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Home > Vascular Annual Meeting^® > PVSS13. Regional Variability in Aortic Remodeling...

PVSS13. Regional Variability in Aortic Remodeling After Thoracic Endografting for Type B Dissection

J. Patrick Austin, MD; Martin R. Back, MD; Murray L. Shames, MD; Ann S. Lopez, ARNP; Bruce Zwiebel, MD
University of South Florida Vascular, Tampa, FL

OBJECTIVES: We reviewed our mid-term results with thoracic endograft exclusion of acute and chronic type B aortic dissections to address whether intervention conferred favorable changes in patient symptomatology, regional aortic size, and luminal morphology.

METHODS: From September 2005 to January 2009, 26 patients (19 men, 7 women, mean age 56 years, range 32-81 years old) required 28 implantations of thoracic endograft devices for complicated type B aortic dissection (20 acute, 8 chronic). Indications for endograft intervention were renal/mesenteric/lower limb malperfusion in 15 cases, aneurysm or pseudoaneurysm formation in 8 patients, persistent back pain or difficult BP control in 3 cases and extensive intramural hematoma formation in 2 patients. Associated with exclusion of proximal dissection entry sites, 76% (13/17) of covered left subclavian arteries were revascularized by carotid-subclavian bypass/transposition. Adjunctive endovascular renal revascularization (stenting) was done in 5 of the 15 (33%) malperfusion cases. Intravascular ultrasound (IVUS) was used for procedural guidance in all cases. Surveillance CT aortic imaging was performed within 1 month of endovascular treatment and at yearly intervals with follow-up ranging from 1 to 36 months (mean 13 months).

RESULTS: Early symptom resolution was achieved in all patients and 30-day operative mortality was 7% (2/28) due to early abdominal aortic rupture or pulmonary failure. Neurological complication rate was 7% due to single episodes of stroke and lower limb paralysis (post-op hypotension). No worsened renal function or need for dialysis occurred during early or late follow-up. Two patients developed late (>30 day) recurrent malperfusion (renal or mesenteric) requiring distal thoracic endograft extensions. Cumulative survival was 81% for the study cohort (3 late non-aortic related deaths). The proximal descending thoracic (containing the dissection entry) was the largest diameter segment (32-100 mm) of the thoracoabdominal aorta in all but 4 patients. Early post-op CT imaging revealed thombosis of the false lumen and true lumen expansion along the endografted segment in all cases. The false lumen remained patent in the (unexcluded) distal thoracoabdominal and iliac segments. Aortic diameters regressed between 4 and 21 mm within the excluded segments containing a thrombosed false lumen in 90% of patients. Mid-arch diameters (non-dissected) did not change during follow-up. Expansion (3-12 mm) occurred in all unexcluded distal thoracoabdominal segments (with patent false lumens) when initial aortic diameters were >35 mm. Smaller diameter aortas (<35 mm) in these locations did not expand (change +4 to -4 mm). One patient required open thoracoabdominal aortic replacement 6 months after proximal endografting due to progressive distal dilatation (initial diameter 50 mm).

CONCLUSIONS: Endograft exclusion of complicated type B aortic dissection can ameliorate initial symptomatology and facilitate early favorable proximal thoracic remodeling. The residual dissected thoracoabdominal segment containing a patent false lumen, may be prone to further dilatation when initial aortic diameters are large (>35 mm). Ongoing surveillance is mandatory and the late natural history of the distal thoracoabdominal segment appears independent of early proximal aortic endografting results.

AUTHOR DISCLOSURES: J.P. Austin, Cook, Medtronic, Gore; M.R. Back, Cook, Medtronic, Gore; M.L. Shames, None; A.S. Lopez, None; B. Zwiebel, None.