Acute Type B dissection. Closure of the infra diaphragmatic tear: how and when? Prof. Olgierd Rowiński II Department of Clinical Radiology Medical University of Warsaw
Disclosure Speaker name: Olgierd Rowiński Proctor for: Medtronic Cook Jotec Vescutek Gore
Complications of Type B aortic dissection aortic rupture partial or complete occlusion of aortic branches (in ~ 30% of patients) intercostal and/or lumbar arteries (paraplegia) celiac axis and mesenteric arteries (bowel ischemia) renal arteries (renal insufficiency, hypertension) iliac arteries (lower extremity ischemia)
Long-term mortality risk factors aneurysm coexistence partial thrombosis of the false lumen hypertension, renal insufficiency false lumen enlargement
End-organ ischemia due to: aortic dissection (type S, D or S+D malperfusion) ruptured (hypotension) or embolizing false lumen thoracic endografting if aortic branch is supplied exclusively from the FL
Extracardiac complications of aortic dissection are present in 18-50% of patients 1/4 of patients after surgery for type A dissection present with persistent ischemic complications. 2/3 of patients with type B dissection have ischemic symptoms in spite of conservative treatment. Surgical treatment for renal and mesenteric malperfusion have 50% and 88% mortality rate, respectively.
Aortic Dissection Acute Complications No Complications Malperfusion Ruprture Aneurysm Cardiac Preventive Treatment dynamic mechanism static mechanism Type A dissection Type B dissection Fenestration Stenting If type A preventive treatment Stent-graft or Open surgery + Medical therapy Medical therapy +/- Stent-graft Figure. Suggested treatment algorithm for aortic dissection, incorporating endovascular procedures with exsting treatment modalities.
Acute Dissection With Ischemia True Lumen Compromise True Lumen Adequate Branch Vessel Stent Patent Flase Lumen Thrombosis of Flase Lumen Dissection Into Branch Vessels Normal Branch Vessels True Lumen Stenting (uncovered stent) Possible Branch Vessel Stent Endograft Proximal True Lumen Fenestration Endograft Proximal True Lumen Fenestration PETTICOAT FENESTRATED GRAFT
Static type DM Wiliams
Case 1 Acute dissection. Primary entry distal to the left subclavian artery, secondary entry in the abdominal aorta. Static malperfusion of the left kidney with unsatisfactory pharmacological control of hypertension. 1. pharmacological treatment? 2. stent-graft? 3. stentgraft and renal stent? 4. fenestration?
Stent-graft and renal stent
Branch dissection with entry tear within its lumen
Case 2 Retrograde inflow to the false lumen due to renal artery dissection. Renal flow alteration. Hypertension. Stentgraft + renal covered stent.
Detached ostium
Case 3 Patient with acute dissection in the course of hypertension. Primary entry in the middle of the descending aorta, no secondary entry. Detached ostium of the right renal artery. 1. What would be the effects of stent-graft placement? 2. How to recover the right renal artery? fenestration? renal stent? covered stent? hybrid surgery?
Follow up study Thoracic stent-graft Covered stent bridging true lumen with right renal artery
Case 4 Symptomatic patient with detached coeliac trunk and dissection of mesenteric artery
Stentgraft + covered stent
Dynamic type DM Wiliams
Acute Type B dissection with dynamic visceral malperfusion
Case 5 Patient with acute type B dissection. Hypertension reluctant to the sodium nitroprusside infusion. Clinical symptoms of bowel ischemia.
Follow up study after stent-graft placement from left femoral approach with fenestration to the right side.
Coexisting Aneurysms
Case 6 Patient with type B dissection of the thoracic aorta and abdominal aortic aneurysm. Distal to the renal arteries, lumina merge into large abdominal aortic aneurysm. 1. thoracic and abdominal stent-graft? 2. surgery? 3. abdominal stent-graft alone?
Thrombosis of the thoracic false lumen after covering the primary entry
Elimination of abdominal aneurysm with stent-graft with fastening of dissection membrane at the level of potential secondary entry
Case 7 Patient with Marfan syndrome after surgical repair of the ascending aorta and exclusion of aortic aneurysm with aorto-iliac Y-graft. Anastomotic aneurysm and type B dissection.
Hybrid surgery
Ruptures
Case 8 Two years after successful thoracic stent-graft placement for type B dissection. Two lumina remaining in the abdominal aorta. Patient came in with acute abdominal pain and rapid abdominal distention. Systolic pressure 50mmHg despite infusion of two catecholamines. 1. emergency surgery? 2. endovascular treatment?
Follow up study in one year after endovascular repair
Case 9 Patient with abdominal aortic aneurysm scheduled for stent-graft placement, came to the Emergency Department with pain in the chest and abdomen.
1. abdominal stent-graft? 2. surgery? 3. thoracic stent-graft?
Follow up study
Case 10 Aortic dissection with primary entry in the left renal artery. Patient treated previously because of thoracic and abdominal aortic ruptures
Treatment with covered renal stent
Case 11 Patient with acute chest and back pain. Sudden worsening of pahrmacological control of hypertension. Primary entry in the ostium of renal artery. 1. stent-graft? 2. stent? 3. covered stent?
Covered renal stent
Case 12 62 years old patient. Dissection Type B. Left iliac artery aneurysm. Rupture of abdominal aorta. Entry points thoracic aorta, coeliac trunk, left renal artery, iliac aneurysm.
In emergency: - stentgraft implantation, - renal covered stent, - iliac artery Viabahn.
Because of failed attempt to close coeliac trunk tear with Viabahn next rupture next day. Renal covered stent displacement. Coiling of renal ostium and false channel. Reversed bell shaped stentgraft exstension used to create unilateral graft. Fem-fem bypass.
Enlarging false channel
Case 13 Staged aortic and branch vessel endovascular repair. Patient with right kidney ischemia, aneurysm of true lumen and retrograde progression of dissection.
Endovascular repair consisted of 2 procedures: thoracoabdominal endografting and covered renal stent placement
Complete FL exclusion required placement of an additional covered renal stent to seal the detached ostium of an accessory renal artery
Case 14 Aortic Type B dissection with AAA and right renal artery supplied from the false lumen
Case 15 Type B dissection treated with thoracic stent-graft Enlargement of abdominal false lumen during follow-up with entries in coeliac trunc and illiac artery Left kidney supplied from the false lumen
Type B dissection Complicated Uncomplicated static malperfusion aneurysm coexistance conservative treatment? stent-graft? dynamic malperfusion detached ostium stent-graft +/or stent stent-graft stent-graft +/or covered stent complex stent-grafts, true lumen branching, hybrid surgery Fenestration - type A dissection with dynamic malperfusion Prof. Olgierd Rowiński Prof. Jacek Szmidt