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J Thorac Cardiovasc Surg 2009;138:324-333
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Infolding and collapse of thoracic endoprostheses: Manifestations and treatment options

Daniel Y. Sze, MD, PhDa,*, R. Scott Mitchell, MDb, D. Craig Miller, MDb, Dominik Fleischmann, MDc, Joan K. Frisoli, MD, PhDa, Stephen T. Kee, MDa, Archana Verma, MDa, Michael P. Sheehan, MSN, RN, FNPb, Michael D. Dake, MDa,b

a Division of Interventional Radiology, Stanford University, Stanford, Calif
b Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
c Department of Radiology, Stanford University, Stanford, Calif

Received for publication September 4, 2008; revisions received November 6, 2008; accepted for publication December 14, 2008.

* Reprint requests: Daniel Y. Sze, MD, PhD, H-3646 Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305-5642. (Email: dansze{at}stanford.edu).

Objectives: We sought to review the clinical sequelae and imaging manifestations of thoracic aortic endograft collapses and infoldings and to evaluate minimally invasive methods of repairing such collapses.

Methods: Two hundred twenty-one Gore endografts (Excluder, TAG; W. L. Gore & Associates, Inc, Flagstaff, Ariz) were deployed in 145 patients for treatment of pathologies including aneurysms and pseudoaneurysms, dissections, penetrating ulcers, transections, fistulae, mycotic aneurysms, and neoplastic invasions in 6 different prospective trials at a single institution from 1997 to 2007. Device collapses and infoldings were analyzed retrospectively, including review of anatomic parameters, pathologies treated, device sizing and selection, clinical sequelae, methods of repair, and outcome.

Results: Six device collapses and infoldings were identified. Oversized devices placed into small-diameter aortas and imperfect proximal apposition to the lesser curvature were seen in all proximal collapses, affecting patients with transections and pseudoaneurysms. Infoldings in patients undergoing dissection represented incomplete initial expansion rather than delayed collapse. Delayed collapse occurred as many as 6 years after initial successful deployment, apparently as a result of changes in the aortic configuration from aneurysmal shrinkage. Clinical manifestations ranged from life-threatening ischemia to complete lack of symptoms. Collapses requiring therapy were remedied percutaneously by bare stenting or in one case by branch vessel embolization.

Conclusions: Use of oversized devices in small aortas carries a risk of device failure by collapse, which can occur immediately or after years of delay. When clinically indicated, percutaneous repair can be effectively performed.

Abbreviations and Acronyms CT = computed tomographic; FDA = US Food and Drug Administration; IFU = Instructions for Use; ISIDE = Investigator-sponsored Investigational Device Exemption; LSCA = left subclavian artery; PIT = primary intimal tear






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