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J Thorac Cardiovasc Surg 2004;127:1808-1810
© 2004 The American Association for Thoracic Surgery

Brief communication

Successful treatment of a Stanford type A dissection by percutaneous placement of a covered stent graft in the ascending aorta

^a Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif, USA
^b Division of Cardiovascular and Interventional Radiology, Stanford University School of Medicine, Stanford, Calif, USA

Received for publication November 11, 2003; revisions received December 2, 2003; accepted for publication December 12, 2003.

^* Address for reprints: Kai Ihnken, MD, Stanford University Hospital, Department of CT-Surgery, Falk CVRB, 300 Pasteur Dr, Stanford, CA 94305, USA
kihnken{at}yahoo.com

Dr Ihnken

The criterion standard treatment for acute Stanford type A aortic dissection is emergency surgical intervention. Stent-graft placement has emerged as an alternative treatment for various descending aortic pathologic conditions, including complicated type B dissections, aortic rupture, giant penetrating ulcers, aneurysms, and stent-graft coverage of the primary intimal tear.^1,2 A combined surgical and endovascular approach for acute ascending aortic dissection has been reported.³ We report on percutaneous stent-graft placement in the ascending aorta as a primary and sole treatment for acute Stanford type A dissection.

Clinical summary

An 89-year old woman was admitted for acute onset of severe chest and back pain. A spiral computed tomographic (CT) angiogram demonstrated severe atherosclerotic degeneration, extensive intramural hematoma from the aortic root to the level of the celiac axis, and a primary intimal tear in the distal ascending aorta. Extensive blood in the mediastinum and pericardium suggested a contained rupture (Figure 1).

View larger version (161K): [in this window] [in a new window]   Figure 1. CT angiography before treatment. A, Axial CT image shows intimal tear (arrow) in ascending aorta with severe intramural hemorrhage (arrowheads). B, Oblique-sagittal reformatted image shows intimal tear (arrow) at undersurface of distal ascending aorta. C and D, Three-dimensional volume-rendered images illustrate relationship of left coronary artery (LCA) and supra-aortic branches to intimal tear (arrow). RBCA, Right brachiocephalic artery; RCA, right coronary artery.

When presented with the option of stent-graft placement, the patient agreed to proceed, and written informed consent was obtained. An aortogram demonstrated progression to complete dissection with patent false lumen (Figure 2). This was confirmed by intraoperative transesophageal echocardiography. With the patient under general anesthesia, a Genesis 3910 bare stent (Cordis, Warren, NJ) was dilated to a diameter of 14 mm in the brachiocephalic artery. A 40 x 10-mm Excluder stent graft (W. L. Gore & Associates, Inc, Flagstaff, Ariz) was deployed in the ascending aorta, above the coronary arteries and flush with the origin of the brachiocephalic artery. It was balloon dilated distally. Aortography demonstrated successful exclusion of the proximal dissection, as well as patent coronary and great vessels (Figure 2). Lack of flow into the false lumen and preservation of flow in the coronary arteries was confirmed by transesophageal echocardiography. Partial avulsion and complete dissection of the right external iliac artery was repaired surgically by means of an interposition graft.

View larger version (103K): [in this window] [in a new window]   Figure 2. Intra-arterial angiography. A, Digital subtraction angiographic image (left anterior oblique projection) shows interval development of Stanford type A aortic dissection. Intimal tear is seen on undersurface of distal ascending aorta (arrow). Faint opacification is visible on false lumen (arrowheads). B, Predeployment angiographic image shows stent graft folded on delivery device (open arrow). Bare stent is seen in brachiocephalic artery (curved arrow). TEE, Transesophageal echocardiographic probe. C, Postdeployment digital subtraction angiographic image shows closure of previous intimal tear (arrow). There is no opacification of false lumen.

View larger version (152K): [in this window] [in a new window]   Figure 3. CT angiography after treatment. Axial (A) and oblique-sagittal (B) CT images at same levels as in Figure 1 confirm coverage of intimal tear with aortic stent graft. Note decreased thickness of thrombosed false lumen surrounding thoracic aorta (arrowheads). Volume-rendered views (C, D) show relationship of stent graft to left coronary artery (LCA) and right brachiocephalic artery (RBCA).

Emergency surgical replacement of the ascending aorta is still considered the criterion standard therapy for acute type A dissection. Treatment of pathologic conditions of the descending aorta is evolving, especially for high-risk patients. In addition to applications for descending thoracic aneurysms, transection, and giant penetrating ulcers, the use of stent grafts to cover the primary intimal tear in the descending aorta has become a viable and increasingly accepted option.^1,2,4 We report here the successful percutaneous treatment of an acute Stanford type A dissection with a covered stent graft as primary and sole treatment. This alternative was chosen because of the unwillingness of the patient to be subjected to the risk of a surgical intervention.

By applying percutaneous interventional methods precluding sternotomy, thoracotomy, and cardiopulmonary bypass, it seems possible to reduce mortality and morbidity in a highly selected patient group with aortic pathologic conditions.⁴ Potential complications of catheter-based interventions are evident.

Another interesting side aspect is the documentation of progression of the disease process from a localized aortic tear with an extensive intramural hematoma to a full-blown aortic dissection within 24 hours, as documented by three imaging techniques. The early result in our case is very encouraging, and the CT scan confirmed achievement of the hemodynamic and anatomic goals associated with successful conventional surgical repair. The durability of stent-graft repair remains to be proven. Further application in highly selected patients seems warranted.

References

1. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340:1546–1552[Medline]
   
2. Grabenwoger M, Fleck T, Czerny M, Hutschala D, Ehrlich M, Schoder M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes. Eur J Cardiothorac Surg. 2003;23:788–793[Abstract/Free Full Text]
   
3. Ishihara H, Uchida N, Yamasaki C, Sakashita M, Kanou M. Extensive primary repair of the thoracic aorta in Stanford type A acute aortic dissection by means of a synthetic vascular graft with a self-expandable stent. J Thorac Cardiovasc Surg. 2002;123:1035–1040[Abstract/Free Full Text]
   
4. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999;340:1539–1545[Medline]
   

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