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Ann Thorac Surg 2007;83:1059-1066
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Endovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of True and False Lumen Diameter Changes

Maria Schoder, MDa,*, Martin Czerny, MDb, Manfred Cejna, MDa, Thomas Rand, MDa, Alfred Stadler, MDa, Gottfried H. Sodeck, MDc, Roman Gottardi, MDb, Christian Loewe, MDa, Johannes Lammer, MDa

a Departments of Angiography and Interventional Radiology, Medical University of Vienna, Vienna, Austria
b Department of Cardio-Thoracic Surgery, Medical University of Vienna, Vienna, Austria
c Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria

Accepted for publication October 24, 2006.

* Address correspondence to Dr Schoder, Department of Angiography and Interventional Radiology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria (Email: maria.schoder{at}meduniwien.ac.at).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: The aim of this study was to determine the technical success after endovascular treatment of acute type B aortic dissections and to evaluate true and false lumen diameter changes at long-term follow-up.

Methods: Twenty-eight patients with acute type B-dissection who were treated by stent graft repair presented with rupture (n = 1), contained rupture (n = 2), compromised branch vessels (n = 14), pleural effusion (n = 11), rapid aortic diameter progression (n = 5), persistent pain (n = 3), refractory hypertension (n = 10), and an aortic diameter of more than 4 cm (n = 4). Taking into account the perfusion status of the false lumen, diameter changes were monitored in the thoracic aorta at the level of the stented segment (L1), distal to the stent graft (L2), and at the level of the celiac trunk (L3).

Results: Severe complications in 9 patients (32%) resulted in 3 deaths for a 30-day mortality rate of 10.7%. Primary sealing of the entry tear was achieved in 86%. At all levels, the true lumen diameter increased significantly after stent graft placement. At the 1-year follow-up, the false lumen in L1 was thrombosed in 90% and the mean difference of diameter reduction was highly significant. In L2, complete false lumen thrombosis occurred in 60% with a significant diameter decrease. In L3, the false lumen thrombosed in only 22%, and the mean difference of false lumen diameter increase reached significance at the 2-year follow-up.

Conclusions: Ninety percent of patients were treated successfully with thrombosis of the false lumen in the stented segment. False lumen perfusion distal to the stent graft resulted in diameter increase in several patients leaving these segments an area of concern.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Until recently, acute uncomplicated Stanford type B dissections were preferably managed by conservative medical treatment; however, complications including rupture, visceral or lower limb ischemia, refractory hypertension, continuing pain, and aortic diameter progression occur in 5% to 20% of patients during the acute phase [1–5]. Furthermore, a considerable number of patients without acute complications experience dissection-related adverse events during the chronic phase that remain a treatment challenge [2, 3, 5]. A more aggressive surgical approach is therefore advocated by some authors [6]. Despite technical advances, the surgical mortality rate in complicated acute dissections remains 14% to 31% [4, 7–10], with a remarkable increase in patients with end-organ ischemia [7, 10–12].

Closure of the primary entry tear by endovascular repair may lead to thrombosis of the false lumen with remodelling of the true lumen in the acute and chronic setting. Furthermore, lowering the pressure in the false lumen may restore the perfusion in the compromised aortic branch vessels. In recent years, encouraging technical results after endovascular repair of acute type B dissection have been reported [13–21]; however, reports on the true and false lumen changes after endovascular therapy during a longer-term follow-up remain limited [13, 20, 22, 23].

The purpose of this study was to assess the clinical outcome and technical success in endovascular repair of acute type B aortic dissections. The significance of true and false lumen diameter changes in the thoracic and abdominal aorta was also evaluated at the long-term follow-up.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Patient Population
From March 2000 to June 2005, 5 women and 23 men with acute type B aortic dissections were treated by stent graft repair. Mean age of patients was 57 years (range, 33 to 83 years). All patients stated an acute onset of chest pain at admission. One patient was hemodynamically instable and 1 patient had paraplegia.

Endovascular repair of thoracic aortic diseases was introduced at Medical University of Vienna as an alternative treatment to surgical repair in high-risk patients in 1996. The local Institutional Review Board gave approval and consent for this retrospective study. Written informed consent was obtained from all conscious patients. In one unconscious patient, the treatment decision was made collaboratively with cardiothoracic surgeons and interventional radiologists.

Confirmation of dissection was based on contrast-enhanced computed tomography (CT) angiography (CTA) using a multidetector scanner (Somatom Volume Zoom; Siemens, Erlangen, Germany). CT scanning ranged from the supraaortic vessels to the common femoral arteries. Routine post acquisition image processing from each CT scan included three-dimensional reconstructions consisting of multiplanar reformations (MPR), curved planar reconstructions (CPR), and a maximum intensity projection (MIP).

Dissections extended down into one (n = 10, 36%) or both iliac arteries (n = 11, 39%), to the renal arteries (n = 3, 13%), to the superior mesenteric artery (SMA; n = 1, 4%), or were limited to the thoracic aorta (n = 3, 13%). The primary intimal tear was located just distal to the left subclavian artery in 26 (93%) patients, whereas in 2 patients, the entry tear was in the middle third of the descending aorta. The false lumen was patent in all patients. Thirty branch vessels were compromised by either an exclusively dynamic process (n = 17) or a combination of a dynamic and a static process. In 12 patients (42.9%), either one branch vessel (renal artery in 10, celiac trunk in 1) or two branch vessels (renal artery and superior mesenteric artery) originated from the false lumen.

Twenty-four symptomatic patients with more than one complication were selected for endovascular therapy because of rupture (n = 1), contained rupture (n = 2), compromised branch vessels (n = 14), pleural effusion (n = 11), rapid aortic diameter progression (n = 5), persistent pain (n = 3), and refractory hypertension (n = 10). Specific patient characteristics with dissection related complications are listed in Table 1. Four clinically asymptomatic patients demonstrating an aortic diameter of more than 40 mm and marked compression of the true lumen were treated to prevent further aortic dilation. Owing to the severity of their symptoms, 9 patients (32%) required emergent (within hours) stent graft implantation after CT diagnosis of an acute type B dissection. Another 11 patients were treated within 7 days. Mean time to treatment was 101 hours (range, 1 to 312 hours).


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  		Table 1 Clinical and Anatomic Characteristics in 24 Patients With Complicated Acute Type B Dissection
 
Endovascular Prosthesis and Procedure
All patients were treated with commercially available stent grafts. A Talent endoprosthesis (Medtronic, Sunrise, FL) was used in 18 patients, and the Thoracic Excluder (W. L. Gore & Assoc, Flagstaff, AZ) stent graft system was used in 10. The diameter of the stent graft was calculated from the largest diameter of the proximal anchoring zone, and an oversizing factor of 10% to 20% was added.

All procedures were performed in an angiosuite that is equipped with digital subtraction angiography (Multistar T.O.P., Siemens, Erlangen, Germany). All patients were under general anesthesia. Antibiotic prophylaxis was administered intravenously in all patients before the procedure. In patients without rupture, 5000 IU of heparin sodium was given after the access site (common femoral or external iliac artery) was surgically exposed.

A 5F pigtail catheter was positioned into the ascending aorta through right-sided percutaneous brachial access to perform an angiogram before stent graft deployment. Gaining access to the true lumen from the iliac route required adjunctive maneuvers in 2 patients. Approaching from the true lumen via brachial access, a pigtail catheter was advanced down to the aortic bifurcation. Subsequently, a 260-cm-long steerable hydrophilic guidewire (Terumo Europe N.V., Leuven, Belgium) was advanced to the iliac artery and snared with an Amplatz gooseneck snare (ev3, Plymouth, MN). A diagnostic catheter was then introduced from the femoral site over the through-and-through wire up to the aortic arch to facilitate placement of the superstiff guidewire (Back-up Meier, Boston Scientific, Natick, MA).

After deployment of the device, an angiogram was performed to evaluate the position of the stent graft relative to supraaortic arch vessels, to confirm closure of the proximal entry tear, to ascertain the true lumen diameter along the aorta, and to document the perfusion status of the branch vessels.

Follow-up Imaging
CTA examinations were routinely performed within 3 days after the procedure, at 3, 6, and 12 months, and yearly thereafter. To assess the extent of the dissection, the diameter of the true and false lumen, and the perfusion status of the false lumen and the branch vessels, the entire aorta and the iliac arteries were included.

Statistical Analysis
Continuous variables are expressed as means and ± standard deviation. For exact analysis of diameter changes of the true and false lumen, preprocedural and follow-up CT examinations were reevaluated. Measurements were obtained at the same levels perpendicular to the line of the intimal flap and at the maximum diameter in three selected aortic segments: stented aortic segment (L1), thoracic aorta distal to the stent graft (L2), and the abdominal aorta at the level of the celiac trunk (L3).

Diameter changes were evaluated for significance between the preprocedural and first postprocedural images. For statistical analysis of diameter changes for long-term follow-up, a 1-year and 2-year CTA examination was required. Differences of aortic measurements were tested for significance using the {chi}2 test for proportions. Significance level was set at p < 0.05. Statistical analysis was performed using SPSS 13 statistical software (SPSS Inc, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Technical Results
In 7 patients, complete overstenting of the left subclavian artery (LSA) was required to close the entry tear. To avoid vertebrobasilarly symptoms after intentional covering of the LSA, transposition was performed in 4 patients with a dominant left vertebral artery before the stent graft procedure. The LSA was partially covered in 19 patients, and 2 patients could be treated with anchoring of the stent graft distal to the LSA. Eight patients were treated with 1 endoprosthesis, 18 patients with 2, and 2 patients with 3. Length of the covered aortic segment was 10 to 21 cm. Deployment of the stent grafts was successful in all patients; however, in 4 patients (14.3%), the entry tear could not be sealed during the first procedure.

Proximal overstenting led to sealing of the entry tear in 1 patient, and in the second patient, the perfusion of the false lumen from the entry tear decreased steadily and was sealed completely at the 1-year follow-up. Two patients (patient 19 and 21) with partial covering of the LSA demonstrated residual flow into the false lumen from the proximal entry tear at the last follow-up. For further proximal overstenting, transposition of the left common carotid artery would be necessary in these 2 patients. One of these patients refused further interventions, and the second patient has a stable thoracic aortic diameter. Consequently, these patients remain under close observation.

Expansion of the true lumen after stent graft deployment resulted in a satisfactory perfusion of compromised vessels in 83% (Fig 1). Additional stenting was necessary in five (17%) arteries (2 visceral arteries, 2 renal arteries, 1 iliac artery) to alleviate persistent obstruction of the true lumen by extension of the intimal flap beyond a vessel’s origin.


Figure 1
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  		Fig 1. A 70-year old woman with acute renal failure caused by acute type B aortic dissection. (A) Angiogram before stent graft implantation shows the entry tear located close to the left subclavian artery (LSA). (B) Compromised visceral, renal, and iliac arteries by a dynamic process. (C) Remarkable true lumen expansion after implantation of two Talent endoprostheses with overstenting of the LSA. (D) Restoration of blood flow in the abdominal branches and iliac arteries after stent grafting.

 
Survival and Complications
Severe complications in 9 (32%) patients resulted in 3 deaths for 30-day mortality rate of 10.7%. One patient died from hemorrhage from a ruptured aortic dissection during surgical evacuation of the hemothorax. The second patient died from pericardial tamponade after a retrograde type A dissection on day 9. The third patient died as a result of cardiac and respiratory insufficiency associated with dissection-related acute ischemic complications of the leg, followed by a massive reperfusion syndrome that required leg amputation. The survival rate at 1, 2, and 3 years was 89.3%.

Further serious complications in the 25 surviving patients were spinal cord ischemia in 2 (7.1%). In patient 11, who sustained permanent paraplegia, the LSA was completely overstented and the stent graft covered Th-8 distally. In patient 6, who had incomplete transient paraplegia, the LSA was partially covered and the device was fixed distally at the level of the ninth thoracolumbar vertebrae. Intentional occlusion of the LSA led to ischemia of the left upper limb requiring secondary transposition of LSA in 1 patient. A retrograde type A dissection that developed in another patient was treated successfully with surgery. Dissection-related infarction of the intestines required a partial small bowel resection and a right-sided hemicolectomy in one patient. Temporary hemodialysis was necessary in 3 patients who had dissection-related acute renal failure.

Follow-Up Analysis of the True and False Lumen
Mean CT follow-up of surviving patients was 859 ± 546 days (range, 40 to 2107 days). The first postprocedural CT examination was completed in 25 patients. Twenty patients were available for the 1-year CT follow-up analysis, and 14 patients had CT examinations at 24 months, 8 at 36, 4 at 48, and 2 at 60 months.

l1-stented thoracic aortic segment
At the first postprocedural CT, a complete thrombosis of the false lumen was seen in 15 (60%) patients. The mean difference of true lumen diameter increase was highly significant (p < 0.0001) between the preprocedural and postprocedural measurements (Fig 2, Table 2).


Figure 2
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  		Fig 2. Box plots show the differences of (A) true and (B) false lumen diameter changes between the preprocedural computed tomography imaging and the 1-year follow-up at the level of the stented segment (L1).

 

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  		Table 2 Mean Differences of Diameter Changes of the False Lumen and the Maximal Aortic Diameter at the 1-Year and 2-Year Follow-Up a
 
Twelve month follow-up images demonstrated total thrombosis of the false lumen in 18 patients (90%) along with complete reabsorption of the thrombus in 9 (50%). The mean true lumen diameter between the initial postprocedural CTA and 1-year follow-up increased further in 16 patients (80%) and was stable in 4 (20%). The diameter of the false lumen increased in 1 patient (5%) with a patent false lumen. The mean false lumen diameter in the remaining 19 patients (95%) decreased.

l2-thoracic aortic segment distal of the stent graft
At the first postprocedural CT a complete thrombosis of the false lumen was observed in 5 patients (20%) and the mean difference of true lumen diameter increase was statistically significant (p = 0.0005; Fig. 3, Table 2).


Figure 3
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  		Fig 3. Box plots show the differences of (A) true and (B) false lumen diameter changes between the preprocedural computed tomography imaging and the 1-year follow-up in the thoracic aorta at the level distal of the stent-graft (L2).

 
At the 1-year follow-up, a complete thrombosis of the false lumen was observed in 12 patients (60%), with complete reabsorption of the thrombus in 4 (20%). The mean true lumen diameter between the first and 1-year follow-up increased in 14 patients (70%), was stable in 4 (20%), and slightly decreased in 2 (10%). Conversely, the false lumen decreased in 10 patients (50%), was stable in 3 (15%), and increased in 7 (35%) in whom the false lumen was patent.

l3-abdominal aorta-level of celiac artery
At the first postprocedural CT, none of the 22 patients demonstrated a thrombosis of the false lumen; however, the true lumen showed a statistically significant mean difference of diameter increase (p = 0.0009; Fig 4, Table 2).


Figure 4
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  		Fig 4. Box plots show the difference of (A) true (B) and false lumen diameter changes between the preprocedural computed tomography imaging and the 1-year follow-up at the level of the celiac trunk (L3).

 
At the 1-year follow-up, thrombosis of the false lumen occurred in 4 (22%) of 18 patients and the thrombus was dissolved completely in one. The mean true lumen diameter between follow-up examinations increased further in 11 patients (61%), was stable in 4 (22%), but slightly decreased in 3 (17%). Conversely, the false lumen decreased only in 6 (33%), and was stable in 2 (11%). In 10 patients (56%), the diameter of the patent false lumen increased.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
The current indications for intervention in acute type B dissections involve rupture or signs of impending rupture, rapid diameter progression malperfusion of abdominal or peripheral vessels, persisting pain, and uncontrollable hypertension, and 24 (85.7%) of our patients met these criteria. Medical management of uncomplicated acute dissections remains the preferable treatment modality. However, several studies showed that adverse events during the clinical course were strongly correlated with a patent false lumen and a maximal thoracic aortic diameter of 40 mm or more [2, 3, 5]. Both predictive indicators were present in the 4 asymptomatic patients. In addition, these patients had a marked compression of the true lumen that led us to undertake urgent stent graft repair.

The effectiveness of surgical or endovascular repair for aortic dissection is dependent on closure of the entry tear, reexpansion of the true lumen, and clotting of the false lumen. Our experience, as well as that in other studies [13, 15, 16, 18, 19, 21, 24], indicates that stent graft repair is an effective approach even in the emergent treatment of patients with a complicated acute type B dissection. In addition to relief of acute symptoms, stent graft placement may prevent aneurysmal degeneration of the thoracic aorta by thrombus formation in the false lumen.

The in-hospital mortality rate in this patient series was 10.7%, which is similar to the 7% to 20% reported in literature [13, 16, 18, 19, 24, 25]. Although these data indicate a superior survival compared with surgery, the serious condition of this category of patients is also reflected in a complication rate of up to 36% as reported by Kato and colleagues [25] and in the 30% occurrence in our patients, corresponding to the study by Eggebrecht and colleagues [20].

As a procedure-related complication, we observed permanent paraplegia in 1 (3.6%) patient. This compares favorably with reported rates in patients who underwent surgery [8, 9, 26]. Another serious procedure-related complication was a retrograde type A dissection occurring in 2 patients who were treated with a Talent endoprosthesis with a free flow design on the proximal cage, resulting in one death. The cause may be related to the limited flexibility of the currently available devices that produce forced wall stress at the outer curvature leading to intimal injuries, which is also reported in previous experiences [24, 27, 28].

Intentional overstenting of the LSA without previous revascularization is described as a feasible and well-tolerated procedure in a few series [17, 21, 29, 30]. However, 1 of our 3 patients with complete LSA occlusion, without previous revascularization, sustained acute arm ischemia that necessitated LSA transposition. Nonserious ischemic arm symptoms in 13.6% of patients were also reported in the study of Görich and associates [29]. Moreover, in the series of Tiesenhausen and colleagues [31], 3 (37.5%) of 8 patients with partial or complete occlusion of the LSA sustained vertebrobasilar symptoms. As reported in the literature, bilateral vertebral artery occlusion, which can be also simulated by overstenting of a dominant LSA and an additional severely stenotic or hypoplastic right vertebral artery, caused irreversible neurologic problems in 23% of patients [32]. Therefore, to rule out patients for whom LSA revascularization might be essential, both the carotid and vertebral arteries should be evaluated before intentional overstenting.

Branch vessels may be compromised by a dynamic or static obstruction, or a combination of both [13, 33]. In a study by Dake and colleagues [13], restoration of blood flow was sufficient after stent graft repair in all branch vessels that were compromised exclusively by a dynamic process. In vessels also affected by a static component, deployment of an uncovered stent within the true lumen of the obstructed artery was necessary in 60% of the patients. In accordance with this, all our patients with a dynamic obstruction of arteries could be treated by stent grafting alone. An additional stent deployment was necessary in five vessels (17%) with an obstruction caused by direct extension of the flap beyond the vessel’s origin. Infradiaphragmatic vessels originating from the false lumen did not suffer from malperfusion after occlusion of the entry tear. An adequate blood supply was provided by existing natural fenestrations of the intimal flap allowing communication between the true and false lumen, which has also been shown in other series [13, 34].

Recent studies have reported patient outcome during the chronic phase in type B dissections that have only been treated with medical therapy [2, 5]. Akutsu and associates concluded [2] that patients with a thrombosed false lumen had a significantly better outcome in terms of dissection-related death and dissection-related events in the chronic phase. In addition, they found that a higher incidence of dissection-related death in patients with the most dilated aortic segment located at the distal arch. Marui and colleagues [5] reported that during the chronic phase, the event-free rate at 1 year was 97% in type B dissections with a thrombosed false lumen and an aortic diameter of less than 40 mm. Conversely, dissections with a patent false lumen and an aortic diameter of 40 mm or more had an event-free rate of only 43% at the same instant. With respect to these findings, the advantage of endovascular treatment of acute type B dissections is not limited to treatment of complications, but might also prevent adverse events during the chronic phase.

Primary closure of the entry tear after stent grafting was reported in 89% to 100% [16, 17, 19, 21, 24, 35] and was achieved in 85.7% of our patients. In our series, complete thrombosis of the false lumen in the stented aortic segment (L1) as well as in the thoracic aorta distally to the stent graft (L2) was observed in 90% and 60%, respectively. A significant reduction of the false lumen diameter was also achieved in these patients. In dissections with a patent false lumen in L2, the false lumen increased without reaching statistical significance at the 2-year follow-up. However, the maximal aortic diameter increased significantly over the same time period.

Thrombosis of the false lumen occurred in the abdominal aorta (L3) in 22% of our patients, a rate consistent with the findings of other studies that reported false lumen thrombosis in the abdominal aorta in 0% to 10% [13, 20, 36]. This circumstance can be explained by the presence of reentries, as mentioned previously. In contrast to the results of Czermak and associates [23], who found no substantial volume change in the abdominal aorta, we showed that the mean difference of diameter increase of a patent false lumen was remarkable at the L3 level at the 1-year follow-up and reached statistical significance at the 2-year follow-up. There was a clear tendency for diameter decrease at this level with a thrombosed false lumen.

A limitation of this study is the small sample size, which did not allow us to draw final conclusions from our results. However, closure of the entry tear and stabilization of the true lumen presents a promising alternative treatment to conventional surgery for relief of life-threatening dissection related complications. Furthermore, aortic segments with a thrombosed false lumen had no substantial diameter changes during the follow-up period. False lumen perfusion distal of the stent graft resulted in substantial diameter increase in several of our patients leaving these segments an area of great concern.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
Medtronic sponsored a research grant for the Department of Angiography and Interventional Radiology.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Sueyoshi E, Sakamoto I, Hayashi K, Yamaguchi T, Imada T. Growth rate of aortic diameter in patients with type B aortic dissection during the chronic phase Circulation 2004;110:II256-II261.[Medline]
  2. Akutsu K, Nejima J, Kiuchi K, et al. Effects of the patent false lumen on the long-term outcome of type B acute aortic dissection Eur J Cardiothorac Surg 2004;26:359-366.[Abstract/Free Full Text]
  3. Onitsuka S, Akashi H, Tayama K, et al. Long-term outcome and prognostic predictors of medically treated acute type B aortic dissections Ann Thorac Surg 2004;78:1268-1273.[Abstract/Free Full Text]
  4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease JAMA 2000;283:897-903.[Abstract/Free Full Text]
  5. Marui A, Mochizuki T, Mitsui N, Koyama T, Kimura F, Horibe M. Toward the best treatment for uncomplicated patients with type B acute aortic dissection Circulation 1999;100:II275-II280.[Medline]
  6. Palma JH, Almeida DR, Carvalho AC, Andrade JCS, Buffolo E. Surgical treatment of acute type B aortic dissection using an endoprosthesis (elephant trunk) Ann Thorac Surg 1997;63:1081-1084.[Abstract/Free Full Text]
  7. Lauterbach SR, Cambria RP, Brewster DC, et al. Contemporary management of aortic branch compromise resulting from acute aortic dissection J Vasc Surg 2001;33:1185-1192.[Medline]
  8. Elefteriades JA, Lovoulos CJ, Coady MA, Tellides G, Kopf GS, Rizzo JA. Management of descending aortic dissection Ann Thorac Surg 1999;67:2002-2005.[Abstract/Free Full Text]
  9. Gysi J, Schaffner T, Mohacsi P, Aeschbacher B, Althaus U, Carrel T. Early and late outcome of operated and non-operated acute dissection of the descending aorta Eur J Cardiothorac Surg 1997;11:1163-1170.[Abstract]
  10. Fann JI, Sarris GE, Mitchell RS, et al. Treatment of patients with aortic dissection presenting with peripheral vascular complications Ann Surg 1990;212:705-713.[Medline]
  11. Cambria RP, Brewster DC, Gertler J, et al. Vascular complications associated with spontaneous aortic dissection J Vasc Surg 1988;7:199-209.[Medline]
  12. Laas J, Heinemann M, Schaefers HJ, Daniel W, Borst HG. Management of thoracoabdominal malperfusion in aortic dissection Circulation 1991;84:20-24.
  13. Dake MD, Kato N, Mitchell RS, 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]
  14. Shimono T, Kato N, Yasuda F, et al. Transluminal stent-graft placements for the treatments of acute onset and chronic aortic dissections Circulation 2002;106:I241-I247.[Medline]
  15. Beregi JP, Haulon S, Otal P, et al. Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study J Endovasc Ther 2003;10:486-493.[Medline]
  16. Lonn L, Delle M, Falkenberg M, Thony F, Aubert A, Blin D. Endovascular treatment of type B thoracic aortic dissection J Card Surg 2003;18:539-544.[Medline]
  17. Nienaber CA, Ince H, Weber F, et al. Emergency stent-graft placement in thoracic aortic dissection and evolving rupture J Card Surg 2003;18:464-470.[Medline]
  18. Bortone AS, De Cillis E, D’Agostino D, de Luca Tupputi Schinosa L. Endovascular treatment of thoracic aortic disease: four years of experience Circulation 2004;110(11 Suppl 1):II262-II267.[Medline]
  19. Leurs LJ, Bell R, Degrieck Y, Hobo R, Lundbom J, EUROSTAR; UK Thoracic Endograft Registry collaborators Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom thoracic endograft registries J Vasc Surg 2004;40:670-680.[Medline]
  20. Eggebrecht H, Herold U, Kuhnt O, et al. Endovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome Eur Heart J 2005;26:489-497.[Abstract/Free Full Text]
  21. Palma JH, de Souza JA, Alves CM, Carvalho AC, Buffolo E. Self-expandable aortic stent-grafts for treatment of descending aortic dissections Ann Thorac Surg 2002;73:1138-1142.[Abstract/Free Full Text]
  22. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years’ experience Circulation 2005;111:2951-2957.[Abstract/Free Full Text]
  23. Czermak BV, Mallouhi A, Perkmann R, et al. Serial CT volume and thrombus length measurements after endovascular repair of Stanford type B aortic dissection J Endovasc Ther 2004;11:1-12.[Medline]
  24. Duebener LF, Lorenzen P, Richardt G, et al. Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections Ann Thorac Surg 2004;78:1261-1267.[Abstract/Free Full Text]
  25. Kato N, Shimono T, Hirano T, et al. Midterm results of stent-graft repair of acute and chronic aortic dissection with descending tear: the complication-specific approach J Thorac Cardiovasc Surg 2002;124:306-312.[Abstract/Free Full Text]
  26. 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]
  27. Fattori R, Napoli G, Lovato L, et al. Descending thoracic aortic diseases: stent-graft repair Radiology 2003;229:176-183.[Abstract/Free Full Text]
  28. Totaro M, Miraldi F, Fanelli F, Mazzesi G. 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]
  29. Görich J, Asquan Y, Seifarth H, et al. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs J Endovasc Ther 2002;9:39-43.
  30. Hausegger KA, Oberwalder P, Tiesenhausen K, et al. Intentional left subclavian artery occlusion by thoracic aortic stent-grafts without surgical transposition J Endovasc Ther 2001;8:472-476.[Medline]
  31. Tiesenhausen K, Hausegger KA, Oberwalder P, et al. Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections J Card Surg 2003;18:429-435.[Medline]
  32. Steinberg GK, Drake CG, Peerless SJ. Deliberate basilar or vertebral artery occlusion in the treatment of intracranial aneurysms J Neurosurg 1993;79:161-173.[Medline]
  33. Williams DM, Lee DY, Hamilton BH, et al. The dissected aortaPart III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology 1997;203:37-44.[Abstract/Free Full Text]
  34. White RD, Ullyot DJ, Higgins CB. MR imaging of the aorta after surgery for aortic dissection Am J Radiol 1988;150:87-92.[Abstract/Free Full Text]
  35. Kato M, Matsuda T, Kaneko M, et al. Outcomes of stent-graft treatment of false lumen in aortic dissection Circulation 1998;98:II305-II312.[Medline]
  36. Lambrechts D, Casselman F, Schroeyers P, De Geest R, D’Haenens P, Degrieck I. Endovascular treatment of the descending thoracic aorta Eur J Vasc Endovasc Surg 2003;26:437-444.[Medline]



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