A Long Term Analysis of Percutaneous Fenestration and Stenting for Acute Type B Dissection with Malperfusion--Implications for Thoracic Aortic Endovascular Repair
Himanshu J. Patel, David M. Williams, Meir Meerkov, Narasimham L. Dasika, G. M. Deeb; University of Michigan Cardiovascular Center, Ann Arbor, MI
Comment on this Abstract
Objective: Open aortic repair to resolve malperfusion in acute type B dissection (B-AD) is associated with a high risk for major morbidity. Thoracic aortic endovascular repair (TEVAR) has emerged as a less invasive therapeutic alternative for B-AD. Benefits of this strategy include the potential for false lumen thrombosis and prevention of rupture. However, its risks include both early morbidity (stroke, spinal cord ischemia, conversion to type A dissection), and the uncertain late results in the setting of potentially unstable landing zones. Accordingly, we present a contemporary long term appraisal of an alternative endovascular approach consisting of percutaneous flap fenestration with branch vessel stenting to restore end-organ perfusion in B-AD.
Methods: 89 consecutive patients presented with suspected B-AD with malperfusion (1997-2007). All patients underwent angiography, and were treated with a combination of flap fenestration, true lumen and branch vessel stenting where appropriate. Outcomes were analyzed for the cohort of 60 patients identified as having impaired organ perfusion on angiography (100% followup; mean 43.3 months).
Results: Mean age was 58.2 years. Comorbidities included CAD(7), hypertension(46), COPD(9), and stroke(2). Identified malperfused vascular beds included spinal cord(4), mesenteric(31), renal(46), and lower extremity(36). Median length of stay was 10 days. While in-hospital mortality was seen in 16.7% (multisystem organ failure n=6; aortic rupture n=4), no mortality was directly attributed to the interventional procedure. Permanent paralysis was seen in 1 who presented with cord ischemia. Complications from malperfusion included need for dialysis(6), and post-procedural stroke(1). Mean Kaplan-Meier survival was 85.2 months, with a crude late mortality rate of 31.7%. Though late mortality was associated with both age(p=0.01) and discharge creatinine(p=0.03), neither the type nor the number of malperfused vascular beds correlated with vital status at last followup(p>0.5). Freedom from subsequent aortic repair or aortic rupture at 1, 5, and 8 yrs was 80.3%, 68.7%, and 51.5% respectively.
Conclusion: Presentation with acute type B dissection with malperfusion carries a significant risk for early mortality. Percutaneous based approaches allow for rapid restoration of end-organ perfusion with acceptable early and late results. These long term data should be considered a benchmark against which to evaluate TEVAR as a primary therapeutic modality for B-AD.
Back to 88th Annual Meeting
Back to Program Outline
