1. Endovascular Repair of Acute
Aortic Dissection
Kent MacKenzie, MD
Division of Vascular Surgery
McGill University
Montreal, Quebec

2. Disclosures
• Medtronic consultancy agreement
• Speaking fees from Cook

3. Acknowledgements
• OK Steinmetz, MM Corriveau, CZ Abraham,
D Obrand
• J Titley MD, Hamilton, Ontario

4. Acute Aortic Dissection
What is it?

7. Basic Epidemiology of Dissection
• 4:1 male to female
• 60-75% are Stanford Type A
– Peak between 50-60 years
• 25% are Stanford Type B
– Peak between 60-70 years
• Hypertension in >70%

8. Basic Epidemiology of Dissection
• Other factors:
– Cystic Medial Necrosis (Marfan’s, E-D synd)
– Pregnancy
– Cocaine
– Bicuspid valve
– Aortic coarctation
– Syndromes - Turner’s, Noonan’s, etc
– Chronobiologic patterns
• Early am
• Winter vs. Summer

9. Clinical Findings in Dissection
• Pain
• Hypertension
• Neurologic
– Syncope
– Stroke
– Spinal cord ischemia
• Limb ischemia

10. Complications of Dissection
• Type A
– Death from coronary malperfusion,
tamponade, rupture
– Stroke and distal malperfusion
• Type B
– Rupture
– Malperfusion - visceral, spinal, extremity
– Aneurysm

11. Intervention
• Complicated or Failure of Medical Therapy
• What is Complicated? (Failure of Medical)
– Rupture
– Aneurysmal false lumen or expansion
– Malperfusion
– Persistent pain
– Untreatable hypertension

12. Open Repair

15. Open Repair
• Advocated by some for all cases of
complicated Type B dissection requiring
intervention
• Role of open repair in the Endo era is
further blurred

16. Endovascular Repair
• Currently accepted as a viable treatment
option in selected cases of complicated
Type B aortic dissection
• What is Complicated? (Failure of Medical)
– Rupture
– Aneurysmal false lumen or expansion
– Malperfusion
– Persistent pain
– Untreatable hypertension

17. Endovascular Repair
• Where did the generalized allure for TEVAR
for Aortic Dissection start?

19. Endovascular Repair
• Case reports
• Case series
• Cohort studies
• Single-center and multi-center Registries

20. Endovascular Repair

21. Endovascular Repair
• At RVH:
–Approx 170 TEVAR
–23% indication is either:
• Acute complicated type B dissection
• IMH with ulcer

22. Endovascular Repair
• Goals
– Cover entry tear of the dissection
– Expansion of compressed true lumen
– Induce false lumen thrombosis
– Allow remodeling of aorta
– Potentially prevent aneurysm development
– Without the morbidity of open repair

23. Endovascular Repair
• Concept of inducing true lumen expansion
and false lumen thrombosis is a valid one:
– Reduces morbidity/mortality of malperfusion
– Lowering the risk of false lumen enlargement
• aneurysm

28. Endovascular Repair
• In the real world:
• True lumen expansion and false lumen
thrombosis in complicated Type B dissection
can be achieved

29. Pain, expansion, HPTN 2008

35. Procedural issues to be considered
• Define your indication
• Review the CT images
• ‘Best guess’ for location of primary tear
• Determine appropriate vessel diameters
– Guiding graft selection

36. Procedural issues to be considered
• Deployment Access Vessel
– Best femoral/iliac for delivery
– Assure true lumen graft deployment
• Femoral access with true lumen imaging
• Brachial access
• TEE confirmation

37. Procedural issues to be considered
• Imaging
– Quality
– Flush catheter access and position
– Contrast delivery
– Image Intensifier angulation

38. Imaging - Angulation

39. 45
LAO
o

40. 45
LAO
o

41. Imaging Quality C-arm

42. Imaging Quality Angiosuite

43. Imaging Quality Angiosuite

44. What procedural issues should be
considered?
• Blood pressure manipulation during
deployment
– Low - nitro, beta blockers
– Very low - adenosine, rapid RV pacing

45. Rapid RV pacing
Nienaber C et al. J Endovasc Ther 2007.

46. What procedural issues should be
considered?
• Graft oversizing (? less)
• ? Limited use of ballooning
• Stent graft specific deployment steps
–Understand your grafts
• Strengths and Weaknesses

47. Graft Selection

48. Graft Selection

49. Have to be familiar with the grafts you will use
– What they are capable of doing
– How they will perform in routine cases
– What they will do when you ask it to do something
• Within the IFU
• Outside the IFU

55. Endovascular Repair
• The technique is useful
• The results can be gratifying

56. Endovascular Repair
• However:
–Caution is required
–Recognition of potential problems
–There is still a lot we don’t understand

60. Dissection Stent

63. Endovascular Repair
• Or:

64. May 2012

65. Ongoing pain, aortic expansion, spikes severe HPTN

72. Endovascular Repair
• What are we still unsure about?
– The use and utility of uncovered dissection stents
– The use of TEVAR for ‘uncomplicated’ dissection
• Predictors where treatment is reasonable?
– What is the best device?

73. Bare Dissection Stents

74. Bare Dissection Stents

75. Endovascular Repair
• What are we still unsure about?
– The use and utility of uncovered dissection stents
– The use of TEVAR for ‘uncomplicated’ dissection
• Predictors where treatment is reasonable?
– What is the best device?

79. • Randomized Trial
• Acute Dissection <2 weeks
• BMT vs. TEVAR
• Primary End-Point
– False-lumen thrombosis at 1 year
– Aortic dilatation at 1 year
– Aortic rupture at 1 year
• Expect to enroll 250-260 patients
ADSORB

80. Endovascular Repair
• What are we still unsure about?
– The use and utility of uncovered dissection stents
– The use of TEVAR for ‘uncomplicated’ dissection
• Predictors where treatment is reasonable?
– What is the best device?

81. Endovascular Repair
• That is for another day

82. Thank You