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Ann Thorac Surg 2002;73:1141-1142
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Department of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria

e-mail: michael.grimm{at}akh-wien.ac.at

Doctor Palma and his associates have provided a remarkable presentation of their 5-year experience with interventional management of aneurysms of the descending aorta. Within this timeframe, the authors have developed and adopted technical approaches that have helped them generate excellent clinical results.

Although great improvements have been made during past years by new surgical approaches, mortality and morbidity related to surgical repair of descending aortic aneurysms remains substantial. The role of catheter-based intraluminal stent grafting in descending aortic aneurysms is currently undergoing active clinical investigation [1]. In the high-risk, clinical setting of endoluminal stent repair of aortic dissection, this new therapeutic approach is yielding extremely promising results. In a recent review of 464 patients with aortic dissection, 30-day mortality in Type B dissection was 11% and 31% for medical or surgical therapy, respectively [2]. Long-term survival with medical therapy ranges around 70% and persistent false lumen patency turns out to be among the most important predictors of late mortality [3]. By noninvasive stent placement the intimal flap is covered and the entry site into the false lumen is obliterated, which results in thrombosis of the false lumen.

In comparison to these "classic" outcomes the authors report a significant step in improving the prognosis of these selected patients. Exclusion of the false lumen– and elimination of the most important predictor of late mortality—was successful in 92% of the patients. Conversion to surgery occurred in 5 patients and procedure-related surgical mortality was 2.8%. Remarkably, 48% of patients required additional stent placement to overcome residual leakage. Nevertheless, in this exceptional series no patient developed paraplegia. Additional complications related to the intervention were stroke or the need for vascular surgery to treat stent-related problems. One might argue that the complications described in the present paper would not occur if patients were only treated medically.

Permanent exclusion of the false lumen—resulting in elimination of the main prognostic factor for adverse outcome—seems to justify a certain number of adverse events related to aggressive interventional therapy in the very early period of disease. Long-term follow-up data are needed to verify this theory. Nevertheless, I believe that in descending aortic aneurysms reduction of mortality and especially morbidity by intraluminal stent graft-ing in comparison to surgery is among the most impressive improvements in medicine during the last decade.

References

1. Grabenwöger M., Hutschala D., Ehrlich M.P., et al. Thoracic aortic aneurysms: treatment with endovascular self-expandable stent grafts. Ann Thorac Surg 2000;69:441-445.[Abstract/Free Full Text]
2. Hagan P.G., Nienaber C.A., Isselbacher E.M., et al. The International Registry of Acute Aortic Dissection (IRAD). New Insight into an old disease. JAMA 2000;283:897-903.[Abstract/Free Full Text]
3. Bernhard Y., Zimmermann H., Chocron S., et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001;87:1378-1382.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael Grimm Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Grimm, M. Search for Related Content PubMed Articles by Grimm, M. Related Collections Great vessels Related Article