Ann Thorac Surg 2005;80:869
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Martin Czerny, MD
Department of Cardiothoracic Surgery, University of Vienna, Waeringer Guertel 18-20, Vienna, 1090 Austria
(Email: bypass{at}eunet.at).
The authors [1] have evaluated the feasibility and safety of endovascular stent-graft placement in acute aortic lesions, aortic dissection, and penetrating aortic ulcer. This is a valuable clinical report with a high success rate. However, as the authors experienced, serious adverse events are observed when dealing with this complex entity. I would like to address some complications and suggest means of prevention.
Every single physician treating acute aortic syndromes by endovascular stent-graft placement faces intra-interventional or post-interventional complications such as retrograde type A dissection (undoubtedly the most serious one), type I endoleaks, and late aneurysm formation. The physical characteristics of the stent-graft (bare springs) present a threat to the aortic wall at the noncovered portion due to the especially high radial forces in these segments. This problem is being addressed with newer devices. Dilatation of the stent-graft after deployment may add substantial risk for retrograde type A dissection and should be avoided as the stent-graft self expands.
A persistent type I endoleak has to be considered as treatment failure, because antegrade perfusion of the false lumen, regardless of extension and independent of the extent, promotes late aneurysm formation. Therefore, every effort must be taken to avoid type IA endoleak. The main effort should be directed to locate a healthy segment of the nondissected aorta to safely deploy the stent-graft. Therefore, aggressive supra-aortic reconstruction, extending up to the autologous or alloplastic reconstruction of the entire arch is warranted to achieve this goal and increase the likelihood of success.
With respect to overstenting the subclavian artery, there is no doubt that the majority of patients do not suffer upper limb ischemia. However, the ipsilateral vertebral artery may be an important vessel supplying the brain. In addition, retrograde perfusion of the false lumen may occur if the subclavian artery is not transposed.
We are aware that endovascular stent-graft placement in acute aortic syndromes, especially in type B dissections, does not prevent every patient from having late aneurysm develop. However, these technical adjuncts may improve the outcomes of this interesting and intelligent, minimally invasive approach to the problem. The domino effect of reuniting the dissecting membrane to the native aortic wall is most effectively achieved by attending to these small refinements.
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References
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- Xu SD, Li ZZ, Huang FJ, et al. Treating aortic dissection and penetrating aortic ulcer with stent graftthirty cases. Ann Thorac Surg 2005;80:864-869.[Abstract/Free Full Text]
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