Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent-Graft Placement

doi:10.1056/NEJM199905203402003

Volume 340:1539-1545		May 20, 1999		Number 20

Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent–Graft Placement

Christoph A. Nienaber, M.D., Rossella Fattori, M.D., Gunnar Lund, M.D., Christoph Dieckmann, M.D., Walter Wolf, M.D., Yskert von Kodolitsch, M.D., Volkmar Nicolas, M.D., and Angelo Pierangeli, M.D.

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ABSTRACT

Background The treatment of thoracic aortic dissection is guidedby prognostic and anatomical information. Proximal dissectionrequires surgery, but the appropriate treatment of distal thoracicaortic dissection has not been determined, because surgery hasfailed to improve the prognosis.

Methods We prospectively evaluated the safety and efficacy ofelective transluminal endovascular stent–graft insertionin 12 consecutive patients with descending (type B) aortic dissectionand compared the results with surgery in 12 matched controls.In all 24 patients, aortic dissection was diagnosed by magneticresonance angiography. In each group, the dissection involvedthe aortic arch in 3 patients and the descending thoracic aortain all 12 patients. With the patient under general anesthesia,either surgical resection was undertaken or a custom-designedendovascular stent–graft was placed by unilateral arteriotomy.

Results Stent–graft placement resulted in no morbidityor mortality, whereas surgery for type B dissection was associatedwith four deaths (33 percent, P=0.09) and five serious adverseevents (42 percent, P=0.04) within 12 months. Transluminal placementof the stent–graft prosthesis was successful in all patients,with no leakage; full expansion of the stents was ensured byballoon inflation at 2 to 3 atm. Sealing of the entry tear wasmonitored during the procedure by transesophageal ultrasonographyand angiography, and thrombosis of the false lumen was confirmedin all 12 patients after a mean of three months by magneticresonance imaging. There were no deaths or instances of paraplegia,stroke, embolization, side-branch occlusion, or infection inthe stent–graft group; nine patients had postimplantationsyndrome, with transient elevation of C-reactive protein levelsand body temperature plus mild leukocytosis. All the patientswho received stent–grafts recovered, as did seven patientswho underwent surgery for type B dissection (58 percent) (P=0.04).

Conclusions These preliminary observations suggest that elective,nonsurgical insertion of an endovascular stent–graft issafe and efficacious in selected patients who have thoracicaortic dissection and for whom surgery is indicated. Endoluminalrepair may be useful for interventional reconstruction of thoracicaortic dissection.

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From the Departments of Cardiology (C.A.N., G.L, Y.v.K), Diagnostic Radiology (C.D., V.N.), and Vascular Surgery (W.W.), University Hospital Eppendorf, Hamburg, Germany; and the Departments of Radiology (R.F.) and Cardiothoracic Surgery (A.P.), Policlinico S. Orsola-Malpighi, Bologna, Italy.

Address reprint requests to Dr. Nienaber at University Hospital Eppendorf, Martinistr. 52, Hamburg 20246, Germany, or at nienaber{at}uke.uni-hamburg.de.

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