Type:
Educational Exhibit
Keywords:
Arteries / Aorta, Vascular, Interventional vascular, CT-Angiography, Catheter arteriography, Stents, Surgery, Dissection, Haemorrhage, Dilatation
Authors:
G. Genadiev1, S. Comelli1, C. Ganau1, P. Enne1, A. Ferrari2, D. Giuseppe1, F. Spanu1, S. Camparini1; 1Cagliari/IT, 2Monserrato/IT
DOI:
10.26044/ecr2019/C-3606
Background
Aortic dissections are a complex disease that presents unique challenges.
About one-third of patients with type B aortic dissections (TBAD) present with complications such as continuous aortic expansion,
rupture,
malpefrusion,
uncontrollable pain or hypertension.[1] Ruptured type B aortic dissections (rTBAD) are a leading cause of death occurring at a rate of 3.6-20%.[2] Thoracic aortic endografting (TEVAR) is indicated as a first-choice therapy for complicated TBADs according to the recent ESVS guidelines (Level IC evidence).
[3] Most large case series or reimbursment code reviews published,
however,
do not deal specifically with ruptures and there is paucity of references in Literature on how to address specific issues regarding the pathology which may present at any diagnostic,
primary and secondary treatment stages.
[4][5][6] The premise of TEVAR for TBAD treatment is that the coverage of the entry tear will lead to reduced pressure and therefore flow in the false lumen (FL) and expansion of the true lumen (TL) and stimulate positive aortic remodeling.
On the other hand when a rupture is present the uncertainty of the persistence of the FL and therefore continual leakage of blood and maintenance of the shock state is a real possibility.
Furthermore there are sizing issues in such patients as the aortic diameter can be smaller in the setting of hypotension thus opening up possibilities of endoleaks when normotension is established.
An important issue is the length of coverage of the aorta.
It can be logical to cover the whole descending aorta up to the celiac trunk but is this always necessary? Spinal cord ischemia is a rare complication of TEVAR but the probability increases the more aorta is covered and even more when hypotension is dominant.
Additionally extensive coverage of the aorta might render future endovascular interventions at the more distal level difficult or impossible.
Perhaps an approach of covering the entry tear and the suspected rupture site and then evaluating the need to do more in a patient-specific manner is more appropriate.