- Email: [email protected]
Endovascular Treatment for Acute Aortic Syndrome
Endovascular Treatment for Acute Aortic Syndrome Paula Vasconcelos Ara ujo, Edwaldo Edner Joviliano, Maurı´cio Serra Ribeiro, Marcelo Bellini Dalio, Carlos Eli Piccinato, and Takachi Moriya, S~ao Paulo, Brazil
Background: The term ‘‘acute aortic syndrome’’ (AAS) includes conditions of high mortality, such as ruptured aneurysm, pseudoaneurysm and, aortic dissection. Open surgery for these cases has demonstrated unsatisfactory results, and endovascular treatment has become an excellent alternative. Methods: We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period. Results: Sixteen patients underwent endovascular treatment: eight ruptured aneurysms, six aortic dissections, one nonruptured painful aneurysm, and one pseudoaneurysm. No intramural hematoma or penetrating atherosclerotic ulcer was found. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities. Technical success rate was 93%, and overall 30-day mortality was 6.25%. Conclusion: Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has became the main technique for AAS in our hospital.
INTRODUCTION The term ‘‘acute aortic syndrome’’ (AAS) was first described by Vilacosta et al.1,2 and describes the acute presentation of patients with one of several lifethreatening aortic pathologies. These include ruptured aneurysm (RA), aortic dissection (AD), pseudoaneurysm, intramural hematoma-penetrating atherosclerotic ulcer, and traumatic transection.3 The patients with these conditions arrive at the emergency department with intense acute pain, which may be described as tearing, ripping, migrating, or pulsating.4 Classically (in nontraumatic cases), patients are elderly and present with a background of severe hypertension
Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeir~ao Preto School of Medicine, University of S~ao Paulo, S~ ao Paulo, Brazil. Correspondence to: Edwaldo Edner Joviliano, MD, PhD, Division of Vascular and Endovascular Surgery, Ribeir~ao Preto School of Medicine, University of S~ ao Paulo, Campus Universitario, 14049-900 Ribeir~ao Preto, Brazil; E-mail: [email protected] Ann Vasc Surg 2012; 26: 516e520 DOI: 10.1016/j.avsg.2011.07.011 Ó Annals of Vascular Surgery Inc. Published online: November 2, 2011
516
and comorbidity, including coronary artery disease, diabetes, and renal insufficiency.5 AAS is complicated with high mortality. The overall risk of death from abdominal RAs is 80-90%, as less than half of the patients reach the hospital alive.6,7 For the thoracic RA, the overall mortality rate is thought to exceed 90%.8 AD presents an overall in-hospital mortality rate of 13%, with most deaths occurring within the first week.9,10 Open surgery for AAS has demonstrated unsatisfactory results, carrying high mortality.11 Patients at greatest risk of rupture are paradoxically poor surgical candidates, being typically elderly with several comorbidities. Medication, although useful in preventing extension of the dissection or rupture of the aorta, does not address the anatomic problem.10,12,13 Endovascular treatment for AAS has become an excellent alternative. The outcomes of the applicability of this technique in emergency situations are still not well known, but recent data has shown it is a very promising alternative.14 The objective of this study was to describe the recent experience and outcomes of endovascular treatment for AAS in a consecutive group of patients
Vol. 26, No. 4, May 2012
Endovascular treatment for aortic syndrome 517
Table I. Demographic data, etiology of acute lesion, surgical time, and hospital stay of 16 patients who underwent endovascular repair Case
Sex
Age (years)
Etiology
Surgical time (minutes)
Hospital stay (days)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
F M M M M F M M M F F M F M F F
79 47 54 66 66 62 58 79 85 77 44 65 66 66 57 58
AD (Thoracic type B) AD (Thoracic type B) RA (Abdominal) RA (Abdominal) RA (Thoracic) AD (Thoracic type B) AD (Thoracic type B) RA (Thoraco-abdominal) RA (Abdominal) RA (Abdominal) Pseudoaneurysm (Thoracic) AD (Thoracic type B + AAA) AIA RA (Abdominal) RA (Abdominal) AD (Thoracic type B)
130 210 375 140 120 200 250 90 300 210 120 180 175 120 160 105
9 5 40 3 5 30 20 32 40 18 5 4 4 3 2 5
AD, aortic dissection; RA, ruptured aneurysm; AIA, aorto-iliac aneurysm; M, male; F, female.
that were admitted in our cardiovascular unit at emergency department.
PATIENTS AND METHODS We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period. The indicators for early interventions were persisting acute aortic pain despite medical management, increasing aortic wall thickness or diameter, increased volume or extend of hematoma, extraadventitial blood, and increasing pleural effusion. The patients presented pain and hemodynamic stability or with mild or moderate shock (grade I, II or III).15 These patients were recommended for computed tomography angiography (CTA), so that an endovascular treatment could be carried out. Patients that presented type A aortic dissection or with severe shock (grade IV) were treated with open surgery and were excluded form this study. Patients treated medically were also excluded. Cases of traumatic etiology were not reviewed because none of these cases were treated with endovascular procedure during this period. We collected demographic data, comorbidities, clinical presentation, etiology, type of endovascular treatment, mean operative time, duration of hospitalization, and procedure-related deaths (<30 days).16 An aneurysm was considered ruptured (free or contained) if blood outside the aortic wall
was observed in CTA scan. Nonruptured aneurysms were defined as absence of blood outside the aneurysmal wall. Aortic dissections were classified following the Stanford Classification.17 Technical success of the endovascular treatment was defined as a successful introduction and deployment of the device in the absence of surgical conversion to open repair, death within 24 hours, type I or III endoleaks evidenced by procedural angiography, or graft obstruction.16 The local research ethics committee approved the study.
RESULTS A total of 16 patients (7 women and 9 men) with AAS underwent endovascular treatment in our emergency department (Table I). RA was the etiology of aortic lesion in eight cases. Among them were one thoracic, one thoracoabdominal, and six abdominal aneurysms (Fig. 1A, B). AD was found in six cases, all of them thoracic Stanford type B lesions. In one case, the lesion was a nonruptured aortoiliac aneurysm presenting with pain. There was also one case of descending thoracic pseudoaneurysm following a surgical open procedure for aortic coarctation (Fig. 2A, B). No intramural hematoma or penetrating atherosclerotic ulcer was found in this series. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities (Table II). Endovascular treatment consisted in covering the diseased segment of aorta with an endograft.
518 Ara ujo et al.
Annals of Vascular Surgery
Fig. 2. (A) Arteriography showing pseudoaneurysm of the descending thoracic aorta after 25 years of an open repair of aortic coarctation. (B) CTA after endovascular repair of the pseudoaneurysm. Fig. 1. (A) Computed tomography angiography (CTA) showing a ruptured aneurism to the right retroperitonium. (B) CTA after stent grafting.
Thoracic lesions (eight) were treated with thoracic endovascular aortic repair (TEVAR) technique, using tubular endografts TAG (W. L. Gore & Associates, Flagstaff, AZ) and Valiant (Medtronic, Minneapolis, MN). Abdominal lesions (eight) were treated with endovascular aneurysm repair (EVAR) technique, with bifurcated endoprosthesis in four cases and aorto-mono-iliac endoprosthesis associated with femoro-femoral crossover bypass with expanded polytetrafluoroethylene graft in three cases. Endografts
used were Excluder (W. L. Gore & Associates, Flagstaff, AZ), Zenith (Cook Medical Inc., Bloomington, Indiana), and Talent (Medtronic, Minneapolis, MN). One abdominal case required conversion to open repair at the original operation owing to an endoleak and a lesion of the artery wall. The choice of each device was made on an individual basis, based on aortic size and anatomy, tortuosity of entry vessels, and local availability of products. Except for the conversion, all cases achieved technical success (93%). The procedures took a mean operative time of 168 minutes (90-375 minutes). The average times of hospitalization of TEVAR and EVAR were 12.8 (4e32) and 15.7 (2e40) days
Vol. 26, No. 4, May 2012
Endovascular treatment for aortic syndrome 519
Table II. Patients’ comorbidities Comorbidity
n
%
Arterial hypertension Present smoking Dyslipidemia Obesity Coronary artery disease Past stroke Chronic obstructive pulmonary disease
16 11 5 3 2 1 1
100.00 64.7 29.40 17.60 11.70 6.25 6.25
respectively. Five patients treated with TEVAR and four treated with EVAR required intensive care for more than 24 hours. The major complications are showed in Table III. There was just one case (ruptured abdominal aortic aneurism) of death within 30 days (pneumonia) after the procedure (6.25%).
DISCUSSION Recent advances in imaging and therapeutic techniques have emphasized the importance of early diagnosis of AAS because it is crucial for survival. Not just because the cardiovascular community knows little, the management of AAS remains a therapeutic challenge, while diverse surgical and percutaneous strategies for the treatment of aortic syndromes are continuously evolving. As a result of increasing knowledge and better management strategies in this area, the outcomes of patients treated for AAS have improved. There is a growing body of evidence to support the use of endovascular treatment in AAS. The first case of successful EVAR for AAS was described in 1994 by Yusuf et al.17 Since then, several authors have published isolated reports and series of cases of AAS treated with endoprosthesis implantation, with a technical success rate between 96% and 100%.18e23 Procedure-related mortality for endovascular treatment of AAS is impressively low. In a number of small studies, hospital and 30-day mortality rates have been reported between 0% and 16.7% for AAS, including type B, AD, and RA.24e28 A literature review of 641 patients including both elective and acute EVAR of AD and RA found an overall mortality of 6.2% with a 2.4% mortality rate for that particular center.29 In our series, the procedure-related mortality was 6.25%, which was compatible with the presented literature; the technical success rate of 93% was also similar. Demographic data of published series were also compatible with our results.
Table III. Complications related to the procedures Complication
n
%
Pneumonia Acute renal failure Othersa
6 4 1
37.5 25 6.25
a
Deep venous thrombosis, acute artery occlusion, endoleak, spinal injury.
Numerous authors have demonstrated that RAs treated with endografting have improved 30-day mortality when compared with standard open repair.18,30,31 Alsac et al. also reported decreased procedure time, blood loss, and length of hospital and intensive care unit (ICU) stay. The average postoperative mortality rate for this series was 24% (range, 9e45%).30 As demonstrated by the mean age and comorbidities of patients in our series, AAS affects individuals that are elderly and poor surgical candidates. Because the endovascular approach has the outcomes and advantages described above, it has become the main treatment in AAS. However, some authors understand that endovascular repair might better be considered as a palliative bridging technique to control hemorrhage during the acute phase so that patients can recover sufficiently to undergo definitive surgical repair.32 The establishment of an acute aortic treatment center to provide the care of AAS reduces mortality and morbidity of this condition.33 We agree with this idea that, since the creation of a cardiovascular unit in our emergency department, enabled the early diagnosis and definitive treatment of all these presented cases.
CONCLUSION Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has become the main technique for surgical AAS in our hospital. REFERENCES 1. Vilacosta I, San Roman JA, Aragoncillo P, et al. Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol 1998;32:83e9. 2. Vilacosta I, Aragoncillo P, Canadas V, San Roman JA, Ferreiros J, Rodriguez E. Acute aortic syndrome: a new look at an old conundrum. Heart 2009;95:1130e9.
520 Ara ujo et al.
3. Ahmad F, Cheshire N, Hamady M. Acute aortic syndrome: pathology and therapeutic strategies. Postgrad Med J 2006; 82:305e12. 4. Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac Cardiovasc Surg 2010;140: S92e7. discussion S142-S146. 5. Ince H, Nienaber CA. The concept of interventional therapy in acute aortic syndrome. J Card Surg 2002;17:135e42. 6. Karkos CD, Harkin DW, Giannakou A, Gerassimidis TS. Mortality after endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. Arch Surg 2009;144:770e8. 7. Ingoldby CJ, Wujanto R, Mitchell JE. Impact of vascular surgery on community mortality from ruptured aortic aneurysms. Br J Surg 1986;73:551e3. 8. Jonker FH, Verhagen HJ, Lin PH, et al. Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms. Circulation 2010;121:2718e23. 9. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD). Eur J Vasc Endovasc Surg 2009;37: 149e59. 10. Tang JD, Huang JF, Zuo KQ, et al. Emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset in 30 cases. J Thorac Cardiovasc Surg 2011;141:926e31. 11. Ramanath VS, Oh JK, Sundt TM 3rd, Eagle KA. Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc 2009;84:465e81. 12. Dialetto G, Covino FE, Scognamiglio G, et al. Treatment of type B aortic dissection: endoluminal repair or conventional medical therapy? Eur J Cardiothorac Surg 2005;27: 826e30. 13. Umana JP, Lai DT, Mitchell RS, et al. Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections? J Thorac Cardiovasc Surg 2002;124: 896e910. 14. Veith FJ, Powell JT, Hinchliffe RJ. Is a randomized trial necessary to determine whether endovascular repair is the preferred management strategy in patients with ruptured abdominal aortic aneurysms? J Vasc Surg 2010;52: 1087e93. 15. The American College of Surgeons. Shock. In: The American College of Surgeons, ed. Advance Trauma Life Support Manual. 1990. pp 59-73. 16. Fillinger MF, Greenberg RK, McKinsey JF, Chaikof EL. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg 2010;52:1022e33. 17. Yusuf SW, Baker DM, Chuter TA, Whitaker SC, Wenham PW, Hopkinson BR. Transfemoral endoluminal repair of abdominal aortic aneurysm with bifurcated graft. Lancet 1994;3;344:650e1.
Annals of Vascular Surgery
18. Moore R, Nutley M, Cina CS, Motamedi M, Faris P, Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms. J Vasc Surg 2007;45:443e50. 19. Dake MD, Kato N, Mitchell RS, et al. Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546e52. 20. Hutschala D, Fleck T, Czerny M, et al. Endoluminal stentgraft placement in patients with acute aortic dissection type B. Eur J Cardiothorac Surg 2002;21:964e9. 21. Haulon S, Koussa M, Beregi JP, Decoene C, Lions C, Warembourg H. Stent-graft repair of the thoracic aorta: short-term results. Ann Vasc Surg 2002;16:700e7. 22. Kawamura S, Nishimaki H, Lin ZB, et al. Emergent endovascular stent-graft placement to treat ruptured Stanford type B acute aortic dissection. J Vasc Surg 2004;39:668e71. 23. Heijmen RH, Deblier IG, Moll FL, et al. Endovascular stentgrafting for descending thoracic aortic aneurysms. Eur J Cardiothorac Surg 2002;21:5e9. 24. Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes. Eur J Cardiothorac Surg 2003;23:788e93. discussion 793. 25. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539e45. 26. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729e34. 27. Bell RE, Taylor PR, Aukett M, Sabharwal T, Reidy JF. Results of urgent and emergency thoracic procedures treated by endoluminal repair. Eur J Vasc Endovasc Surg 2003;25:527e31. 28. Semba CP, Kato N, Kee ST, et al. Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337e42. 29. Brunkwall J, Gawenda M, Sudkamp M, Zahringer M. Current indication for endovascular treatment of thoracic aneurysms. J Cardiovasc Surg (Torino) 2003;44:465e70. 30. Alsac JM, Kobeiter H, Becquemin JP, Desgranges P. Endovascular repair for ruptured AAA: a literature review. Acta Chir Belg 2005;105:134e9. 31. Lee WA, Hirneise CM, Tayyarah M, Huber TS, Seeger JM. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg 2004;40:211e5. 32. Amabile P, Rollet G, Vidal V, et al. Emergency treatment of acute rupture of the descending thoracic aorta using endovascular stent-grafts. Ann Vasc Surg 2006;20:723e30. 33. Davies MG, Younes HK, Harris PW, et al. Outcomes before and after initiation of an acute aortic treatment center. J Vasc Surg 2010;52:1478e85.
Background: The term ‘‘acute aortic syndrome’’ (AAS) includes conditions of high mortality, such as ruptured aneurysm, pseudoaneurysm and, aortic dissection. Open surgery for these cases has demonstrated unsatisfactory results, and endovascular treatment has become an excellent alternative. Methods: We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period. Results: Sixteen patients underwent endovascular treatment: eight ruptured aneurysms, six aortic dissections, one nonruptured painful aneurysm, and one pseudoaneurysm. No intramural hematoma or penetrating atherosclerotic ulcer was found. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities. Technical success rate was 93%, and overall 30-day mortality was 6.25%. Conclusion: Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has became the main technique for AAS in our hospital.
INTRODUCTION The term ‘‘acute aortic syndrome’’ (AAS) was first described by Vilacosta et al.1,2 and describes the acute presentation of patients with one of several lifethreatening aortic pathologies. These include ruptured aneurysm (RA), aortic dissection (AD), pseudoaneurysm, intramural hematoma-penetrating atherosclerotic ulcer, and traumatic transection.3 The patients with these conditions arrive at the emergency department with intense acute pain, which may be described as tearing, ripping, migrating, or pulsating.4 Classically (in nontraumatic cases), patients are elderly and present with a background of severe hypertension
Division of Vascular and Endovascular Surgery, Department of Surgery and Anatomy, Ribeir~ao Preto School of Medicine, University of S~ao Paulo, S~ ao Paulo, Brazil. Correspondence to: Edwaldo Edner Joviliano, MD, PhD, Division of Vascular and Endovascular Surgery, Ribeir~ao Preto School of Medicine, University of S~ ao Paulo, Campus Universitario, 14049-900 Ribeir~ao Preto, Brazil; E-mail: [email protected] Ann Vasc Surg 2012; 26: 516e520 DOI: 10.1016/j.avsg.2011.07.011 Ó Annals of Vascular Surgery Inc. Published online: November 2, 2011
516
and comorbidity, including coronary artery disease, diabetes, and renal insufficiency.5 AAS is complicated with high mortality. The overall risk of death from abdominal RAs is 80-90%, as less than half of the patients reach the hospital alive.6,7 For the thoracic RA, the overall mortality rate is thought to exceed 90%.8 AD presents an overall in-hospital mortality rate of 13%, with most deaths occurring within the first week.9,10 Open surgery for AAS has demonstrated unsatisfactory results, carrying high mortality.11 Patients at greatest risk of rupture are paradoxically poor surgical candidates, being typically elderly with several comorbidities. Medication, although useful in preventing extension of the dissection or rupture of the aorta, does not address the anatomic problem.10,12,13 Endovascular treatment for AAS has become an excellent alternative. The outcomes of the applicability of this technique in emergency situations are still not well known, but recent data has shown it is a very promising alternative.14 The objective of this study was to describe the recent experience and outcomes of endovascular treatment for AAS in a consecutive group of patients
Vol. 26, No. 4, May 2012
Endovascular treatment for aortic syndrome 517
Table I. Demographic data, etiology of acute lesion, surgical time, and hospital stay of 16 patients who underwent endovascular repair Case
Sex
Age (years)
Etiology
Surgical time (minutes)
Hospital stay (days)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
F M M M M F M M M F F M F M F F
79 47 54 66 66 62 58 79 85 77 44 65 66 66 57 58
AD (Thoracic type B) AD (Thoracic type B) RA (Abdominal) RA (Abdominal) RA (Thoracic) AD (Thoracic type B) AD (Thoracic type B) RA (Thoraco-abdominal) RA (Abdominal) RA (Abdominal) Pseudoaneurysm (Thoracic) AD (Thoracic type B + AAA) AIA RA (Abdominal) RA (Abdominal) AD (Thoracic type B)
130 210 375 140 120 200 250 90 300 210 120 180 175 120 160 105
9 5 40 3 5 30 20 32 40 18 5 4 4 3 2 5
AD, aortic dissection; RA, ruptured aneurysm; AIA, aorto-iliac aneurysm; M, male; F, female.
that were admitted in our cardiovascular unit at emergency department.
PATIENTS AND METHODS We performed a retrospective review of patients with AAS who underwent endovascular treatment in our emergency department from July 2009 to February 2011. They represent 64% (16 of 25) of all patients with AAS seen during this period. The indicators for early interventions were persisting acute aortic pain despite medical management, increasing aortic wall thickness or diameter, increased volume or extend of hematoma, extraadventitial blood, and increasing pleural effusion. The patients presented pain and hemodynamic stability or with mild or moderate shock (grade I, II or III).15 These patients were recommended for computed tomography angiography (CTA), so that an endovascular treatment could be carried out. Patients that presented type A aortic dissection or with severe shock (grade IV) were treated with open surgery and were excluded form this study. Patients treated medically were also excluded. Cases of traumatic etiology were not reviewed because none of these cases were treated with endovascular procedure during this period. We collected demographic data, comorbidities, clinical presentation, etiology, type of endovascular treatment, mean operative time, duration of hospitalization, and procedure-related deaths (<30 days).16 An aneurysm was considered ruptured (free or contained) if blood outside the aortic wall
was observed in CTA scan. Nonruptured aneurysms were defined as absence of blood outside the aneurysmal wall. Aortic dissections were classified following the Stanford Classification.17 Technical success of the endovascular treatment was defined as a successful introduction and deployment of the device in the absence of surgical conversion to open repair, death within 24 hours, type I or III endoleaks evidenced by procedural angiography, or graft obstruction.16 The local research ethics committee approved the study.
RESULTS A total of 16 patients (7 women and 9 men) with AAS underwent endovascular treatment in our emergency department (Table I). RA was the etiology of aortic lesion in eight cases. Among them were one thoracic, one thoracoabdominal, and six abdominal aneurysms (Fig. 1A, B). AD was found in six cases, all of them thoracic Stanford type B lesions. In one case, the lesion was a nonruptured aortoiliac aneurysm presenting with pain. There was also one case of descending thoracic pseudoaneurysm following a surgical open procedure for aortic coarctation (Fig. 2A, B). No intramural hematoma or penetrating atherosclerotic ulcer was found in this series. The mean age was 64.3 years, and arterial hypertension (100%) and smoking (64.7%) were the major comorbidities (Table II). Endovascular treatment consisted in covering the diseased segment of aorta with an endograft.
518 Ara ujo et al.
Annals of Vascular Surgery
Fig. 2. (A) Arteriography showing pseudoaneurysm of the descending thoracic aorta after 25 years of an open repair of aortic coarctation. (B) CTA after endovascular repair of the pseudoaneurysm. Fig. 1. (A) Computed tomography angiography (CTA) showing a ruptured aneurism to the right retroperitonium. (B) CTA after stent grafting.
Thoracic lesions (eight) were treated with thoracic endovascular aortic repair (TEVAR) technique, using tubular endografts TAG (W. L. Gore & Associates, Flagstaff, AZ) and Valiant (Medtronic, Minneapolis, MN). Abdominal lesions (eight) were treated with endovascular aneurysm repair (EVAR) technique, with bifurcated endoprosthesis in four cases and aorto-mono-iliac endoprosthesis associated with femoro-femoral crossover bypass with expanded polytetrafluoroethylene graft in three cases. Endografts
used were Excluder (W. L. Gore & Associates, Flagstaff, AZ), Zenith (Cook Medical Inc., Bloomington, Indiana), and Talent (Medtronic, Minneapolis, MN). One abdominal case required conversion to open repair at the original operation owing to an endoleak and a lesion of the artery wall. The choice of each device was made on an individual basis, based on aortic size and anatomy, tortuosity of entry vessels, and local availability of products. Except for the conversion, all cases achieved technical success (93%). The procedures took a mean operative time of 168 minutes (90-375 minutes). The average times of hospitalization of TEVAR and EVAR were 12.8 (4e32) and 15.7 (2e40) days
Vol. 26, No. 4, May 2012
Endovascular treatment for aortic syndrome 519
Table II. Patients’ comorbidities Comorbidity
n
%
Arterial hypertension Present smoking Dyslipidemia Obesity Coronary artery disease Past stroke Chronic obstructive pulmonary disease
16 11 5 3 2 1 1
100.00 64.7 29.40 17.60 11.70 6.25 6.25
respectively. Five patients treated with TEVAR and four treated with EVAR required intensive care for more than 24 hours. The major complications are showed in Table III. There was just one case (ruptured abdominal aortic aneurism) of death within 30 days (pneumonia) after the procedure (6.25%).
DISCUSSION Recent advances in imaging and therapeutic techniques have emphasized the importance of early diagnosis of AAS because it is crucial for survival. Not just because the cardiovascular community knows little, the management of AAS remains a therapeutic challenge, while diverse surgical and percutaneous strategies for the treatment of aortic syndromes are continuously evolving. As a result of increasing knowledge and better management strategies in this area, the outcomes of patients treated for AAS have improved. There is a growing body of evidence to support the use of endovascular treatment in AAS. The first case of successful EVAR for AAS was described in 1994 by Yusuf et al.17 Since then, several authors have published isolated reports and series of cases of AAS treated with endoprosthesis implantation, with a technical success rate between 96% and 100%.18e23 Procedure-related mortality for endovascular treatment of AAS is impressively low. In a number of small studies, hospital and 30-day mortality rates have been reported between 0% and 16.7% for AAS, including type B, AD, and RA.24e28 A literature review of 641 patients including both elective and acute EVAR of AD and RA found an overall mortality of 6.2% with a 2.4% mortality rate for that particular center.29 In our series, the procedure-related mortality was 6.25%, which was compatible with the presented literature; the technical success rate of 93% was also similar. Demographic data of published series were also compatible with our results.
Table III. Complications related to the procedures Complication
n
%
Pneumonia Acute renal failure Othersa
6 4 1
37.5 25 6.25
a
Deep venous thrombosis, acute artery occlusion, endoleak, spinal injury.
Numerous authors have demonstrated that RAs treated with endografting have improved 30-day mortality when compared with standard open repair.18,30,31 Alsac et al. also reported decreased procedure time, blood loss, and length of hospital and intensive care unit (ICU) stay. The average postoperative mortality rate for this series was 24% (range, 9e45%).30 As demonstrated by the mean age and comorbidities of patients in our series, AAS affects individuals that are elderly and poor surgical candidates. Because the endovascular approach has the outcomes and advantages described above, it has become the main treatment in AAS. However, some authors understand that endovascular repair might better be considered as a palliative bridging technique to control hemorrhage during the acute phase so that patients can recover sufficiently to undergo definitive surgical repair.32 The establishment of an acute aortic treatment center to provide the care of AAS reduces mortality and morbidity of this condition.33 We agree with this idea that, since the creation of a cardiovascular unit in our emergency department, enabled the early diagnosis and definitive treatment of all these presented cases.
CONCLUSION Endovascular treatment for AAS was feasible. Technical success, 30-day mortality, hospital stay, and procedure time were similar to those of the other series reported in the literature, and the endovascular approach has become the main technique for surgical AAS in our hospital. REFERENCES 1. Vilacosta I, San Roman JA, Aragoncillo P, et al. Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography. J Am Coll Cardiol 1998;32:83e9. 2. Vilacosta I, Aragoncillo P, Canadas V, San Roman JA, Ferreiros J, Rodriguez E. Acute aortic syndrome: a new look at an old conundrum. Heart 2009;95:1130e9.
520 Ara ujo et al.
3. Ahmad F, Cheshire N, Hamady M. Acute aortic syndrome: pathology and therapeutic strategies. Postgrad Med J 2006; 82:305e12. 4. Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac Cardiovasc Surg 2010;140: S92e7. discussion S142-S146. 5. Ince H, Nienaber CA. The concept of interventional therapy in acute aortic syndrome. J Card Surg 2002;17:135e42. 6. Karkos CD, Harkin DW, Giannakou A, Gerassimidis TS. Mortality after endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. Arch Surg 2009;144:770e8. 7. Ingoldby CJ, Wujanto R, Mitchell JE. Impact of vascular surgery on community mortality from ruptured aortic aneurysms. Br J Surg 1986;73:551e3. 8. Jonker FH, Verhagen HJ, Lin PH, et al. Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms. Circulation 2010;121:2718e23. 9. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD). Eur J Vasc Endovasc Surg 2009;37: 149e59. 10. Tang JD, Huang JF, Zuo KQ, et al. Emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset in 30 cases. J Thorac Cardiovasc Surg 2011;141:926e31. 11. Ramanath VS, Oh JK, Sundt TM 3rd, Eagle KA. Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc 2009;84:465e81. 12. Dialetto G, Covino FE, Scognamiglio G, et al. Treatment of type B aortic dissection: endoluminal repair or conventional medical therapy? Eur J Cardiothorac Surg 2005;27: 826e30. 13. Umana JP, Lai DT, Mitchell RS, et al. Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections? J Thorac Cardiovasc Surg 2002;124: 896e910. 14. Veith FJ, Powell JT, Hinchliffe RJ. Is a randomized trial necessary to determine whether endovascular repair is the preferred management strategy in patients with ruptured abdominal aortic aneurysms? J Vasc Surg 2010;52: 1087e93. 15. The American College of Surgeons. Shock. In: The American College of Surgeons, ed. Advance Trauma Life Support Manual. 1990. pp 59-73. 16. Fillinger MF, Greenberg RK, McKinsey JF, Chaikof EL. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg 2010;52:1022e33. 17. Yusuf SW, Baker DM, Chuter TA, Whitaker SC, Wenham PW, Hopkinson BR. Transfemoral endoluminal repair of abdominal aortic aneurysm with bifurcated graft. Lancet 1994;3;344:650e1.
Annals of Vascular Surgery
18. Moore R, Nutley M, Cina CS, Motamedi M, Faris P, Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms. J Vasc Surg 2007;45:443e50. 19. Dake MD, Kato N, Mitchell RS, et al. Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546e52. 20. Hutschala D, Fleck T, Czerny M, et al. Endoluminal stentgraft placement in patients with acute aortic dissection type B. Eur J Cardiothorac Surg 2002;21:964e9. 21. Haulon S, Koussa M, Beregi JP, Decoene C, Lions C, Warembourg H. Stent-graft repair of the thoracic aorta: short-term results. Ann Vasc Surg 2002;16:700e7. 22. Kawamura S, Nishimaki H, Lin ZB, et al. Emergent endovascular stent-graft placement to treat ruptured Stanford type B acute aortic dissection. J Vasc Surg 2004;39:668e71. 23. Heijmen RH, Deblier IG, Moll FL, et al. Endovascular stentgrafting for descending thoracic aortic aneurysms. Eur J Cardiothorac Surg 2002;21:5e9. 24. Grabenwoger M, Fleck T, Czerny M, et al. Endovascular stent graft placement in patients with acute thoracic aortic syndromes. Eur J Cardiothorac Surg 2003;23:788e93. discussion 793. 25. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539e45. 26. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729e34. 27. Bell RE, Taylor PR, Aukett M, Sabharwal T, Reidy JF. Results of urgent and emergency thoracic procedures treated by endoluminal repair. Eur J Vasc Endovasc Surg 2003;25:527e31. 28. Semba CP, Kato N, Kee ST, et al. Acute rupture of the descending thoracic aorta: repair with use of endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337e42. 29. Brunkwall J, Gawenda M, Sudkamp M, Zahringer M. Current indication for endovascular treatment of thoracic aneurysms. J Cardiovasc Surg (Torino) 2003;44:465e70. 30. Alsac JM, Kobeiter H, Becquemin JP, Desgranges P. Endovascular repair for ruptured AAA: a literature review. Acta Chir Belg 2005;105:134e9. 31. Lee WA, Hirneise CM, Tayyarah M, Huber TS, Seeger JM. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg 2004;40:211e5. 32. Amabile P, Rollet G, Vidal V, et al. Emergency treatment of acute rupture of the descending thoracic aorta using endovascular stent-grafts. Ann Vasc Surg 2006;20:723e30. 33. Davies MG, Younes HK, Harris PW, et al. Outcomes before and after initiation of an acute aortic treatment center. J Vasc Surg 2010;52:1478e85.