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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
Rivista di Chirurgia Vascolare ed Endovascolare
REVIEWS ALL ABOUT AORTIC DISSECTIONS
Italian Journal of Vascular and Endovascular Surgery 2010 June;17(2):117-28
Limitations of endovascular management of symptomatic acute and chronic type B aortic dissection
Kim K. M., Khoynezhad A., Donayre C. E., White R. A.
1 Division of Vascular and Endovascular Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA
2 Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
The aim of this study is to review the outcomes and limitations of thoracic aortic endovascular repair (TEVAR) in acute and chronic type B aortic dissection (TBAD). A search using the “Pubmed” resulted in 264 records by combining the Medical Subject Heading keywords (listed separately). The articles were assessed for their validity, correct pathology and patient cohort. Inclusion criteria included all patients with complicated acute or chronic TBAD who were candidates for TEVAR. The exclusion criteria included type A, asymptomatic acute or chronic TBAD, penetrating ulcer or intramural hematoma, and studies with fewer than nine subjects. Six publications from each symptomatic group met the inclusion and exclusion criteria. Early mortality rates for complicated acute and chronic TBADs were 12% and 3.4%, respectively. Postoperative rates of spinal cord injury were 9% for acute versus 1.8% for chronic TBAD. One-year-survival rates were 85% and 90.6%, respectively. A complete to partial reverse aortic remodeling occurred in 78% of survivors of acute TBAD and 86% of chronic TBAD survivors. Limitations for TEVAR include short or severely diseased landing zones, significant tortuosity of access vessels and aortic arch. Frequent and costly follow-up studies, endoleaks requiring further interventions, progressive aneurysmal changes distal and proximal to the endograft specially in patients with connective tissue disorder are further limitations of TEVAR. TEVAR of acute symptomatic and chronic TBAD is associated with relatively low morbidity and mortality. In depth understanding of the limitations of TEVAR helps gain insights into consulting patients with appropriate surgical or endovascular option, and need for improvement of the stent graft device designs.