HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Permission Requests Google Scholar Articles by Neuhauser, B. PubMed Articles by Neuhauser, B. Related Collections Great vessels

Letters to the Editor

Reply to Mastroroberto et al.

Serious complications following endovascular thoracic aortic stent-graft repair for type B dissection

Department of Vascular Surgery, University Hospital Innsbruck, Austria

Received 22 January 2008; accepted 24 January 2008.

^_* Corresponding author. Address: Department of Vascular Surgery, University Hospital Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. Tel.: +43 512 504 80800; fax: +43 512 504 22559. (Email: Beate.Neuhauser{at}i-med.ac.at).

Key Words: Endovascular thoracic aortic repair • Severe complication • Type B dissection

We would like to thank Mastroroberto et al. for their comments [1] on our paper regarding our observations in our report called serious complications following endovascular thoracic aortic stent-graft repair for type B dissection [2].

Indication for endovascular repair at our department is a complicated course of type B dissection including thoracic aortic rupture, suspicion of impending rupture, visceral and/or peripheral ischemia, uncontrollable hypertension, and severe therapy-resistant pain as mentioned in our paper within the method part. Medical therapy using vasodilators and beta-blockers is preferred in patients with an uncomplicated course. Conversely to Winnerkvist et al. [3], Marui et al. [4] reported that 43% of patients initially medically treated for acute type B dissection progressed to have aortic enlargement. Dilatation to 6 cm or greater occurred in nearly 30% within a mean follow-up time of 59 months. Therefore life-long follow-up investigations and strict antihypertensive medication are mandatory even after successful initial stent graft therapy.

We agree with your statement that the initial act of retrograde dissection might be the ‘stent-graft-procedure’ itself. Wire and sheath handling during the endovascular procedure might cause localized intimal minimal tears in the extremely fragile and easily injured intimal flap and aortic wall. Balloon dilatation needs to be avoided whenever possible to avoid iatrogenic intimal injuries. Extremely careful handling of the endovascular devices by a widely experienced interventionalist is mandatory to contribute to a successful endovascular procedure in patients suffering from acute type B dissection. The device itself may have also contributed to the new onset dissection. It is well known that the Gore Excluder prosthesis has a better longitudinal flexibility that adapts better to the aortic curve of the distal arch than the Talent device, which has a semi-rigid design. However, both types of stent-grafts might require balloon dilatation to accommodate the curved geometry of the aortic arch and to form a tight seal. Intimal injuries directed by local forces against the intima may have occurred. In addition, routinely performed stent-graft oversizing may have contributed to the intimal injuries despite exact measurements and the use of stent-graft oversizes recommended by the manufactures were used. Our inserted stent-grafts are usually 10% larger than the diameter of the non-effected segment of the aorta proximal to the entry tear to achieve secure proximal sealing.

Acute surgical treatment in type B dissection is reserved for patients with a complicated course such as dissection progression bearing the risk of aortic rupture, branch vessel occlusion resulting in visceral and/or leg ischemia, refractory hypertension or pain. Aortic replacement for acute aortic dissection showed significant mortality (29–50%) and paraplegia rate (30–36%) [5]. The 30-day mortality rate following endovascular type B dissection repair is acceptably low at 8.4%. There was and is a clear need for less invasive techniques. Better patient selection, precise stent-graft deployment, and the avoidance of balloon dilatation whenever possible may help to prevent these complications.

References

1. Mastroroberto P, di Virgilio A, Renzulli A, Indolfi C. Endovascular repair of type B aortic dissection: is possible to prevent post-procedure complications?. Eur J Cardiothorac Surg 2008;33:945-946.[Free Full Text]
2. 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]
3. 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]
4. Marui A, Mochizuki T, Mitsui N, Koyama T, Kimura F, Horibe M. Toward the best treatment for uncomplicated patients with type B acute aortic dissection: a consideration for sound surgical indication. Circulation 1999;100:275-280.
5. Crawford ES, Svensson LG, Hess KR, Shenaq SS, Coselli JS, Safi HJ, Mohindra PK, Rivera V. A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 1991;13:36-45[discussion 45–6].[CrossRef][Medline]

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 Permission Requests Google Scholar Articles by Neuhauser, B. PubMed Articles by Neuhauser, B. Related Collections Great vessels