Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 142; no. 5; pp. 1074 - 1083
• Main Authors: Kang, Woong Chol, MD, PhD, Greenberg, Roy K., MD, Mastracci, Tara M., MD, Eagleton, Matthew J., MD, Hernandez, Adrian V., MD, PhD, Pujara, Akshat C., BA, Roselli, Eric E., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Mosby, Inc 01-11-2011; Elsevier
• Subjects: Adult; Aged; Aged, 80 and over; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Aneurysm, Dissecting - complications; Aneurysm, Dissecting - diagnosis; Aneurysm, Dissecting - mortality; Aneurysm, Dissecting - surgery; Aortic Aneurysm - complications; Aortic Aneurysm - diagnosis; Aortic Aneurysm - mortality; Aortic Aneurysm - surgery; Aortography - methods; Biological and medical sciences; Blood and lymphatic vessels; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - mortality; Cardiology. Vascular system; Cardiothoracic Surgery; Chronic Disease; Diseases of the aorta; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Endovascular Procedures - adverse effects; Endovascular Procedures - mortality; Female; Humans; Kaplan-Meier Estimate; Linear Models; Male; Medical sciences; Middle Aged; Ohio; Pneumology; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Survival Rate; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ohio; 36.1; thoracic endovascular repair; 26.1.2; CDAD; chronic distal aortic dissection; TEVAR; Corrective surgery; Prognosis; Cardiovascular disease; Endovascular route; Arterial disease; Vascular disease; Chronic; Treatment; Distal; Anesthesia; Aortic dissection; Complication; Circulatory system; Cardiology; Repair; Aortic disease
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2011.03.008

Introduction Patients with chronic distal aortic dissection (CDAD) remain at high risk for late aorta-related events and reinterventions, and the ideal management strategy remains undefined. Open surgical procedures carry morbidity, but scant data for thoracic endovascular aortic repair (TEVAR) of CDAD exist. This study reports our intermediate-term results with TEVAR for complicated CDAD. Methods All cases of TEVAR for complicated (aortic growth, malperfusion, intractable pain) CDAD at our institution between 2000 and 2007 were retrospectively reviewed. Demographic information, indications for repair, complications, and aortic morphologic changes were collected from medical records and imaging studies. Aortic morphology (aneurysm size, false lumen thrombosis) was assessed at multiple levels with 3-dimensional image analysis techniques. Kaplan-Meier analysis was used to estimate survival, freedom from reintervention, and likelihood of false lumen thrombosis, with log-rank tests used to discriminate between Kaplan-Meier curves. Results In total, 144 stent–grafts were implanted in 76 consecutive patients (49 male) with complicated CDAD. Early (<30 postoperative days) mortality was 5%. There was no paraplegia, and 1 patient died of stroke. At mean follow-up of 34 months, 12 patients had died (1 aorta-related death). Seventeen patients (22%) underwent 19 secondary aortic reinterventions, mainly for enlargement of the untreated aorta remote to stent–graft repair. Three secondary procedures treated retrograde proximal dissections. Estimated survivals were 86%, 82%, and 80% at 12, 24, and 36 months, respectively, and freedoms from both death and reintervention were 72%, 64%, and 59% at similar time points. Of 67 patients (88%) with complete imaging follow-up, TEVAR resulted in significantly decreased aortic diameter through the stent–grafted segment but not untreated segments. Complete thrombosis of the entire false lumen was uncommon in patients with extensive dissections (13% vs 78% P  < .001). Conclusions Management of complicated CDAD remains challenging for clinicians. TEVAR is a reasonable treatment modality for dissections limited to the thoracic aorta and for prevention of focal aortic growth in extensive dissections. Late complications and the need for secondary interventions emphasize the complexity of this patient population and the need for long-term follow-up.