Long-term follow-up after endovascular treatment of acute aortic emergencies

Abstract

Purpose: To investigate the long-term outcome and efficacy of emergency treatment of acute aortic diseases with endovascular stent-grafts.

Methods: From September 1995 to April 2007, 37 patients (21 men, 16 women; age 53.9 +/- 19.2 years, range 18-85 years) with acute complications of diseases of the descending thoracic aorta were treated by endovascular stent-grafts: traumatic aortic ruptures (n = 9), aortobronchial fistulas due to penetrating ulcer or hematothorax (n = 6), acute type B dissections with aortic wall hematoma, penetration, or ischemia (n = 13), and symptomatic aneurysm of the thoracic aorta (n = 9) with pain, penetration, or rupture. Diagnosis was confirmed by contrast-enhanced CT. Multiplanar reformations were used for measurement of the landing zones of the stent-grafts. Stent-grafts were inserted via femoral or iliac cut-down. Two procedures required aortofemoral bypass grafting prior to stent-grafting due to extensive arteriosclerotic stenosis of the iliac arteries. In this case the bypass graft was used for introduction of the stent-graft.

Results: A total of 46 stent-grafts were implanted: Vanguard/Stentor (n = 4), Talent (n = 31), and Valiant (n = 11). Stent-graft extension was necessary in 7 cases. In 3 cases primary graft extension was done during the initial procedure (in 1 case due to distal migration of the graft during stent release, in 2 cases due to the total length of the aortic aneurysm). In 4 cases secondary graft extensions were performed--for new aortic ulcers at the proximal stent struts (after 5 days) and distal to the graft (after 8 months) and recurrent aortobronchial fistulas 5 months and 9 years after the initial procedure--resulting in a total of 41 endovascular procedures. The 30-day mortality rate was 8% (3 of 37) and the overall follow-up was 29.9 +/- 36.6 months (range 0-139 months). All patients with traumatic ruptures demonstrated an immediate sealing of bleeding. Patients with aortobronchial fistulas also demonstrated a satisfactory follow-up despite the necessity for reintervention and graft extension in 3 of 6 cases (50%). Two patients with type B dissection died due to mesenteric ischemia despite sufficient mesenteric blood flow being restored (but too late). Two suffered from neurologic complications, 1 from paraplegia and 1 from cerebral ischemia (probably embolic), 1 from penetrating ulcer, and 1 from persistent ischemia of the kidney. Five of 9 (56%) patients with symptomatic thoracic aneurysm demonstrated endoleaks during follow-up and there was an increase in the aneurysm in 1.

Conclusion: Endovascular treatment is safe and effective for emergency treatment of life-threatening acute thoracic aortic syndromes. Results are encouraging, particularly for traumatic aortic ruptures. However, regular follow-up is mandatory, particularly in the other pathologies, to identify late complications of the stent-graft and to perform appropriate additional corrections as required.