Early outcomes after endovascular management of acute, complicated type B aortic dissection

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1 From the Society for Vascular Surgery Early outcomes after endovascular management of acute, complicated type B aortic dissection Robert J. Feezor, MD, a Tomas D. Martin, MD, b Philip J. Hess Jr, MD, b Thomas M. Beaver, MD, b Charles T. Klodell, MD, b and W. Anthony Lee, MD, a Gainesville, Fla Objectives: Surgical management of acute, complicated type B aortic dissection is associated with significant morbidity and mortality. This study examined the feasibility and safety of endovascular treatment of this pathology. Methods: We reviewed a prospectively maintained thoracic endovascular database and medical records at a single institution from 2005 to The study group comprised of acute, complicated type B dissections, defined as duration of symptoms <14 days and involving either false lumen rupture, malperfusion, intractable pain, or uncontrolled hypertension. All repairs were performed using the TAG device (W. L. Gore and Associates, Flagstaff, Ariz). Select 30-day or in-hospital outcomes were reported. Results: Of the 216 thoracic endovascular aortic aneurysm repairs performed during the study period, 33 (15%) were for acute, complicated type B dissections. There were eight women (24%). The mean age was years. The average duration of symptoms was (median, 1) days. The indications for repair included rupture in 15 patients (46%) and mesenteric/renal/lower extremity malperfusion in 11 (33%). Mean fluoroscopy time and contrast volume were minutes and ml, respectively. Eight (73%) of 11 patients with malperfusion required branch vessel stenting. The 30-day in-hospital mortality was 21% (7 of 33). Causes of death included cardiac arrest in 3, progressive multisystem organ failure in 2, rupture in 1 and unknown in 1. At least one major complication occurred in 76% of the patients, including respiratory failure in 11 (33%), permanent spinal cord ischemia in 5 (15%), renal failure requiring dialysis in 4 (12%), and stroke in 4 (12%). The mean postoperative length of stay was days, and only 14 (42%) were discharged to home. Conclusions: Emergency endovascular repair of acute, complicated type B dissection is associated with significant mortality and morbidity. The overall role of this therapy in the treatment of this lethal problem should be better defined and compared with other surgical or interventional options before being generally adopted. (J Vasc Surg 2009;49:561-7.) Aortic dissection is a relatively rare entity, with an incidence of 2.9 cases per 100,000 per year. 1 Current management of uncomplicated type B dissections is intensive medical therapy with blood pressure and pulse rate reduction using nitrates and -blockers, which has been associated with a 3-year actuarial survival of 78%. 2 However, urgent intervention is indicated when an acute dissection is complicated by malperfusion or rupture. 3,4 Treatment options have included direct aortic replacement, extra-anatomic revascularization (eg, axillary-femoral bypass) for lower extremity ischemia, and percutaneous fenestrations for visceral malperfusion. 5,6 More recently, endovascular stent graft treatment of acute aortic dissections has been used as a potentially minimally invasive alternative to conventional aortic surgery. 7 The principles of therapy involve restoration of true lumen flow with closure of the primary tear and restoration of From the Divisions of Vascular Surgery and Endovascular Therapy a and Thoracic and Cardiovascular Surgery, b University of Florida College of Medicine. Competition of interest: none. Presented at the Society for Vascular Surgery Annual Meeting, San Diego, Calif, Jun 5-8, Correspondence: W. Anthony Lee, MD, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Rd, Ste NG-45, PO Box , Gainesville, FL ( anthony.lee@surgery.ufl. edu) /$36.00 Copyright 2009 Published by Elsevier Inc. on behalf of The Society for Vascular Surgery. doi: /j.jvs visceral/lower extremity perfusion. Although no commercially available device in the United States is currently approved for this indication, the TAG endograft (W. L. Gore and Associates, Flagstaff, Ariz) has been used off-label in these cases. In this study, we review the early outcomes of endovascular stent graft repair of acute, complicated acute aortic dissections at a single institution. METHODS We retrospectively reviewed our prospectively maintained database of thoracic endovascular aortic repairs (TEVAR), electronic medical records, and preoperative and postoperative imaging studies at a single tertiary-care university medical center. During the 27 months between September 2005 and December 2007, 216 TEVARs were performed. Fig 1 illustrates the distribution of underlying pathologies that were treated. Of these, 33 (15%) were performed for acute (duration of symptoms 14 days), complicated DeBakey type III/Stanford type B dissections, defined as a primary tear distal to the left subclavian artery. Specific indications included rupture in 15 (46%); malperfusion in 11 (33%), comprising mesenteric in 3, renal in 3, and lower extremity in 10; intractable pain in 3 (9%), limited retrograde extension of the dissection in 2 (6%), intramural hematoma in 1 (3%), and severe hemolysis in 1 (3%; Fig 2). All repairs were performed using the TAG device (off-label). The last three indications deserve additional clarification. In the two patients with limited retrograde exten- 561

2 562 Feezor et al JOURNAL OF VASCULAR SURGERY March 2009 Fig 1. Distribution of pathologies treated with thoracic endovascular aneurysm repair during the study period. AD, Acute, complicated type B dissections; APU, aortic penetrating ulcers; BTT, blunt traumatic transections; CD, chronic dissections; dtaa, descending thoracic aortic aneurysms repaired with TAG and other devices under an investigational device exemption clinical trial; hybrid, includes both abdominal visceral and thoracic arch debranching procedures. Fig 2. Rupture from an acute type B dissection. Note the large left hemothorax, which was drained by tube thoracostomy after endovascular repair. sion, although the primary tear was distal to the left subclavian artery, the proximal extent of the dissection involved the arch but did not extend proximal to the innominate artery and the ascending aorta, which would technically make the condition a type A dissection. In these Fig 3. Multiplanar reformation of a computed tomography angiogram shows the measurements of the proximal landing zone that were used to determine anatomic suitability and endograft selection. situations, coverage of the primary tear would theoretically depressurize the false lumen proximal as well as distal to the tear. 8 Although patients with intramural hematoma are older, more commonly present with hypertension, and have radiographic features distinct from a classic aortic dissection, 9 this condition was included in the study because it may represent a forme fruste of an aortic dissection, 10 and its natural history can be accompanied by similar complications of intractable pain, progression, and rupture. 11,12 The case of severe hemolysis was an unusual indication. Extensive preoperative imaging, including color-flow Doppler transesophageal echocardiography (TEE), which demonstrated high-flow jets through several small fenestrations in the descending thoracic aorta, and consultations with hematology were obtained to exclude other potential etiologies before proceeding with treatment. Anatomic suitability was based on a reference aortic (between the left common carotid and left subclavian artery) inner diameter (intimal) 37 mm, and a centerline distance from the distal margin of the left common carotid artery to the start of the primary tear 20 mm (Fig 3). Device oversizing was based on manufacturer s instructions for use. The side of insertion of the primary introducer sheath was based on the size of the access vessels and distal extension of the dissection. Intravascular ultrasound (IVUS) was used in 27 of 33 (82%) patients to verify the preoperative anatomy and true lumen passage of the principle guidewire. TEE was not routinely used. Endograft coverage typically started at the distal margin of the left common carotid artery origin and extended

3 JOURNAL OF VASCULAR SURGERY Volume 49, Number 3 Feezor et al mm of the celiac artery. Balloon molding was avoided accept for a significant endoleak at completion angiography, and only compliant balloons were used (Coda, Cook Medical, Bloomington, Ind). A left carotid subclavian bypass was performed in the setting of a dominant left vertebral artery or a patent left internal mammary to left anterior descending artery bypass graft. Adjunctive stenting was performed based on angiographic assessment of visceral or lower extremity vessel lumen and contrast flow after deployment of the thoracic endograft and closure of the primary tear. Spinal drainage was used inconsistently either preoperatively or postoperatively based on a combination of operator preference or new-onset symptoms of spinal cord ischemia (SCI), or both. No patient presented with preoperative paraparesis or paraplegia. All patients were monitored postoperatively in the cardiac intensive care unit. For those patients who did not have spinal drainage, any evidence of lower extremity neurologic symptoms were managed with pharmacologic elevation of systolic blood pressure 160 mm Hg, fluid resuscitation, and prompt insertion of a spinal catheter 60 minutes by an on-call cardiac anesthesiologist. The spinal catheter was placed at 10 cm above the level of the heart and adjusted higher or lower depending on therapeutic effect and amount of spinal fluid drainage. Drainage was limited to 15 ml/h or 350 ml/24 h to avoid potential complications of subdural hematoma or cerebral herniation. The catheter was left to drain for 72 hours. If any degree of therapeutic effect was achieved, the catheter was clamped for another 24 hours in case symptoms returned, and then removed. Reported outcomes included 30-day or in-hospital mortality, morbidity, intraoperative procedural measures, and discharge disposition from the index hospitalization. The study was approved by the Institutional Review Board. RESULTS The mean age of the patients was years, and eight (24%) were women. The mean duration of symptoms was days (median, 1; range, 0-14 days). Immediately before repair, in the subset of patients with malperfusion, eight (73%) had an estimated glomerular filtration rate of 60 ml/min/m 2 and 5 (45%) had a lactic acid level 1.5 mmol/l. The mean diameter and length of the proximal landing zone were mm and mm, respectively, and the TAG devices were oversized at a mean of 17.3% 9.3%. The mean fractional aortic coverage (length of aorta covered/total length of thoracic aorta from left common carotid to celiac artery) was 87%. In 22 of 33 patients (67%), the proximal landing zone involved coverage of the left subclavian artery and extension to the left common carotid artery. A left carotid subclavian bypass was required in three (14%) of these 22 patients and was performed either immediately before or after the endovascular repair based on radiographic assessments of their vertebrobasilar circulation by preoperative computed tomography angiography or intraoperative angiography, or Fig 4. Thick maximum intensity projection of adjunctive aortic branch vessel stenting that was required to treat malperfusion due to residual static flaps. Note the self-expanding nitinol stent (Protégé, ev3, Plymouth, Minn) in the superior mesenteric artery and a balloon-expandable covered stent (icast, Atrium Medical, Hudson, NH) in the left renal artery. both. No symptomatic left arm ischemia occurred in the remaining 19 patients. No patient required an iliac conduit for compromised access. Mean fluoroscopy time was minutes, contrast volume was ml, overall procedure time was minutes, and estimated blood loss was ml. Right brachial catheterization was used in 10 of 33 (30%) for angiographic access when the dissection extended into the contralateral external iliac or femoral artery, or both, and precluded safe vascular entry into the true lumen. Adjunctive endovascular stenting was required in 13 (39%) using either self-expanding or balloonexpandable covered or bare-metal stents, as appropriate (Fig 4). Among the subset of 11 patients who presented with malperfusion, 73% required branch vessel stenting. By comparison, only 27% of 15 patients who underwent repair for rupture required adjunctive stenting (P.04). The locations of adjunctive stenting included the iliac artery in five cases, the mesenteric arteries in five, and the renal arteries in four.

4 564 Feezor et al JOURNAL OF VASCULAR SURGERY March 2009 Additional surgical or endovascular procedures were required in 16 patients (48%) after their endograft repair, including 6 aortic bandings (4 distally, 2 proximally and distally), 3 aortic replacements, 2 exploratory laparotomies with small bowel resections, 1 bilateral iliofemoral bypass for disrupted iliac vessels, and 2 tube thoracostomies. More specifically, aortic banding was performed to treat either a persistent false lumen flow or type I endoleak. Briefly, a 26- or 30-mm Dacron tube graft (InterVascular, Datascope, Montvale, NJ) was bi-valved, resulting in an 8- or 9.5-cmwide patch that was cut to approximate length ( desired diameter). The aorta was circumferentially exposed either at the proximal or distal landing zones of the endograft through a thoracotomy with division of one or more intercostal arteries, as necessary. The graft was wrapped around the aorta, and the ends were stapled together. The seam was gradually tightened until an epiaortic ultrasound probe detected cessation of flow. Three patients underwent direct surgical replacements of the descending thoracic aorta to treat persistent false lumen flow. One patient had a proximal endoleak associated with an ascending aortic aneurysm, and the ascending aorta and arch were replaced. In another patient, after a failed proximal banding for a persistent endoleak, the arch and proximal descending aorta were replaced with distal anastomosis performed directly to the remaining endograft. In the third patient, a distal aortic banding was complicated by a pseudoaneurysm and the aorta distal to the endograft was replaced. Exploratory laparotomies and segmental resection of small-bowel infarctions were performed in the two patients with malperfusion immediately after their endovascular repair. These were likely secondary to their initial visceral ischemia (vs intraoperative emboli). The 30-day in-hospital mortality rate was 21% (7 of 33), with a mean time to death of 19 days (median, 12; range, 1-69 days). All of the deaths occurred in those who presented initially with either malperfusion (n 2, 18%) or rupture (n 5, 33%). The causes of death were cardiac arrest in 3 (43%), progressive multisystem organ failure in 2 (29%), rupture in 1 (14%), and unknown in 1 (14%). Of the three patients who died of cardiac arrest, one was hemodynamically unstable, required escalating pharmacologic supportive care, and the family decided to withdraw support; one had persistent hypotension of unclear etiology, and one had an acute type A dissection with pericardial tamponade at autopsy. 13,14 Overall, 25 of 33 patients (76%) experienced some type of major complication. These included respiratory failure in 11 (33%), renal failure in 4 (12%), permanent SCI in 5 (15%), and stroke in 4 (12%). SCI and stroke deserve additional clarification. Six patients had preoperative and 11 had postoperative spinal drainage. No SCI developed in those who had preoperative drainage. Symptoms of lower extremity weakness developed in eight patients (24%) who did not have preoperative drainage. This was completely reversed in three patients with prompt placement of a spinal catheter, but five were left with some degree of permanent deficit. By indication, in the 11 patients with malperfusion, six never had a spinal drain (SCI developed in one, which never resolved, but a drain could not be placed due to hemodynamic instability) and five were placed postoperatively (3 for SCI: 2 reversed, 1 permanent). In the 15 patients treated for rupture, seven did not have spinal drainage, two were placed preoperatively, and six postoperatively (4 for SCI: 1 reversed, 3 permanent). All three patients with intractable pain had preoperative spinal drainage. The remaining four patients did not receive spinal drainage. No complications occurred related to spinal drainage. With regards to strokes, two patients had posterior circulation strokes, one had an anterior circulation stroke, and one had both anterior and posterior circulation strokes. In all of the patients, the repair had extended to the left common carotid artery. However, the left carotid artery flow was not compromised, and all had either a dominant right or codominant vertebral arteries and did not require preemptive subclavian artery revascularizations. The mean hospital length of stay was days (median, 11; range, 1-69 days). At discharge, only 14 (42%) of the original 33 patients were able to go home, 12 (36%) were transferred to another inpatient facility, and one (3%) left against medical advice. Postoperative imaging obtained 1 month of the TEVAR (mean, 13 days) was available in 20 patients (61%). Of these, there were seven endoleaks (35%), consisting of two type Ia and five type II-5, and 15 (75%) had complete false lumen thrombosis of the thoracic aorta. At a mean follow-up of 5.5 months, only 20 patients (61%) were alive and only 15 (45%) were living at home. DISCUSSION The early mortality rate after endovascular stent graft repair of acute, complicated aortic dissections may be up to 25%, with a significant number of complications involving bowel infarction, extremity gangrene, pneumonia, and renal failure. 16,17 Although false lumen patency has been shown to be an independent predictor of dissectionrelated death, 21 endovascular therapy for aortic dissection has been associated with only a 75% rate of false lumen thrombosis. 19 Alternative techniques to treat malperfusion syndromes have included primary percutaneous fenestrations with or without adjunctive branch vessel stenting. In a review of 165 cases of renal malperfusion treated with this technique, Barnes et al 22 reported a mortality rate of 21%. Using a variety of endovascular stenting or fenestration, or both, Slonim et al 23 reported a mortality of 25% despite a successful revascularization rate of 93%. Endovascular stent graft repair of complicated acute dissections may offer several theoretic advantages over other catheter-directed therapies such as primary percutaneous fenestrations. Endograft repair aims to restore the native aortic anatomy by closure of the primary tear, redirection of blood flow through the true lumen, and depressurization of the false lumen. Percutaneous fenestration, in contrast, aims to increase true lumen perfusion by equalizing the pressures in both lumens by creating additional tears in the flap, but does not address the underlying

5 JOURNAL OF VASCULAR SURGERY Volume 49, Number 3 Feezor et al 565 anatomic abnormality of the dissection itself. In the era of endograft therapy, we believe that the role of percutaneous fenestrations should be limited to those patients who lack a suitable proximal landing zone or complex multilumen dissections that are not corrected by closure of the primary tear. Similarly, extra-anatomic surgical revascularizations only address the ischemic complication without treatment of the dissection itself. In both of these treatment modalities, the patient still faces an ongoing risk of rupture or extension of the dissection, which could result in recurrent malperfusion and late aneurysmal degeneration of the false lumen. Despite the minimally invasive nature of endovascular repair, the early mortality (21%) and morbidity (76%) associated with this therapy was not insignificant. The favorable early clinical results of endovascular repair seen for elective repairs of atherosclerotic, degenerative thoracic aortic aneurysms have not been mirrored in the current series. Clearly, this is related to the compromised pathophysiology of these patients at the time of their initial presentation and the unavailability of a suitable endograft system that is able to accommodate some of the unique anatomic issues that involve aortic dissections. In a single-center review of acute, complicated aortic dissections managed by a variety of techniques, the mortality rate of those who presented with malperfusion (28%) was much higher than those who did not (23% vs 16%, P.26). One-third of the patients who presented with malperfusion in this series were managed with peripheral intervention alone (including percutaneous fenestration, branch vessel stenting, or surgical bypass), whereas the remainder were treated medically or had direct aortic replacements. The mortality rates for patients treated with peripheral intervention were lower than those who underwent aortic therapy (12% vs 28%, P.19). 24 Duebener et al 18 reviewed a series of patients who underwent endografting for acute type B dissections and found an overall mortality rate of 20%, although there was no mortality among the two patients presenting with rupture. 18 In a study by Verhoye et al 20 involving 16 patients with complicated type B aortic dissections who had endovascular repairs, early mortality was 25%, and fully half of the deaths were attributable to ruptures. Our practice has been to routinely cover most of the descending thoracic aorta and an average of 87% of the aorta was covered in this series. The issue of how much of the thoracic aorta should be covered (proximal tear alone vs entire dissected segment) remains controversial. The disadvantages of extended aortic coverage include increased cost of additional devices, risk of SCI, procedural time, and contrast volume. On the other hand, our rationale was as follows: 1. Although the primary tear is often the focus of endovascular treatment, in reality, numerous re-entry tears are present throughout the descending and thoracoabdominal aorta, many of which are not always seen with preoperative CT/MR or intraoperative angiographic or IVUS imaging. 2. The hemodynamic significance of these re-entry tears cannot be assessed by any straightforward means, and closure of the primary tear may simply transfer the role of primary false lumen perfusion to one or more of these re-entry tears. 3. False-lumen thrombosis occurs up to the distal extent of the endograft coverage. 4. Although it stands to reason that extent of aortic coverage is related to SCI, because a proportion of intercostal perfusion (especially the distal segments T8 to T12) is often maintained by the false lumen, which invariably remains patent in the perioperative period due to the re-entry tears that occur opposite the abdominal branch vessels, the correlation between aortic coverage and SCI may not be as strong in the setting of dissections as it may be in degenerative, atherosclerotic pathologies. In the current study, SCI developed in nearly a quarter of those who did not receive prophylactic spinal drainage, two-thirds of whom were left with permanent deficits even after prompt placement of a spinal drain. Based on this study and observations made of our entire TEVAR practice, we now place prophylactic drains in those patients (1) requiring 15 cm thoracic aortic coverage, (2) coverage of the last 5 cm of the distal thoracic aorta, (3) who do not have coagulopathy, and (4) who are hemodynamically stable. Postoperatively, although theoretically more physiologic, we have not routinely monitored intrathecal pressures for regulation of spinal drainage but have only used volumetric measures. To date, significant complications have not occurred from this approach. CONCLUSIONS Emergency endovascular repair of acute, complicated type B aortic dissections may be feasible, with outcomes that seem comparable with other therapies; however, these repairs are technically challenging and are still associated with significant mortality and morbidity, which is likely reflective of the pathophysiology of the underlying disease. The overall role of this therapy relative to other established surgical or interventional options remains to be better defined before its generalized adoption in the treatment of acute aortic dissections. AUTHOR CONTRIBUTIONS Conception and design: RF, WL Analysis and interpretation: RF, WL Data collection: RF, WL Writing the article: RF, WL Critical revision of the article: RF, TM, PH, TB, CK, WL Final approval of the article: RF, TM, PH, TB, CK, WL Statistical analysis: RF, WL Obtained funding: Not applicable Overall responsibility: WL

6 566 Quinones-Baldrich JOURNAL OF VASCULAR SURGERY March 2009 REFERENCES 1. Mészáros I, Mórocz J, Szlávi J, Schmidt J, Tornóci L, Nagy L, et al. Epidemiology and clinicopathology of aortic dissection. Chest 2000; 117: Tsai TT, Fattori R, Trimarchi S, Isselbacher E, Myrmel T, Evangelista A, et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation 2006;114: Atkins MD Jr, Black JH 3rd, Cambria RP. Aortic dissection: perspectives in the era of stent-graft repair. J Vasc Surg 2006;43(suppl A):30A- 43A. 4. Xu SD, Huang FJ, Yang JF, Li ZZ, Wang XY, Zhang ZG, et al. Endovascular repair of acute type B aortic dissection: early and mid-term results. J Vasc Surg 2006;43: Pradhan S, Elefteriades JA, Sumpio BE. Utility of the aortic fenestration technique in the management of acute aortic dissections. 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Quinones-Baldrich, MD, Los Angeles, Calif Patients presenting with complicated type B aortic dissection represent the highest risk group of all patients with acute type B dissection. Medical management remains the preferred method of treatment for patients without complications such as intractable pain, malperfusion, or rupture. Surgical treatment of complicated type B aortic dissection improves the outcome compared with medical therapy but is still associated with significant mortality (15% to 30%). 1 The authors have presented a relatively large, well-analyzed experience on the management of patients with complicated type B aortic dissection primarily treated with an endovascular approach. Additional surgical or endovascular procedures were required in almost 50% of patients (hybrid procedure). This included six aortic bandings; it remains to be seen whether this particular combination is an effective treatment on long-term follow-up. All deaths occurred in patients with either rupture or malperfusion, underscoring the high risk in this cohort. These results suggest that a primary endovascular approach is a promising alternative to manage acute type B dissection in the absence of malperfusion or rupture. The morbidity and mortality reported in this series is comparable with contemporary results with the standard surgical approach. Survival for the endovascular approach, however, was only 61% at 5.5 months. Persistent endoleaks (35%) and false lumen patency (25%) threaten long-term results. The authors have appropriately concluded that the overall role of endovascular treatment for complicated acute type B aortic dissection remains to be better defined. Most reports of endovascular treatment of thoracoabdominal aortic pathology identify two elements that are associated with spinal cord ischemia: hypotension and lack of spinal catheter drainage. Spinal cord ischemia did not develop in any patients in this series with preoperative spinal catheter drainage (SCD), but it did occur in 24% of patients without preoperative SCD. The method used by the authors for SCD was based on volume, not pressure. In 1994 Safi and associates concluded that maintaining intraspinal pressure 15 mm Hg was key in their improved results compared with the previous experience when SCD was limited to a certain volume (50 ml). 2 Thus, a preferred approach for SCD is to continuously monitor intraspinal pressure, keeping it 15 mm Hg (10 mm Hg at our institution) at all times. The authors now recommend that SCD be used in patients who require 15 cm of thoracic aortic coverage and in those who will have coverage of