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Endovascular repair may be an option for patients with ascending aortic dissection who are considered poor surgical candidates, according to a small observational study published online October 31, 2012, ahead of print in the Journal of the American College of Cardiology.
Zaiping Jing, MD, PhD, and colleagues at Changhai Hospital, Second Military Medical University (Shanghai, China), looked at 41 consecutive patients with ascending aortic dissection who were treated at their institution from May 2009 to January 2011. Among them, 15 were considered poor surgical candidates and therefore received endovascular repair using the TX2 ProForm endograft (Cook Medical, Bloomington, IN).
According to the paper, the endovascular cohort represented patients who had already survived the initial phase of acute aortic dissection with medical therapy alone but were referred because of persistent symptoms and anatomic findings thought to require therapeutic intervention.
Promising Results, Researchers Say
Mean procedure time was 128.6 ± 26.2 minutes. Deployment was successful in 100% of cases. Intensive care unit stays lasted a mean of 3.3 ± 1.0 days, with a total hospitalization time of 9.4 ± 2.5 days. In-hospital complications consisted of 2 arrhythmias (13.3%).
Over a median follow-up of 26 months (range, 16-35 months), 1 new dissection occurred (6.7%) and was treated successfully using a customized branched stent graft. Complete thrombosis of the false lumen of the ascending aorta was seen in all cases, while that of the descending aorta was seen in 10 of 14 patients (71.4%). Maximal diameter of the ascending aorta decreased from 56.88 ± 6.7 mm at baseline to 45.51 ± 4.6 mm over follow-up (P = 0.001), and the diameter of the distal ascending aorta decreased from 46.5 ± 11.3 mm to 41 ± 11.7 mm (P = 0.04).
No deaths occurred in-hospital or during follow-up.
“Our results of endovascular repair of ascending aortic dissection have given us an optimistic view of this procedure,” the investigators conclude. The treatment, they say, “may prove to be a very acceptable alternative therapy. Design improvements for the delivery system, especially with respect to the nose cone, will be a necessary consideration for endograft devices planned for use in the ascending aorta.”
In addition, Dr. Jing and colleagues see the potential for this therapy to dovetail with TAVR. “It is conceivable that combining this technology with an endograft may make the possibility of treating ascending aortic dissections associated with compromised aortic valve function a reality,” they suggest, stressing that multidisciplinary heart teams are required to make treatment decisions and optimize outcomes in such cases.
Median time from onset of aortic dissection to endovascular treatment was 25.5 days, with the majority of patients (66.7%) treated in the chronic phase beyond 14 days. The main risk factor barring open surgery was advanced age (38.9%), followed by severe COPD (16.7%), cardiac dysfunction (11.1%), renal insufficiency (11.1%), and other issues (22.2%). A minority of patients had dissections that were confined to the ascending aorta (6.7%); some dissections involved the descending aorta (6.7%), but most involved the abdominal aorta (86.7%).