Abstract
Aortic dissection is most often a catastrophic medical emergency which, if untreated, can be potentially fatal. The intention of therapy in patients with aortic dissection is to prevent aortic rupture or aneurysm formation as well as to relieve branch vessel ischaemia. Patients with aortic dissection are often poor candidates for anaesthesia and surgery and the surgical procedure itself is challenging requiring thoracotomy, aortic cross clamping, blood transfusion as well as prolonged hospital stay in some cases. Operative mortality is especially high in patients with critical mesenteric or renal ischaemia. The past decade has experienced the emergence of a number of interventional radiological or minimally invasive techniques which have significantly improved the management of patients with aortic dissection. These include stent grafting for entry site closure to prevent aneurysmatic widening of the false lumen as well as percutaneous techniques such as balloon fenestration of the intimal flap and aortic true lumen stenting to alleviate branch vessel ischaemia. False lumen thrombosis following entry closure with stent grafts has been observed in 86–100% of patients, whereas percutaneous interventions are able to effectively relieve organ ischaemia in approximately 90% of the cases. In the years to come, it is to be expected that these endoluminal techniques will become the method of choice for treating most type-B dissections and will assist in significantly reducing the number of open surgical procedures required for type-A dissections. The intention of this article is to provide an overview of the current status of these endoluminal techniques based on our own experience as well as on a review of the relevant literature.
Similar content being viewed by others
References
Borst HG, Heinemann MK, Stone CD (eds) (1996) Surgical treatment of aortic dissection. Churchill Livingstone, New York
Kato M, Matsuda T, Kaneko M, Kuratani T, Mizushima T, Seo Y, Uchida H, Kichikawa K, Maeda M, Ohnishi K (1998) Outcomes of stent-graft treatment of false lumen in aortic dissection. Circulation 98:305–312
Dake MD, Noriyuki Kato, Mitchell RS, Semba CP, Razavi MK, Shimono T, Hirano T, Takeda K, Yada I, Miller DC (1999) Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 340:1546–1552
Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, Kodolitsch Y von, Nicolas V, Pierangeli A (1999) Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 340:1539–1545
Williams DM, Lee DY, Hamilton BH, Marx MV, Narasimham DL, Kazanjian SN, Prince MR, Andrews JC, Cho KJ, Deeb GM (1997) The dissected aorta: percutaneous treatment of ischemic complications: principles and results. J Vasc Interv Radiol 8:605–625
Slonim SM, Nyman U, Semba CP, Miller DC, Mitchell SR, Dake MD (1996) Aortic dissection: percutaneous management of ischaemic complications with endovascular stents and balloon fenestration. J Vasc Surg 23:241–253
Slonim SM, Nyman U, Semba CP, Miller DC, Mitchell SR, Dake MD (1996) True lumen obliteration in complicated aortic dissection: endovascular treatment. Radiology 201:161–166
Slonim SM, Miller DC, Mitchell RS, Semba CP, Razavi MK, Dake MD (1999) Percutaneous balloon fenestration and stenting for life-threatening ischaemic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg 117:1118–1127
Chavan A, Hausmann D, Dresler C, Rosenthal H, Jaeger K, Haverich A, Borst HG, Galanski M (1997) Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta. Circulation 96:2124–2127
Chavan A, Kutschka I, Rosenthal H, Goehde SC, Haverich A, Galanski M (1999) Percutaneous management of ischemic complications of aortic dissection. Radiology 213 (Suppl):S477
Chavan A, Galanski M, Pichlmaier M (2000) Minimal invasive therapieansätze bei der aortendissektion. Fortschr Röntgenstr 172:576–586
Doroghazi RM, Slater EE, Desanctis RW, Buckley MJ, Austen WG, Rosenthal S (1984) Long-term survival of patients with treated aortic dissection. J Am Coll Cardiol 3:1026–1034
Wheat MW Jr (1987) Acute dissection of the aorta. Cardiovasc Clin 17:241–262
Miller DC (1988) Vascular complications associated with spontaneous aortic dissection (discussion). J Vasc Surg 7:208–209
Heinemann MK, Buehner B, Schaefers HJ, Jurmann MJ, Laas J, Borst HG (1994) Malperfusion of the thoracoabdominal vasculature in aortic dissection. J Card Surg 9:748–757
Cambria RP, Brewster DC, Gertler J, Moncure AC, Gusberg R, Tilson D, Darling RC, Hammond G, Megerman J, Abbott WM (1988) Vascular complications associated with spontaneous aortic dissection. J Vasc Surg 7:199–209
Fann JI, Sarris GE, Mitchell RS, Shumway NE, Stinson EB, Oyer PE, Miller CD (1990) Treatment of patients with aortic dissection presenting with peripheral vascular complications. Ann Surg 212:705–713
Elefteriades JA, Hammond GL, Gusberg RJ, Kopf GS, Baldwin JC (1990) Fenestration revisited: a safe and effective procedure for descending aortic dissection. Arch Surg 125:786–790
Williams DM, Brothers TE, Messina LM (1990) Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum. Radiology 174:450–452
Vernhet H, Marty-Ané CH, Lesnik A, Chircop R, Serres-Cousiné O, Picard E, Mary H, Senac JP (1997) Dissection of the abdominal aorta in blunt trauma: management by percutaneous stent placement. Cardiovasc Interv Radiol 20:473–476
Erbel R, Oelert H, Meyer J et al. (1993) For the European cooperative study group on echocardiography: effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. Circulation 87:1064–1615
Williams DM, Andrews JC, Marx V, Abrams GD (1993) Creation of reentry tears in aortic dissection by means of percutaneous balloon fenestration: gross anatomic and histologic considerations. J Vasc Interv Radiol 4:75–83
Ergin MA, Phillips RA, Galla JD et al. (1994) Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 57:820–825
Vlahakes GJ (1999) Catheter-based treatment of aortic dissection. N Engl J Med 340:1585–1586
Chung JW, Elkins C, Sakai T, Kato N, Vestring T, Semba CP, Slonim SM, Dake MD (2000) True-lumen collapse in aortic dissection. Part II: evaluation of treatment methods in phantoms with pulsatile flow. Radiology 214:99–106
Dake MD (2001) Endovascular stent-graft management of thoracic aortic diseases. Eur J Radiol 39:42–49
Sailer J, Peloschek P, Rand T, Grabenwöger M, Thurnher S, Lammer J (2001) Endovascular treatment of aortic type B dissection and penetrating ulcer using commercially available stent-grafts. AJR 177:1365–1369
Czermak BV, Waldenberger P, Fraedrich G, Dessl AH, Roberts KE, Bale RJ, Perkmann R, Jaschke WR (2000) Treatment of Stanford type B aortic dissection with stent-grafts: preliminary results. Radiology 217:544–550
Kato N, Hirano T, Kawaguchi T, Ishida M, Shimono T, Yada I, Takeda K (2001) Aneurysmal degeneration of the aorta after stent-graft repair of acute aortic dissection. J Vasc Surg 34:513–518
Hausegger KA, Tiesenhausen K, Schedlbauer P, Oberwalder P, Tauss J, Rigler B (2001) Treatment of acute aortic type B dissection with stent-grafts. Cardiovasc Intervent Radiol 24:306–312
Kato N, Shimono T, Hirano T, Ishida M, Yada I, Takeda K (2001) Transluminal placement of endovascular stent-grafts for the treatment of type A aortic dissection with an entry tear in the descending thoracic aorta. J Vasc Surg 34:1023–1028
Shimshak TM, Giorgi LV, Hartzler GO (1988) Successful percutaneous angioplasty of an obstructed abdominal aorta secondary to a chronic dissection. Am J Cardiol 61:486–487
Saito S, Arai H, Kim K, Aoki N, Tsurugida M (1992) Percutaneous fenestration of dissecting intima with a transseptal needle: a new therapeutic technique for visceral ischaemia complicating acute aortic dissection. Cathet Cardiovasc Diagn 26:130–135
Cowling MG, Redwood D, Buckenham TM (1995) Case report: critical limb ischaemia due to aortic dissection relieved by percutaneous transfemoral fenestration. Clin Radiol 50:654–657
Faykus MH, Hiette P, Koopot R (1992) Percutaneous fenestration of type I aortic dissection for relief of lower extremity ischaemia. Cardiovasc Intervent Radiol 15:183–185
Kato N, Sakuma H, Takeda K, Hirano T, Nakagawa T (1993) Relief of acute lower limb ischaemia with percutaneous fenestration of intimal flap in a patient with type III aortic dissection: a case report. Angiology 44:755–759
Schild HH, Düber C, Grebe P, Hake U, Oelert H, Thelen M, Meyer J (1994) Transvaskuläre fensterung eines disseziierenden aortenaneurysmas. Fortschr Röntgenstr 2:164–167
Manke C, Strotzer M, Seitz J, Lenhart M, Aebert H, Kasprzak P, Kaiser B, Feurbach ST (1999) Ischämische komplikationen bei aortendissektion: perkutane behandlung mit ballonfensterung und stentimplantation. Fortschr Röntgenstr 198–204
Lookstein RA, Mitty H, Falk A, Guller J, Scott-Nowakowski F (2001) Aortic intimal dehiscence: a complication of percutaneous balloon fenestration for aortic dissection. J Vasc Interv Radiol 12:1347–1350
Nyman U, Ivancev K, Gottsäter A, Lindblad B, Lindh M, Uher P (1999) Chronic aortic dissection: stenting of aortic true lumen obliteration with late dynamic variations of both lumens. Cardiovasc Interv Radiol 22:135–149
Müller-Lung U, König M, Heidrich M, Sivitanidis E, Heuser L (1998) Stentimplantation bei akuter zerebraler ischämie infolge einer dissektion der arteria carotis communis im rahmen einer thorakalen aortendissektion. Fortschr Röntgenstr 4:447–449
Bernard Y, Zimmermann H, Chocron S, Litzler J-F, Kastler B, Etievent J-P, Meneveau N, Schiele F, Bassand J-P (2001) False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 87:1378–1382
Kang S-G, Lee DY, Maeda M, Kim ES, Choi D, Kim B-O, Yoon HK, Sung KB, Song H-Y (2001) Aortic dissection: percutaneous management with a separating stent-graft: preliminary results. Radiology 220:533–539
Song J-K, Kim H-S, Song J-M, Kang D-H, Ha J-W, Rim S-J, Chung N, Kim KS, Park SW, Kim YJ, Sohn DW (2002) Outcomes of medically treated patients with aortic intramural hematoma. Am J Med 113:181–187
Karck M, Chavan A, Hagl C, Friedrich H, Galanski M, Haverich A (2003) The "frozen elephant trunk technique": a new treatment for thoracic aortic aneurysms. J Thorac Cardiovasc Surg 125:1550-1553
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Chavan, A., Lotz, J., Oelert, F. et al. Endoluminal treatment of aortic dissection. Eur Radiol 13, 2521–2534 (2003). https://doi.org/10.1007/s00330-003-1936-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-003-1936-2