

Aortic Dissection: Simulation Tools for Disease Management and Understanding

“…Despite significant improvements in mortality rates for CVD overall (Svensson et al, 1990), AD remains an extremely severe condition with high mortality rates (Delsart et al, 2013). AD is one of the most catastrophic cardiovascular events (Sbarzaglia et al, 2006) and although the incidence of the disease is relatively rare (5-35 per million per year (Khan & Nair, 2002;Meszaros et al, 2000)), the outcomes are dire, with 20% of patients dying before reaching the hospital and a further 30% dying during admission (Masuda et al, 1991). For those patients that survive, the choice of treatment is critical and 70% of all deaths caused by AD occur within the first 2 weeks (Crawford, 1990).…”

“…In such cases, the relative risks of withholding surgical treatment compared to surgery, and the choice of surgical approach, are less clear. Although successful surgical intervention will have a favourable outcome for the patient, due to the complexity of the procedure and the danger of influencing arteries branching from the aorta, there is a high level of risk associated with carrying out the surgical procedure along the dissected abdominal aorta (Khan & Nair, 2002), as well as a corresponding risk of post-operative complications such as respiratory failure, renal failure and paraplegia (Sbarzaglia et al, 2006). Unpredictable outcomes, such as complete blockage of the TL by expansion of the thrombosed FL (Takahashi et al, 2008), or thrombi occluding the intercostal arteries (Yamashiro et al, 2003), can lead to paraplegia, defined as weakness or complete loss of function of the lower limbs (Bozinovski & Coselli, 2008).…”

MR imaging of aortic coarctation

“…Similarly to aortic dissection [26], CoA can be diagnosed using transesophageal echocardiography (TEE), digital subtraction angiography (DSA), computed tomography (CT), and MR imaging. TEE is regarded as an invasive modality, especially in infants and children.…”

“…Come per la dissezione aortica [26], la diagnosi di CoA può essere posta mediante ecocardiografia transesofagea (ETE), angiografia digitale con sottrazione d'immagine (ADS), tomografia computerizzata (TC) e RM. L'ETE è considerata tecnica invasiva, soprattutto nei soggetti in età imaging techniques, i.e.…”