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      Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection

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          Abstract

          Objective

          This study aimed to describe treatment of serious complications after primary thoracic endovascular aortic repair (TEVAR) in type B aortic dissection.

          Methods

          From June 2008 to March 2016, serious complications occurred in 58 patients without Marfan syndrome who received TEVAR for type B aortic dissection.

          Results

          Complications included endoleak, distal true lumen collapse, retrograde dissection, stroke, stent–graft (SG) migration and mistaken deployment, lower limb ischaemia, and SG fracture. Treatment included endovascular repair, surgical procedures, or conservative medication. Forty-six patients recovered from complications. Twelve patients were not cured. The median follow-up time was 29.5 months (2–61 months). The overall 30-day mortality rate was 1.7% (1/58) and the total mortality rate following secondary complications was 8.6% (5/58). The causes of death were stroke and aortic rupture.

          Conclusion

          Some treatments need to be performed after TEVAR because of severe complications. A reduction in these complications can be achieved by optimal evaluation of patients, selection of SGs, and specialized endovascular manipulation.

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          Most cited references22

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          Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection.

          Bin Chen, Jun-Yuan Ji, Z Dong … (2009)
          Retrograde type A aortic dissection has been deemed a rare complication after endovascular stent graft placement for type B dissection. However, this life-threatening event appears to be underrecognized and is worth being investigated further. Eleven of 443 patients developed retrograde type A aortic dissection during or after stent grafting for type B dissection from August 2000 to June 2007. Of these 11 patients, 3 had Marfan syndrome. The Kaplan-Meier estimate of the rate of freedom from this event at 36 months is 97.4% (95% confidence interval, 0.95 to 0.99). The new entry was located at the tip of the proximal bare spring of the stent graft in 9 patients, was within the anchoring area of the proximal bare spring in 1, and remained unknown in 1 patient. Eight patients were converted to open surgery, and 2 received medical treatment. One patient suddenly died 2 hours after the primary stent grafting, and 2 died within 1 week after the surgical conversion, so mortality reached 27.3%. During the follow-up from 3 to 50 months, type I endoleak was identified in 1 patient 3 months after the surgical exploration and disappeared at 6 months. Retrograde type A aortic dissection after stent grafting for type B dissection appears not to be rare and results from mixed causes. Fragility of the aortic wall and disease progression may predispose to it, whereas stent grafting-related factors make important and provocative contributions. Avoiding aortic arch stent grafting in Marfan patients, preferably selecting the endograft without the proximal bare spring for patients with a kinked aortic arch or with Marfan syndrome (if endografting is used), improving the device design, and standardizing endovascular manipulation might lessen its occurrence.
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            Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept.

            Christoph Nienaber, Stephan Kische, Thomas Zeller … (2006)
            To report the use of a technique (PETTICOAT: provisional extension to induce complete attachment) to obliterate sustained abdominal false lumen flow and pressurization despite successful stent-graft sealing of the thoracic entry tear in patients with complicated type B aortic dissection.
            Article 0 comments Cited 38 times – based on 0 reviews     Review now
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              Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries.

              Steve Thomas, Lina Leurs, Yvan Degrieck … (2004)
              The objective of this study was to assess the initial and 1-year outcome of endovascular treatment of thoracic aortic aneurysms and dissections collated in the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair (EUROSTAR) and the United Kingdom Thoracic Endograft registries. Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4 major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic aneurysm (n = 13), and traumatic aortic injury (n = 50). Mean age in the entire study group was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency treatment. Conventional indications for treatment of aortic dissection, including aortic expansion, continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection. Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%, with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0% vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively. This multicenter experience demonstrates acceptable rates for operative mortality and paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this technique is currently unknown, and continued use of registries should provide data from long-term follow-up.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Int Med Res
                Journal ID (iso-abbrev): J. Int. Med. Res
                Journal ID (publisher-id): IMR
                Journal ID (hwp): spimr
                Title: The Journal of International Medical Research
                Publisher: SAGE Publications (Sage UK: London, England )
                ISSN (Print): 0300-0605
                ISSN (Electronic): 1473-2300
                Publication date (Electronic): 12 July 2017
                Publication date (Print): October 2017
                Volume: 45
                Issue: 5
                Pages: 1574-1584
                Affiliations
                [1 ]Department of Vascular Surgery, The Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
                [2 ]Southeast University Medical School, Nanjing, China
                Author notes
                [*]

                These authors contributed equally to this work.

                [*]Chang-jian Liu and Min Zhou, Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, China. Emails: dr_cjliu@ 123456163.com ; zhouminnjuseu@ 123456sina.com
                Article
                Publisher ID: 10.1177_0300060517708893
                DOI: 10.1177/0300060517708893
                PMC ID: 5718725
                PubMed ID: 28701057
                SO-VID: fb4a0af3-4bf6-4fcc-8977-933ff71e1b31
                Copyright © © The Author(s) 2017
                License:

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License ( http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                Date received : 20 September 2016
                Date accepted : 10 April 2017
                Categories
                Subject: Clinical Reports

                Keywords: aortic dissection,thoracic endovascular aortic repair,stent–graft,complication
                Data availability:
                Keywords: aortic dissection, thoracic endovascular aortic repair, stent–graft, complication

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