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Endovascular treatment of thoracic aortic disease

Authors:
Rachel E Bell at Guy's and St Thomas' NHS Foundation Trust
Rachel E Bell
John Reidy at LONDON BRIDGE HOSPITAL
John Reidy
  • LONDON BRIDGE HOSPITAL
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Abstract

Endoluminal repair is now a realistic alternative to open surgery for the treatment of thoracic aortic disease.
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EDITORIAL
Endovascular treatment of thoracic aortic disease
R E Bell, J F Reidy
.............................................................................................................................
Heart
2003;89:823–824
Endoluminal repair is now a realistic alternative to open
surgery for the treatment of thoracic aortic disease
..........................................................................
S
ince Volodos and colleagues performed the
first endoluminal repair of a thoracic aneu-
rysm, the technique has been used to treat
descending thoracic aneurysms, type B (Stan-
ford) aortic dissection, false aneurysms, penetrat-
ing ulcers, and aortic transection.
12
This mini-
mally invasive approach has many advantages
over conventional surgery as it avoids open thora-
cotomy, single lung ventilation, and aortic cross
clamping.
The main criticism of endoluminal repair is
poor durability of the stent grafts. The first
published series from Stanford used home made
stent grafts and reported a primary success rate of
73%.
3
However, there were problems associated
with the large introducer catheters and rigidity of
these devices. The now commercially available
stent grafts are more flexible with smaller
delivery systems and have improved deployment
mechanisms. Notably, stent graft failure has been
reported with the early home made grafts and
more recently the Gore Excluder (WL Gore Asso-
ciates, Inc, Flagstaff, Arizona, USA) has been
withdrawn for redesigning following reports of
fractures in the nitinol frame. The longer experi-
ence from the infrarenal devices has shown that
lifelong surveillance is essential.
INDICATIONS FOR TREATMENT
Descending thoracic aneurysms are life threaten-
ing, with an estimated incidence of 6 cases per
100 000 person years.
4
The number of patients
with thoracic aneurysms is increasing presum-
ably because of better diagnostic modalities and
longer life expectancy.
5
We advise treatment for
symptomatic aneurysms and for asymptomatic
aneurysms greater than 6 cm in diameter. Several
reports have reported the risk of rupture in
patients with untreated aneurysms to range from
46–74%, with five year survival rates estimated at
9–13%.
4
The contraindications for endovascular
repair of thoracic aneurysms are absence of an
aneurysm neck, an excessively large neck, or
insufficient normal aorta to fix the stent graft
either proximally or distally. For aneurysms
involving the proximal descending aorta it is
sometimes necessary to intentionally cover the
origin of the left subclavian artery. This can be
done without the need for carotid subclavian
transposition.
6
Currently all patients have a com-
puterised tomographic (CT) scan and calibration
angiography as a planning procedure. The proce-
dure can be carried out in the operating theatre or
the angiography suite, but good quality imaging
is essential. We prefer to use regional or local
anaesthesia as this allows monitoring of distal
neurological function throughout the procedure.
A major indication for endoluminal treatment
in the thoracic aorta is type B (Stanford) aortic
dissection.
7
The majority of patients with acute
type B aortic dissection are treated medically with
antihypertensive drugs and β blockers. Endovas-
cular intervention is reserved for ongoing pain,
refractory hypertension, localised false aneurysm,
end organ ischaemia, and rupture, which occur in
30–40% of patients.
89
Open surgery in this group
of patients is associated with a very high morbid-
ity and mortality (35–50%). Endovascular treat-
ment has also been recommended for penetrating
ulcers and intramural haematomas of the de-
scending aorta, which have been identified as
precursors of dissection.
10
Endovascular treatment of complicated type B
dissection includes covering the primary entry
tear with a stent graft, percutaneous fenestration
of the intimal flap, and stenting of obstructed
aortic side branches. The primary endovascular
technique is placement of a stent graft across the
primary entry tear which will decompress the
false lumen and can relieve both static and
dynamic obstruction of aortic branches. Experi-
ments have shown that decreasing the false
lumen inflow by placing a stent across the
primary entry tear is the most effective treatment
for true lumen collapse.
11
In addition, endolumi-
nal exclusion promotes thrombosis of the false
lumen, which has been shown to decrease the risk
of aneurysm formation.
12
Some authorities have
recommended stenting all patients presenting
with acute type B dissection to reduce the
incidence of late aneurysm formation. However,
as only about a third of patients will develop
aneurysms this should be assessed against best
medical treatment in a randomised controlled
trial.
The Stanford group were the first to report
their experiences with home made grafts and
acute aortic dissection.
7
They reported that revas-
cularisation of obstructed aortic branches oc-
curred in 76%. Long term follow up has shown
79% (15/19) patients had complete thrombosis of
the false lumen.
7
Nienaber and colleagues re-
ported a 0% mortality and morbidity in a small
series of 12 patients treated by endoluminal
repair, which compared very favourably with their
own surgical experience.
13
They have since pub-
lished results on a further 82 patients with excel-
lent results. However, it is difficult to interpret this
data as it does not specify the distribution of acute
and chronic cases, or the number with rupture or
end organ ischaemia.
14
It appears that stent graft
placement in the acute situation can prevent late
aneurysm formation by facilitating complete
thrombosis of the thoracic aortic false lumen.
See end of article for
authors’ affiliations
.......................
Correspondence to:
Dr John F Reidy,
Department of Radiology,
Guy’s & St Thomas’
Hospital, Lambeth Palace
Road, London SE1 7EH,
UK; john.reidy@
gstt.sthames.nhs.uk
.......................
823
www.heartjnl.com
However, there are still problems with rigid stent grafts, which
can erode through the intimal flap and cause pressurisation of
the false lumen leading to rupture. There is a place for a stent
graft that is specifically designed for the treatment of aortic
dissection, which is blunt with a tapered end. Despite these
problems, endoluminal repair is currently the treatment of
choice for acute and chronic type B dissection, penetrating
ulcers, and intramural haematomas.
COMPLICATIONS
The avoidance of aortic cross clamping reduces the risk of end
organ damage from ischaemia and ischaemia–reperfusion.
Cardiac (1% v 10%), respiratory (8% v 28%), and renal compli-
cations are significantly lower than for open surgery.
14 15
The
most common complication of endoluminal repair is damage
to the access artery, which is caused by a combination of the
large calibre delivery system and pre-existing iliofemoral
atheromatous disease. For patients with small arteries an
iliofemoral bypass can be inserted to allow safe passage of the
introducer. An incidence of stroke has been reported as 4–7%
and is usually caused by manipulation of the guidewire or
device in the aortic arch causing cerebral embolisation.
14
As with open surgery, paraplegia is the most devastating
complication of endoluminal repair of thoracic aortic disease.
The incidence of paraplegia following endoluminal repair for
thoracic aneurysmal disease is comparable to open surgery
(2–5%).
316
However, for aortic dissection the incidence of
paraplegia is notably reduced following endoluminal repair
when compared with open surgery (0% v 19%).
71317
It is well recognised that in patients with thoracic aneurys-
mal disease the spinal cord circulation is disturbed and is
often reliant on collaterals. Jacobs and colleagues have shown
that the main blood supply of the spinal cord arises from lum-
bar and pelvic collaterals in 25%.
18
Various techniques have
been instituted in an attempt to reduce the incidence of
neurological deficit following open surgery: cerebrospinal
fluid (CSF) drainage, epidural cooling, pharmacotherapy, left
heart bypass, motor evoked potentials (MEPs), and intercostal
reimplantation. In contrast, adjunctive techniques are not
used routinely during endoluminal repair of thoracic aortic
disease. Simultaneous or previous aortic surgery, long
segment coverage, and perioperative hypotension have been
identified as risk factors for the development of paraplegia
following endoluminal repair. Some groups advocate the use
of prophylactic CSF drainage in high risk patients.
16
CSF
drainage for open surgery is used to reduce raised CSF
pressure, which occurs on aortic cross clamping and conse-
quently improves spinal cord perfusion. There have also been
reports of successful reversal of delayed onset paraplegia with
CSF drainage for both open surgery and endoluminal repair.
There have been a total of 13 reported cases of paraplegia fol-
lowing endoluminal repair, of which 5/13 (38%) recovered
with CSF drainage. Other groups have attempted to identify
patients at risk of neurological complications by using
retrieveable stent grafts and balloon occlusion of the aorta in
association with MEPs.
19
Unfortunately both techniques
increase the risk of embolism and, if positive, would mean
abandoning the procedure in favour of open surgery. In
patients who are fit for open surgery MEPs could be used to
monitor motor function after deployment of thoracic stent
grafts. If critical MEPs develop there is the option of convert-
ing to an open procedure to allow intercostals or lumbar reim-
plantation.
Current opinion is that it would be unethical to perform a
randomised controlled trial comparing endoluminal repair
with open surgery, given the notable difference in results in
favour of endoluminal treatment. Hence, endoluminal repair
should be offered as first line treatment for thoracic aortic dis-
ease if technically feasible. To allow further evaluation of the
technique it is important that all cases are entered into the
national thoracic registry.
In conclusion endoluminal repair appears to be a safe alter-
native to open surgery for descending thoracic aneurysms,
acute and chronic type B dissection, and traumatic aortic rup-
ture. It also has the additional benefits of being a less invasive
procedure that significantly reduces the length of hospital
stay. However, the durability of the stent grafts remains
unproven in the long term.
.....................
Authors’ affiliations
R E Bell, Department of Vascular Surgery, Guy’s & St Thomas’ Hospital,
London, UK
J F Reidy, Department of Radiology, Guy’s & St Thomas’ Hospital
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824 Editorial
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Long-term experience with descending aortic dissection: The complication-specific approach
Article
  • Feb 1992
  • ANN THORAC SURG
We analyzed long-term results in 71 patients (45 men and 26 women) treated over 17 years for documented descending aortic dissection. Forty-nine patients were treated medically and 22, surgically. Actuarial survival was 65% at 1 year, 57% at 3 years, 50% at 5 years, and 28% at 10 years for the whole group. For the group treated medically, survival was 73%, 63%, 58%, and 25% at 1 year, 3 years, 5 years, and 10 years, respectively, and for the group treated surgically, 47%, 40%, and 28% at 1 year, 3 years, and 5 years, respectively. Ten (20.4%) of the 49 medically treated patients died early (5 of rupture), and 14 (28.6%) died late (8 of dissection). Five medically treated patients crossed over to surgical management for complications of dissection. Among the surgically treated patients, 6 underwent standard graft replacement of the proximal descending aorta, 8 underwent the fenestration procedure (with a standardized retroperitoneal abdominal approach), and 4 underwent the thromboexclusion operation. Specific analysis of fenestration in 14 patients (including some with persistent descending aortic dissection after replacement of the ascending aorta for dissection) found it to be safe and effective. Actuarial survival after fenestration was 77%, 77%, and 53% at 1 year, 3 years, and 5 years, respectively. Thromboexclusion was found effective, and postoperative studies confirmed thrombosis of the descending aorta with preservation of the lowest intercostal arteries. Fifteen of the 21 surviving medically treated patients agreed to return for follow-up imaging. Nine had thrombosis of the false lumen. An interesting radiographic finding was that 4 of the 15 restudied patients had a saccular aneurysm in the aorta at the level of the left subclavian artery. We recommend a complication-specific approach to the management of descending aortic dissection. Uncomplicated dissection is treated medically, whereas complicated dissection is treated surgically, with realized rupture treated by standard graft replacement, limb ischemia treated by fenestration, and enlargement or impending rupture treated by thromboexclusion.
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Treatment of Patients with Aortic Dissection Presenting with Peripheral Vascular Complications
Article
  • Jan 1991
The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.
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Increasing incidence of aortic aneurysms England and Wales
Article
  • Feb 1989
The numbers of patients being admitted to hospital with aortic aneurysms have increased recently. A study was carried out to try to find out whether this was a true increase in incidence or whether it could be attributable to more accurate diagnosis and better surgical techniques. From analyses of routine statistics it was found that from 1950 to 1984 age standardised mortality rose 20-fold in men to 47.1 per 100,000 population and 11-fold in women to 22.2 per 100,000 and that this was mainly due to more deaths from abdominal aneurysms. Hospital admissions of men with abdominal aneurysms were found to have increased steadily from 1968 to 1983, but the increase for women admitted did not begin until 1978. An increase in both emergency and elective admissions and only a marginal fall in deaths in hospital (from 45% to 39%) suggest that admissions for abdominal aneurysms increased across a wide range of severity of disease. It is concluded for the following reasons that the true incidence of aortic aneurysms, particularly abdominal aneurysms, has been increasing in England and Wales: the trends are not wholly compatible with advances in diagnosis and surgery, there are inconsistencies by age and sex, and increases have occurred in the number of complicated as well as uncomplicated cases.
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Thoracic Aortic Aneurysms: A Population-Based Study
Article
  • Jan 1983
  • SURGERY
Thoracic aortic aneurysms were detected in 72 residents (44 women and 28 men) in a stable midwestern community over a 30-year period, for an age- and sex-adjusted incidence of 5.9 new aneurysms per 100,000 person-years. The incidence was equal in both sexes and decreased slightly over the 30 years. Ages ranged from 47 to 93 years (median 65 years for men and 77 years for women). The ascending aorta was involved in 37 patients, the aortic arch in 8, and the descending aorta in 27. Pathologic examination was performed in 51 patients. The cause was aortic dissection in 27 patients (53%), atherosclerosis in 15 (29%), aortitis in 4 (8%), cystic medial necrosis in 3 (6%), and syphilis in 2 (4%). All autopsied patients had pathologic evidence of significant hypertension. Eleven patients (25%) had concomitant abdominal aortic aneurysms. Rupture occurred in 53 patients (74%) and 50 died. Thirty-seven of these patients had no prior diagnosis of aneurysm. The median interval between diagnosis and rupture in the 16 remaining patients was 2 years (range 1 month to 16 years). Ninety-five percent of aortic dissections ruptured and 51% of nondissecting aneurysms ruptured. The actuarial 5-year survival for all 72 patients was 13%; for patients with aortic dissection, 7% and for patients without dissection, 19.2%.
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Treatment of Aortic Dissections with a Percutaneous Intravascular Endoprosthesis: Comparison of Covered and Bare Stents
Article
  • Nov 1994
  • J VASC INTERV RADIOL
The authors developed a percutaneous endoprosthesis for treatment of aortic dissections. The device is a Gianturco stent wrapped with Dacron or nylon mesh. Effectiveness of the covered stent versus a bare stent was compared in the treatment of acute aortic dissection. Experimental aortic dissections were created in 10 mongrel dogs. Occlusion of intimal tears was attempted with covered stents in five dogs (group 1) and with bare stents in the remaining five dogs (group 2). In group 1, entry tears were obliterated within 1 day (n = 3) or 1 week (n = 2) after stent placement and false lumina were thrombosed within 1 week (n = 3) or 1 month (n = 2). In group 2, entry tears and false lumina remained patent. Histologic specimens showed that the covered stents were entirely covered with smooth neointima. This endoprosthesis offers an alternative to surgical treatment for dissections of the descending aorta.
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