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Letters to the Editor

Endovascular repair of type B aortic dissection: is it possible to prevent post-procedure complications?

^a Cardiovascular Surgery Unit, Department of Experimental and Clinical Medicine, University Magna Græcia, Viale Europa-88100, Catanzaro, Italy
^b Cardiology Unit, Department of Experimental and Clinical Medicine, University Magna Græcia, Catanzaro, Italy

Received 4 January 2008; accepted 24 January 2008.

^_* Corresponding author. Tel.: +39 09613647421; fax: +39 09613647142. (Email: mastroroberto{at}unicz.it).

Key Words: Thoracic aorta • Dissection • Endovascular surgery

We read with great interest the article on secondary complications following endovascular repair of type B aortic dissection [1], which helps all surgical teams involved in this procedure. Nevertheless, on the basis of the following reported personal experience, we believe that some observations may be pointed out.

From January 2002 to July 2007, 11 patients underwent a thoracic endovascular stent-graft procedure for progressive type B aortic dissection at our institution. We circumscribed indication for treatment only on the evidence or high suspicion of impending aortic rupture and visceral and/or peripheral ischemia. Patients with severe hypertension and persistent pain were treated with aggressive medical therapy because of the conviction that primary conservative treatment determines a low incidence of aneurysm formation and rupture during the chronic phase [2]. CT-scan and angiography of the entire aorta were performed to determine the site of aortic tear and the relationship between dissection and aortic branches. Nine patients presented also signs of aortic ulceration and two left pleural effusion considered as suspicion of aortic rupture without hemodynamic instability. In all patients we used the Talent^TM endoluminal stent-graft system (Medtronic Vascular Inc., Sunrise, FL, USA) and the left subclavian artery was crossed with the uncovered portion of the stent-graft in six cases and the covered segment in the other five patients without prior carotid-to-carotid or subclavian-to-carotid bypass intervention. In all cases balloon dilatation was not performed and no patients showed persistent blood flow in the false lumen at the end of the procedure. One patient presented paraplegia at 30 days follow-up and in two cases a thoracentesis was performed because of post-procedural left pleural severe effusion. At the follow-up no cases of endoleak and/or retrograde type A dissection were revealed.

We agree with Neuhauser et al. [1] that extension of dissection is one of well-known events in type B dissection [3]. Nevertheless it is clear that the initial act of retrograde dissection is the ‘graft-stent procedure’ itself and is probably related to a repeated balloon dilatation in an extremely fragile aorta.

We do not consider ‘endovascular stent-graft repair of the thoracic aorta an alternative to surgical repair’ [1] but the treatment of choice with more indications in the near future in all cases when descending thoracic aorta is involved. We believe that the high incidence of retrograde type A dissection with high risk of mortality related to a second procedure may be prevented by (a) using a stent-graft with an appropriate size not requiring balloon dilatation, (b) trying the ‘chronicity’ of the dissection by an aggressive medical therapy in order to perform the stent-graft implantation on a ‘stabilized aorta’ and (c) paying attention that the guide wire is not misplaced in the false lumen [4].

These considerations obviously are not a dogma or a paradigm for a successful treatment but the confirmation of the speculative analysis already presented [1] and supported by our encouraging results.

Again we congratulate the authors for their fine observation and their contribution to improving our knowledge in this field.

References

1. Neuhauser B, Greiner A, Jaschke W, Chemelli A, Fraedrich G. Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection. Eur J Cardiothorac Surg 2008;33:58-63.[Abstract/Free Full Text]
2. Winnerkvist A, Lockowandt U, Rasmussen E, Radegran K. A prospective study of medically treated acute type B aortic dissection. Eur J Vasc Endovasc Surg 2006;32(4):349-355.[CrossRef][Medline]
3. Fanelli F, Salvatori FM, Marcelli G, Bezzi M, Totaro M, Vagnarelli S, Dake, MD, Rossi P, Passariello R. Type A aortic dissection developing during endovascular repair of an acute type B dissection. J Endovasc Ther 2003;10:254-259.[CrossRef][Medline]
4. Fayad A. A misplaced guide wire in the false lumen during endovascular repair of a type B aortic dissection. Can J Anaesth 2007;54(11):947-948.[Free Full Text]

This article has been cited by other articles:

				B. Neuhauser Reply to Mastroroberto et al.Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection. Eur. J. Cardiothorac. Surg., May 1, 2008; 33(5): 946 - 947. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pasquale Mastroroberto Antonio di Virgilio Attilio Renzulli Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Mastroroberto, P. Articles by Indolfi, C. PubMed Articles by Mastroroberto, P. Articles by Indolfi, C. Related Collections Great vessels