Skip to main content

Endovascular Therapy for Thoracic Aortic Dissection and Intramural Hematoma

  • Chapter
  • First Online:
Vascular Reconstructions

Abstract

Endovascular therapy is becoming the standard of care for treating aortic diseases. The continuously evolving technology helps improve new-generation stent grafts and the imaging modalities, so that it is possible to obtain durable results and decrease the amount of complications. The imaging modalities of CT angiography (CTA), transesophageal echocardiography (TEE), and in some cases, MR angiography (MRA), are used preoperatively to give an overview of the anatomy, including the aortic side branches, the landing zone, the angle of the take-off branch vessels, and the entry and re-entry tears. Intraoperatively, fluoroscopy and intravascular ultrasound (IVUS) are widely used. This chapter outlines the steps of endovascular therapy for aortic dissection and intramural hematoma.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 229.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 299.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. VIRTUE Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE registry. Eur J Vasc Endovasc Surg. 2014;48:363–71. https://doi.org/10.1016/j.ejvs.2014.05.007.

    Article  Google Scholar 

  2. Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation. 2003;108:628–35. https://doi.org/10.1161/01.CIR.0000087009.16755.E4.

    Article  PubMed  Google Scholar 

  3. Suzuki T, Eagle KA, Bossone E, Ballotta A, Froehlich JB, Isselbacher EM. Medical management in type B aortic dissection. Ann Cardiothorac Surg. 2014;3:413–7. https://doi.org/10.3978/j.issn.2225-319X.2014.07.01.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Li FR, Wu X, Yuan J, Wang J, Mao C, Wu X. Comparison of thoracic endovascular aortic repair, open surgery and best medical treatment for type B aortic dissection: a meta-analysis. Int J Cardiol. 2018;250:240–6. https://doi.org/10.1016/j.ijcard.2017.10.050.

    Article  PubMed  Google Scholar 

  5. Goldberg JB, Kim JB, Sundt TM. Current understandings and approach to the management of aortic intramural hematomas. Semin Thorac Cardiovasc Surg. 2014;26:123–31. https://doi.org/10.1053/j.semtcvs.2014.07.003.

    Article  PubMed  Google Scholar 

  6. Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, et al. Outcomes of patients with acute type a aortic intramural hematoma. Circulation. 2009;120:2046–52. https://doi.org/10.1161/CIRCULATIONAHA.109.879783.

    Article  PubMed  Google Scholar 

  7. Tittle SL, Lynch RJ, Cole PE, Singh HS, Rizzo JA, Kopf GS, Elefteriades JA. Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta. J Thorac Cardiovasc Surg. 2002;123:1051–9.

    Article  Google Scholar 

  8. Song JK, Kim HS, Song JM, Kang DH, Ha JW, Rim SJ, et al. Outcomes of medically treated patients with aortic intramural hematoma. Am J Med. 2002;113:181–7.

    Article  Google Scholar 

  9. Sueyoshi E, Sakamoto I, Fukuda M, Hayashi K, Imada T. Long-term outcome of type B aortic intramural hematoma: comparison with classic aortic dissection treated by the same therapeutic strategy. Ann Thorac Surg. 2004;78:2112–7.

    Article  Google Scholar 

  10. Pelzel JM, Braverman AC, Hirsch AT, Harris KM. International heterogeneity in diagnostic frequency and clinical outcomes of ascending aortic intramural hematoma. J Am Soc Echocardiogr. 2007;20:1260–8.

    Article  Google Scholar 

  11. Estrera A, Miller C 3rd, Lee TY, De Rango P, Abdullah S, Walkes JC, et al. Acute type A intramural hematoma: analysis of current management strategy. Circulation. 2009;120:S287–91. https://doi.org/10.1161/CIRCULATIONAHA.108.844282.

    Article  PubMed  Google Scholar 

  12. Ferrera C, Vilacosta I, Gómez-Polo JC, Villanueva-Medina S, Cabeza B, Ortega L, et al. Evolution and prognosis of intramural aortic hematoma. Insights from a midterm cohort study. Int J Cardiol. 2017;249:410–3. https://doi.org/10.1016/j.ijcard.2017.09.170.

    Article  PubMed  Google Scholar 

  13. Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, et al. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2015;47:209–17. https://doi.org/10.1093/ejcts/ezu386.

    Article  PubMed  Google Scholar 

  14. Idrees J, Arafat A, Johnston DR, Svensson LG, Roselli EE. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg. 2014;147:151–4. https://doi.org/10.1016/j.jtcvs.2013.08.075.

    Article  PubMed  Google Scholar 

  15. Moore AG, Eagle KA, Bruckman D, Moon BS, Malouf JF, Fattori R, et al. Choice of computed tomography, transesophageal echocardiography, magnetic resonance imaging, and aortography in acute aortic dissection: International Registry of Acute Aortic Dissection (IRAD). Am J Cardiol. 2002;89:1235–8.

    Article  Google Scholar 

  16. Baliga RR, Nienaber CA, Bossone E, Oh JK, Isselbacher EM, Sechtem U, et al. The role of imaging in aortic dissection and related syndromes. JACC Cardiovasc Imaging. 2014;7:406–24. https://doi.org/10.1016/j.jcmg.2013.10.015.

    Article  PubMed  Google Scholar 

  17. Hayter RG, Rhea JT, Small A, Tafazoli FS, Novelline RA. Suspected aortic dissection and other aortic disorders: multi-detector row CT in 373 cases in the emergency setting. Radiology. 2006;238:841–52. http://pubs.rsna.org/doi/10.1148/radiol.2383041528

    Article  Google Scholar 

  18. Schwein A, Khan M, Bennett M, Chakfé N, Lumsden AB, Bismuth J, Shah DJ. Proposed magnetic resonance imaging criteria to diagnose intramural haematoma and to predict aortic healing after acute type B aortic syndrome. Eur J Vasc Endovasc Surg. 2019;57:350–9. https://doi.org/10.1016/j.ejvs.2018.09.017.

    Article  PubMed  Google Scholar 

  19. Schulz CJ, Schmitt M, Böckler D, Geisbüsch P. Feasibility and accuracy of fusion imaging during thoracic endovascular aortic repair. J Vasc Surg. 2016;63:314–22. https://doi.org/10.1016/j.jvs.2015.08.089.

    Article  PubMed  Google Scholar 

  20. Lortz J, Tsagakis K, Rammos C, Horacek M, Schlosser T, Jakob H, et al. Intravascular ultrasound assisted sizing in thoracic endovascular aortic repair improves aortic remodeling in type B aortic dissection. PLoS One. 2018;13:e0196180. https://doi.org/10.1371/journal.pone.0196180.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Wallace GA, Starnes BW, Hatsukami TS, Sobel M, Singh N, Tran NT. Intravascular ultrasound is a critical tool for accurate endograft sizing in the management of blunt thoracic aortic injury. J Vasc Surg. 2015;61:630–5. https://doi.org/10.1016/j.jvs.2014.10.014.

    Article  PubMed  Google Scholar 

  22. Marty B, Tozzi P, Ruchat P, Haesler E, von Segesser LK. Systematic and exclusive use of intravascular ultrasound for endovascular aneurysm repair - the Lausanne experience. Interact Cardiovasc Thorac Surg. 2005;4:275–9.

    Article  Google Scholar 

  23. Pearce BJ, Jordan WD Jr. Using IVUS during EVAR and TEVAR: improving patient outcomes. Semin Vasc Surg. 2009;22:172–80. https://doi.org/10.1053/j.semvascsurg.2009.07.009.

    Article  PubMed  Google Scholar 

  24. Agricola E, Slavich M, Rinaldi E, Bertoglio L, Civilini E, Melissano G, et al. Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure. Eur Heart J Cardiovasc Imaging. 2016;17:67–75. https://doi.org/10.1093/ehjci/jev118.

    Article  PubMed  Google Scholar 

  25. Agricola E, Slavich M, Bertoglio L, Civilini E, Melissano G, Marone E, et al. Contrast-enhanced TEE during thoracic endovascular aortic repair procedure. JACC Cardiovasc Imaging. 2015;8:980–2. https://doi.org/10.1016/j.jcmg.2014.07.029.

    Article  PubMed  Google Scholar 

  26. McNally MM, Scali ST, Feezor RJ, Neal D, Huber TS, Beck AW. Three-dimensional fusion computed tomography decreases radiation exposure, procedure time, and contrast use during fenestrated endovascular aortic repair. J Vasc Surg. 2015;61:309–16. https://doi.org/10.1016/j.jvs.2014.07.097.

    Article  PubMed  Google Scholar 

  27. Hertault A, Maurel B, Sobocinski J, Martin Gonzalez T, Le Roux M, Azzaoui R, et al. Impact of hybrid rooms with image fusion on radiation exposure during endovascular aortic repair. Eur J Vasc Endovasc Surg. 2014;48:382–90. https://doi.org/10.1016/j.ejvs.2014.05.026.

    Article  CAS  PubMed  Google Scholar 

  28. Miao S, Liao R, Pfister M, Zhang L, Ordy V. System and method for 3-D/3-D registration between non-contrast-enhanced CBCT and contrast-enhanced CT for abdominal aortic aneurysm stenting. Med Image Comput Comput Assist Interv. 2013;16:380–7.

    PubMed  Google Scholar 

  29. Khoynezhad A, Kruse MJ. Guidewires, catheters, and sheaths used for thoracic endografting procedures. J Card Surg. 2009;24:113–9. https://doi.org/10.1111/j.1540-8191.2008.00628.x.

    Article  PubMed  Google Scholar 

  30. Kinney EV, Fogarty TJ, Newman CE. Catheter skills. In: White RA, Fogarty TJ, editors. Peripheral endovascular interventions. 2nd ed. New York: Springer; 1999. p. 247–58.

    Chapter  Google Scholar 

  31. Poon SS, Theologou T, Harrington D, Kuduvalli M, Oo A, Field M. Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2016;5:156–73. https://doi.org/10.21037/acs.2016.05.06.

    Article  PubMed  PubMed Central  Google Scholar 

  32. MacGillivray TE. How I teach hemi-arch replacement. Ann Thorac Surg. 2016;101:1251–4. https://doi.org/10.1016/j.athoracsur.2016.02.047.

    Article  PubMed  Google Scholar 

  33. Vallabhajosyula P, Szeto WY, Desai N, Komlo C, Bavaria JE. Type II arch hybrid debranching procedure. Ann Cardiothorac Surg. 2013;2:378–86. https://doi.org/10.3978/j.issn.2225-319X.2013.05.08.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Di Bartolomeo R, Murana G, Di Marco L, Pantaleo A, Alfonsi J, Leone A, Pacini D. Frozen versus conventional elephant trunk technique: application in clinical practice. Eur J Cardiothorac Surg. 2017;51:i20–8. https://doi.org/10.1093/ejcts/ezw335.

    Article  PubMed  Google Scholar 

  35. LeMaire SA, Weldon SA, Coselli JS. Total aortic arch replacement: current approach using the trifurcated graft technique. Ann Cardiothorac Surg. 2013;2:347–52. https://doi.org/10.3978/j.issn.2225-319X.2013.05.02.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jean Bismuth .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Science+Business Media, LLC, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Belvroy, V.M., Chinnadurai, P., Bismuth, J. (2021). Endovascular Therapy for Thoracic Aortic Dissection and Intramural Hematoma. In: Hoballah, J.J., Bechara, C.F. (eds) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_31

Download citation

  • DOI: https://doi.org/10.1007/978-1-0716-1089-3_31

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-0716-1087-9

  • Online ISBN: 978-1-0716-1089-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics