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J Thorac Cardiovasc Surg 2007;134:1360-1362
© 2007 The American Association for Thoracic Surgery

Brief Communication

Immediate "total" aortic true lumen expansion in type A and B acute aortic dissection after endovascular aortic endografting and GZSD bare stenting

^a Vascular Interventional Section, Medical Imaging, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
^b Department of Cardiothoracic Surgery, St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia
^c Department of Vascular Surgery, Monash Medical Centre, Melbourne, Victoria, Australia
^d Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.

Received for publication August 31, 2006; revisions received February 20, 2007; accepted for publication March 8, 2007.

^_* Address for reprints: Peter J Mossop, MB, BS, FRACR, Director of Vascular Interventional Radiology, St Vincent’s Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria 3065 Australia. (Email: Peter.MOSSOP{at}svhm.org.au).

Use of bare metal stenting is a novel approach for more complete reconstruction of aortic dissection.¹ Treatment advancement with endografting^2,3 and bare stenting for total aortic reconstruction has been previously reported.¹ In this article we report our results for complete endovascular aortic stenting in acute dissection for both type A and B cases.

Deficiencies have persisted with endografts in the treatment of thoracic dissections.⁴ Stent graft closure of the primary entry tear, typically in the proximal descending aorta, results in decompression of the thoracic false lumen with proximal thrombosis and remodeling. However, this technique does not address the need in some cases to more fully remodel the entire aorta and ensure distal branch vessel perfusion.^2,3 Furthermore, the presence of complex distal re-entries, often related to branch vessels, prohibits extensive treatment with standard tube endografts.

Case reports of Z-stent use for prevention of malperfusion suggest its utility in aortic dissection.⁵ Additionally, we have found bare metal stenting accelerates true lumen remodeling, reduces false lumen volume, and enhances branch vessel perfusion. Our study evaluates quantitatively the postdissection true lumen expansion as a result of Z stenting with or without additional endografting of the primary entry tear.

From 2002 to 2005, 9 patients were treated for acute aortic dissection (3 type A and 6 type B) using Z stenting of the thoracic and abdominal aorta. Patient selection included acute phase false lumen growth (>0.5 cm), malperfusion or mesenteric branch involvement, and true lumen collapse (which did not expand after proximal endograft placement) (Table 1). Initially Gianturco Z stents and subsequently the purpose built Zenith DISSECTION thoracic endovascular stent (Cook Vascular Inc, Bloomington, Ind) were used. The latter consisted of a self-expanding stainless steel Z-stent assembly with an unconstrained diameter of 46 mm (Figure 1, A and B). Zenith TX2 thoracic endovascular grafts (Cook Vascular Inc) were used in conjunction with body and iliac extension pieces to close both primary and secondary entries as required. In type B dissection after endograft closure of the primary entry tear, bare metal Z stents were deployed in the residually delaminated aorta (Figure 1, C and D). The stented segment overlapped the distal endograft and extended to cover the mesenteric vessels. All type A dissections were treated by surgical repair of the ascending aorta followed by immediate endograft and/or bare aortic stenting. Type A repair in 2 patients with no significant proximal descending thoracic entry tear was performed with bare metal stenting alone. Technically successful deployment was achieved in all patients. An average of 1.5 stents was used per patient. Average deployment time for bare stenting was 12 minutes (range 10–16 minutes).

View larger version (86K): [in this window] [in a new window]   Figure 1. A, The Zenith DISSECTION thoracic endovascular stent is a one-piece cylindrical device constructed from self-expanding stainless steel Cook-Z stent segments sewn together with polyester suture in multiple lengths (4, 6, or 8 stent segments) and preloaded in a 16F introducer sheath. The stent seen deployed in glass model with proximal overlap into a Zenith TX2 thoracic endovascular graft has a single diameter (46 mm), which can be deployed in aortic diameters ranging from 24 to 38 mm. B, An example of a postprocedure maximum intensity projection computed tomographic angiogram showing endograft and Z-stent reconstructed thoracoabdominal aorta with complete obliteration of the dissection at 1 month. C, Preprocedure computed tomographic scan showing acute type B dissection with false lumen compression of the true lumen. D, Computed tomographic scan 6 month after the procedure showing position of bare metal stents with reexpansion of the true lumen and obliteration of the false lumen.

The true lumen index represents the percentage of true lumen relative to the total aortic cross-sectional area on computed tomography. Expansion indexes were percentage changes in true lumen area compared with the posttreatment area and were derived from the thoracic and abdominal aorta (at thoracic T8 and celiac axis L1 levels, respectively) at 3 time points: before treatment, immediately after treatment, and 3 months after treatment. The thoracic cross-sectional area was below the endograft in all cases. Statistics were performed with a Student t test for 2 groups or an analysis of variance followed by a post hoc Tukey test.

Stent deployment in the thoracic aorta resulted in an immediate increase in thoracic true lumen index (true lumen area/total aorta area) from 39% ± 15% (standard deviation [SD]) to 71% ± 16% (SD) (P < .001) and average true lumen expansion was 141%. This was maintained at 3 months’ follow-up: 74% ± 17% (SD). The mean abdominal aortic true lumen index increased from 41% ± 17% (SD) to 75% ± 14% (SD) (P < .001) after stenting and was maintained at 3 months’ follow-up: 79% ± 16% (SD). Mean immediate abdominal true lumen expansion was greater than 130%.

Follow-up over a mean of 18 months revealed no mortality. One patient with type A dissection (Table 1) had a perioperative cerebrovascular accident but recovered fully.

No long-term adverse events related to Z-stent implantation, including stent migration, fracture, intimal flap erosion, or redissection, was seen.

Z stenting is a safe ancillary endovascular technique in the treatment of acute aortic dissection. Z stenting allows rapid support and immediate expansion of the aortic true lumen without the necessity to resort to extensive endograft implantation, while facilitation of thrombosis and obliteration of the false lumen often effectively eliminates residual aortic dissection.

Footnotes

¹ Peter Mossop, MB, BS, FRACR, and Ian Nixon, MB, BS, FRACS, report consulting fees and royalties from Cook, Inc.

References

1. Mossop PJ, McLachlan CS, Amukotuwa SA, Nixon IK. Staged endovascular treatment for complicated type B aortic dissection. Nat Clin Pract Cardiovasc Med 2005;2:316-332.[Medline]
   
2. 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]
   
3. 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]
   
4. Gaxotte V, Thony F, Rousseau H, Lions C, Otal P, Willoteaux S, et al. Midterm results of aortic diameter outcomes after thoracic stent-graft implantation for aortic dissection: a multicenter study. J Endovasc Ther 2006;13:127-138.[Medline]
   
5. Ito N, Tsunoda T, Nakamura M, Iijima R, Matsuda K, Suzuki T, et al. Percutaneous bare Z-stent implantation as an alternative to surgery for acute aortic dissection with visceral ischemia. Catheter Cardiovasc Interv 2003;58:95-100.[Medline]
   

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