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Ann Thorac Surg 2005;80:864-868
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Treating Aortic Dissection and Penetrating Aortic Ulcer with Stent Graft: Thirty Cases

Shang Dong Xu, MD a , * , Zhi Zhong Li, MD b , Fang Jiong Huang, MD a , Jin Fei Yang, MD a , Xue Yong Wang, MD c , Zhao Guang Zhang, MD a , Jia Hui Du, MD d , Yan Qing Sun, MD a

a Division of Cardiac Surgery, Beijing Institute of Heart, Pulmonary and Vascular Diseases, Capital University of Medical Science, Beijing Anzhen Hospital, Beijing, China
b Division of Emergency, Beijing Institute of Heart, Pulmonary and Vascular Diseases, Capital University of Medical Science, Beijing Anzhen Hospital, Beijing, China
c Division of Anesthesiology, Beijing Institute of Heart, Pulmonary and Vascular Diseases, Capital University of Medical Science, Beijing Anzhen Hospital, Beijing, China
d Division of Radiology, Beijing Institute of Heart, Pulmonary and Vascular Diseases, Capital University of Medical Science, Beijing Anzhen Hospital, Beijing, China

Accepted for publication March 23, 2005.

* Address reprint requests to Dr Xu, Beijing Anzhen Hospital, Cardiac Surgery Division, Beijing Chaoyan Qu, Anzhen Li, Beijing 100029, China (Email: xushangdong{at}vip.sina.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
BACKGROUND: The purpose of this study is to evaluate the feasibility and safety of stent graft in the treatment of aortic dissection and penetrating aortic ulcer.

METHODS: From June 2001 to April 2004, 25 patients with aortic dissection and 5 patients with penetrating aortic ulcer received stent-graft implantation. Within this group were 24 male and 6 female patients, with an average age of 52.3 ± 11.9 years. One patient was diagnosed as type A dissection, 23 patients as chronic type B dissection, 1 patient as acute type B dissection, and the remaining 5 patients with penetrating aortic ulcer. Among the 25 patients with aortic dissection, 3 had contained rupture. All patients were followed up in 1 to 32 months.

RESULTS: All patients received stent-graft implantation. There were 5 type I endoleaks. Retrograde ascending aortic dissection occurred during the operation in 1 patient. Two other retrograde ascending aortic dissections occurred in 2 patients 1 day and 7 days, respectively, after stent-graft implantation. Two patients died 1 day and 18 days, respectively, after operation because of rupture of ascending aortic dissection. One-month mortality rate was 6.7%. No death occurred during follow-up time. One patient received a second stent-graft implantation 20 months after the first procedure.

CONCLUSIONS: Serious complications may develop after stent-graft implantation, but the early results of treatment of aortic dissection and penetrating aortic ulcer with stent graft were satisfactory. Long-term follow-up was needed.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
From June 2001 to April 2004, in order to evaluate the feasibility and safety of stent graft in the treatment of aortic dissection and penetrating aortic ulcer, we treated 30 patients with aortic dissection or penetrating aortic ulcer with stent-graft implantation.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patients
There were 24 male and 6 female patients with a mean age of 52.3 ± 11.9 years (32–72 years). Among these patients, 23 were diagnosed to have chronic type B dissection, 1 acute type B dissection, 1 chronic type A dissection, and 5 penetrating aortic ulcer. Twenty-one patients out of the 25 patients with aortic dissection had hypertension, 2 of which had sleep apnea syndrome, and another two patients had Marfan’s syndrome. No confirmed causes were identified in the remaining two patients with aortic dissection. All 5 patients with penetrating aortic ulcer presented with atherosclerosis. One of them also had coronary artery disease with old myocardial infarction. Contained rupture was confirmed in 3 patients with aortic dissection, two of which presented with massive right hemothorax, and one of which had a huge hematoma in the upper mediastinum. One patient with chronic type B dissection also suffered severe aortic insufficiency. The average diameter of the dissecting aneurysm in patients with aortic dissection was 4.7 ± 1.4 cm (3.5–8.0 cm). The shortest distance between the opening of the left subclavian artery (LSCA) and the primary tear was 0.5 cm and the longest distance was 8.0 cm.

Preoperative Examination
Routine examination of the heart, lung, liver, and kidney functions was conducted. Renal insufficiency was found in 7 patients. All patients received magnetic resonance imaging (MRI) or enhanced computer tomography (CT). The landing zone diameter was measured on MRI or CT scan.

Stent Graft
Five types of stent-graft systems have been used. The TALENT (Medtronic, Sunrise, FL) was used in 4 patients, the ENDOFIT (Endomed, Phoenix, AR) in 2 patients, the VASOFLOW (Vascore, Suzhou, China) in 10 patients, the AEGIS (Microport, Shanghai, China) in 7 patients, and the KINPRIDE (Grikin, Beijing, China) in 7 patients. The TALENT and KINPRIDE were made of nitinol skeleton and Dacron. The others were made of nitinol skeleton and polytetrafluoroethylene.

Stent-Graft Implantation
Stent-graft implantation was performed in the catheter lab by a team of cardiovascular surgeons, an interventional cardiologist, a radiologist, and an anesthetist. All procedures were selective except three emergency cases with contained rupture. Transesophageal echocardiography was used in 4 patients. General anesthesia was applied in 24 patients with local anesthesia used in 6 patients. Blood pressure was monitored by right radial artery cannulation. A 5F sheath was inserted into the left radial artery or surgically exposed left brachial artery. A calibrated 5F pigtail catheter was introduced into the ascending aorta through LSCA. The unilateral femoral artery was exposed by surgical dissection. A 6F sheath was inserted. A 6F pigtail catheter was introduced into the ascending aorta through the femoral artery. Angiography was performed. By using a calibrated pigtail catheter, the diameter of the landing zone was measured. The measurement was compared to the digital number obtained from the MRI or CT image. The average of the two numbers was regarded as the diameter of the landing zone. Precise location of the primary tear of the dissection or the penetrating ulcer was also confirmed by angiography. A stent graft with a larger diameter (usually 10% to 20%) was chosen. Prior to the deployment of the stent graft, 1 mg/kg or 5,000U heparin was given intravenously. Through the pigtail catheter an extra-stiff guide wire was threaded into the ascending aorta. A transverse or a longitude arteriotomy was made on the femoral artery. The delivery system was introduced over the super-stiff guide wire, and was then advanced to the appropriate position. After the systolic blood pressure had been lowered to less than 100 mm Hg, and the heart rate lowered to less than 90 beats per minute, the stent graft was deployed under fluoroscopy. Angiography was performed again. If there was endoleak at the proximal or distal end of the stent graft, a cuff was deployed to seal the endoleak. Three stent grafts were implanted in one patient, two stent grafts in each of the 6 patients, and one stent graft in each of the remaining patients. If the distance between the primary tear and the opening of the LSCA was less than 2 cm, the bare stent at the proximal end of the stent graft would surpass the opening of the LSCA. The opening of the LSCA would therefore be partially or totally occluded. A total of nine patients’ LSCAs were partially or totally occluded. Figure 1 shows the angiography of a patient with penetrating aortic ulcer before and after stent-graft implantation. Figure 2 showed the angiography of a patient with Stanford B dissection before and after stent-graft implantation.



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  		Fig 1. Aortography during procedure of a patient with penetrating aortic ulcer. (Left) Aortography before stent-graft implantation. (Right) Aortography after stent-graft implantation.

 


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  		Fig 2. Aortography during procedure of a patient with Stanford B dissection. (Left) Aortography before stent-graft implantation. (Right) Aortography after stent-graft implantation.

 
Postoperative Care
All patients were transferred to the intensive care unit after operation. The systolic blood pressure was lowered to less than 120 mm Hg by sodium nitroprusside. Respiration assistance was usually withdrawn after the patient became fully awake. Oral medicine was given to control blood pressure; intravenous antibiotic was applied for 3 days. No anticoagulant was used.

Combined Procedure
One patient received aortic valve replacement two weeks after stent-graft implantation. A bioprosthetic valve was used. One patient with old myocardial infarction received percutaneous coronary intervention simultaneously with stent-graft implantation, with three coronary stents being implanted. An anticoagulant was used routinely after the procedure.

Follow-Up
Computed tomography was conducted before discharge and at least once a year after operation.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Stent-graft implantation was technically successful in 25 patients (83.4%). Type I endoleak was found in 5 patients with aortic dissection immediately after stent-graft implantation. In other patients, the primary tears or penetrating ulcers were sealed totally. Mean operation time was 3 hours. Mean blood loss was 150 mL. Average length of hospital stay was 10 days. Transient renal insufficiency was observed in 5 patients. Postoperative fever was found in 9 patients. No paraplegia occurred after the procedure. Retrograde ascending aorta dissection occurred in three patients, with one occurring during procedure after balloon dilation (Fig 3). Fortunately the patient is still alive three years later. The retrograde false lumen in the ascending aorta is partially thrombosed. Retrograde ascending aorta dissection also occurred in another two patients one day and seven days, respectively, after stent-graft implantation. These two patients died of cardiac tamponade one day and eighteen days, respectively, after stent-graft implantation. The operative mortality rate was 6.7%. The LSCA was totally occluded in five patients. The pulse of the left radial artery disappeared 2 or 3 days after stent-graft implantation. No left upper extremity ischemia or brain steal phenomenon occurred. All patients were followed up for a period of 1 to 32 months. No death occurred. Computed tomographic angiography showed that the false lumen was totally thrombosed in the descending aorta in 20 patients with aortic dissection. In 5 patients with type I endoleak the false lumen was partially thrombosed (Fig 4). The diameter of the dissecting aneurysm remained unchanged. One patient with type I endoleak received a second stent-graft implantation 20 months after the first procedure. In patients with penetrating ulcer, all ulcers were totally sealed.



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  		Fig 3. Aortography during procedure of a patient with type B dissection. (Left) Aortography before stent-graft implantation. (Right) Aortography after stent-graft implantation and balloon dilation. Retrograde ascending aortic dissection formed.

 


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  		Fig 4. Three-dimensional reconstruction of computed tomographic angiography of a patient with Stanford B dissection 6 months after stent-graft implantation.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Since the introduction of endovascular therapy in artery disease by Dotter in 1969 [1], the technique has progressed dramatically. In 1991, Parodi [2] first applied the stent graft in abdominal aortic aneurysm. In 1994, Dake and colleagues [3] first used the stent graft in descending aortic aneurysm. Now the indication of stent graft includes acute and chronic type B dissection, some type A dissection, and penetrating aortic ulcer [4–7]. The indication for type A dissection in our group is that the primary tear is distal to the LSCA and the retrograde false lumen in the ascending aorta is totally thrombosed. For acute aortic dissection, unless there is organ or extremity ischemia, the diameter of the dissecting aneurysm is more than 4 cm, or pain cannot be relieved and blood pressure is refractory, stent-graft implantation should be performed two weeks after the onset of the disease. Contained rupture and hemothorax were definite indications for emergency intervention. Since most of the penetrating aortic ulcers have intramural hematoma, it has been regarded for many years as a variant of aortic dissection or atypical dissection. Now it has become an independent diagnosis [8]. But we do have a patient initially diagnosed as penetrating ulcers progressed into type A aortic dissection one month later, so we included the 5 cases in this article. Most of the penetrating aortic ulcers can heal automatically and should be treated by medicine. The indication of stent graft in our group is that the ulcer is at least 0.5 cm in depth or 1 cm in diameter.

Although stent-graft implantation is a kind of minimally invasive therapy, sometimes it can cause severe complications. Retrograde ascending aortic dissection is, no doubt, the most severe. We encountered it in 3 patients. The newly developed tears were all at the proximal end of the stent graft in the right aortic arch (Fig 5). Three possible reasons may exist. (1) The first one is procedure related. We used a balloon to dilate the stent graft in the first case. Before we inflated the balloon, we did not lower the blood pressure. The descending aorta was totally blocked while the balloon was fully inflated. The systolic blood pressure went up to more than 200 mm Hg proximal to the balloon. Ascending aortic dissection appeared immediately after balloon dilation. (2) The second reason may be related to the structure of the stent graft and size of the stent graft chosen. All the newly developed ruptures were at the proximal end of the stent graft and all types of stent grafts we used have a bare spring at the proximal end. The bare spring contacts with the aortic intima directly and tightly. The pulsation of the aorta may cause friction between the two; intima damage may develop as a result. Three stent grafts that we used in the three patients who developed retrograde dissection were from three different companies. Thus, we cannot say it is device related. The larger the size of the stent graft, the greater the radial force it gives to the aortic wall. In the second case, we chose a relatively larger size of the stent graft; 25% larger than the diameter of the landing zone. The patient felt sudden severe chest pain in the morning one day after operation and died in the afternoon. Autopsy confirmed ascending aortic dissection and cardiac tamponade. (3) The third reason may be related to congenital weakness of the aortic wall. The aortic wall cannot bear the radial strength of the stent graft. Congenital weakness of the aortic wall must be considered in those patients with no obvious cause of dissection. The third patient developed ascending aortic dissection 7 days after stent-graft implantation. He had no history of hypertension or atherosclerosis. He had no Marfan’s syndrome either. His older brother died of aortic dissection, so we believe that he may have congenital weakness of the aortic wall. It is common sense that the aortic wall is fragile in Marfan’s patients. We have two patients with Marfan’s syndrome who received stent-graft implantation. Then why did we perform stent-graft implantation in patients with Marfan’s syndrome? The two patients both had type B dissection and moderate aortic root enlargement. The aortic insufficiency was mild. It would be too aggressive to perform Bentall’s operation, total arch replacement, and stent-graft implantation in the descending aorta at one time. Stent-graft implantation to seal the tear in the descending aorta was considered. The two patients were monitored closely. If the aorta deteriorates with the stent graft we will make total arch replacement. The two patients were followed up 12 months and 16 months, respectively. They showed no symptoms and a CT scan showed no dilation of the landing zone and no displacement of the stent grafts. They are still under close supervision.



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  		Fig 5. Computed tomographic angiography of a patient with retrograde ascending aortic dissection 10 days after stent-graft implantation. (Left) Cross-section of aortic arch. The new rupture was at the proximal end of the stent-graft. (Right) Cross-section of thoracic aorta. False lumen of the ascending aorta could be seen.

 
Once retrograde ascending aortic dissection occurs, emergency operation should be carried out as soon as possible [9]. This is the lesson we have learned. When we encountered retrograde dissection in the first patient, we chose the wait-and-see policy. One week later, CT scan showed thrombosed false lumen in the ascending aorta. The patient is still alive. This gave us a wrong concept, which retrograde dissection could thrombose spontaneously. The fates of the second and third patients told us that immediate ascending aorta replacement was the only choice.

Endoleak is a common complication. Five out of 25 patients with aortic dissection had type I endoleak. The incidence rate was 20%. The shorter the distance between the opening of LSCA and the primary tear, the greater the chance of type I endoleak. Although the opening of the LSCA was partially or totally sealed, a small volume of blood still entered the false lumen through the primary tear. Palma and colleagues [10] reported an incidence of type I endoleak of 7.1%. All the patients with type I endoleak underwent conversion to surgery. We think this may be too aggressive. We chose a wait and see policy. Fortunately, the false lumens of the five patients with type I endoleak were partially thrombosed. The diameter of the dissecting aneurysm did not increase. This may be due to the hemodynamic change in the false lumen. The blood pressure and blood velocity in the false lumen are related to the blood volume, which enters the false lumen. When a large entry is turned into a small one, blood volume that enters the false lumen decreases dramatically; the blood pressure and blood velocity in the false lumen may decrease simultaneously. This may explain the partial thrombosis of the false lumen. One of the patients received a cuff implantation 20 months after the first procedure. Close follow-up should be carried out for these patients.

Chronic aortic dissection always has reentry. The reentry or reentries may locate in the descending aorta, abdominal aorta, or iliac artery. In all cases, except that the reentry is in the descending aorta, it is left open. Buffolo and colleagues [11] share the same opinion as the authors. By magnetic resonance angiography or enhanced CT scan, we evaluated all visceral arteries in each patient and found that most visceral arteries arise from the true lumen. The most common artery that arises from the false lumen is the right or left renal artery; so we do not worry about the visceral ischemia. No visceral organ ischemia occurred after stent-graft implantation in our group. In our experience, in some cases the false lumen in the abdominal aorta will still exit, but the diameter of the abdominal aorta seldom increases.

There were seven patients with renal insufficiency before operation. The reasons for this may be as follows. (1) Chronic renal insufficiency. Since most of the patients had hypertension disease, chronic hypertension can, itself, cause renal insufficiency. (2) Some patients had hypovolemic shock; usually patients who had contained rupture. (3) Contrast material used in an MRI or a CT scan may cause damage to renal function. Five patients had renal insufficiency after the procedure. This may be due to the contrast used in the procedure.

The opening of the LSCA was totally sealed in 5 patients. The left radial pulse disappeared 2 or 3 days after the procedure. The blood pressure of the left arm was lowered to 40–30 mm Hg. There was no left arm ischemia or steal phenomenon, so the left carotid artery- LSCA bypass was not conducted.

In both acute and chronic dissection, the choice of the stent graft depends on the diameter of the proximal landing zone. Usually we chose a stent graft with a diameter 20% larger than the landing zone. Now we have found that 10% is enough.

Another problem we met is placing the extra-stiff guide wire into the true lumen. Since there was always reentry in the abdominal aorta or iliac artery, when the guide wire advanced up the aorta, it could enter a false lumen. If this happened, we introduced an exchange guide wire through the LSCA and all the way down to the descending aorta, abdominal aorta, iliac artery, and femoral artery. The exchange guide wire would be pulled out of the femoral artery through the arteriotomy. Then the exchange guide wire was replaced by an extra-stiff guide wire. In this way we can ensure that the extra-stiff guide wire is in the true lumen.

Serious complications may develop after stent-graft implantation, but the early results of stent-graft treatment of aortic dissection and penetrating aortic ulcer were satisfactory. Since the stent-graft therapy is still in its early stage, more procedures should be performed and longer follow-up is needed.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Dotter CT. Transluminally-placed coilspring endarterial tube graftslong-term patency in canine popliteal artery. Invest Radiol 1969;4:329-332.[Medline]
  2. Parodi JC. Endovascular repair of abdominal aortic aneurysms and other arterial lesions J Vasc Surg 1995;21:549-557.[Medline]
  3. Dake MD, Miller DC, Semba CP, et al. Transluminal placement of endovascular stent graft for the treatment of descending thoracic aortic aneurysms N Engl J Med 1994;331:1729-1734.[Abstract/Free Full Text]
  4. Dake MD, Kato N, Mitchell S, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection N Engl J Med 1999;340:1546-1552.[Abstract/Free Full Text]
  5. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement N Engl J Med 1999;340:1539-1545.[Abstract/Free Full Text]
  6. Hutschala D, Fleck T, Czerny M, et al. Endoluminal stent-graft placement in patients with acute aortic dissection type B Eur J Cardiothorac Surg 2002;21:964-969.[Abstract/Free Full Text]
  7. Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes Eur J Cardiothorac Surg 2003;23:788-793.[Abstract/Free Full Text]
  8. Coady MA, Rizzo JA, Hammond GL, et al. Penetrating aortic ulcer of the thoracic aorta: what is it? how do we recognize it? how do we manage it? J Vasc Surg 1998;27:1006-1016.[Medline]
  9. Totaro M, Miraldi F, Fanelli F, et al. Emergency surgery for retrograde extension of type B dissection after endovascular stent graft repair Eur J Cardiothorac Surg 2001;20:1057-1058.[Abstract/Free Full Text]
  10. Palma JH, Souza JAM, Alves CMR, et al. Self-expandable aortic stent-grafts for treatment of descending aortic dissections Ann Thorac Surg 2002;73:1138-1142.[Abstract/Free Full Text]
  11. Buffolo E, Palma JH, Souza JAM, et al. Revolutionary treatment of aneurysms and dissections of descending aortathe endovascular approach. Ann Thorac Surg 2002;74:S1815-S1817.[Abstract/Free Full Text]



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