Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
권호 표지
DOI QR코드

DOI QR Code

Endovascular Repair of Acute Type B Aortic Dissection: The Early Results and Aortic Wall Changes

급성 B형 대동맥 박리의 혈관내 스텐트-그라프트 삽입이 초기성적 및 대동맥 벽의 변화

  • Her, Keun (Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital) ;
  • Won, Yong-Soon (Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital) ;
  • Shin, Hwa-Kyun (Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital) ;
  • Yang, Jin-Sung (Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital) ;
  • Baek, Kang-Seok (Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Gumi Hospital)
  • 허균 (순천향대학교 부천병원 흉부외과) ;
  • 원용순 (순천향대학교 부천병원 흉부외과) ;
  • 신화균 (순천향대학교 부천병원 흉부외과) ;
  • 양진성 (순천향대학교 부천병원 흉부외과) ;
  • 백강석 (순천향대학교 구미병원 흉부외과)
  • Received : 2010.07.22
  • Accepted : 2010.09.29
  • Published : 2010.12.05
Download PDF
⟨ Previous Next ⟩

Abstract

Background: This study assessed the early results of endovascular repair of acute type B aortic dissection and the aortic wall changes following endovascular repair. Material and Method: From July 2008 to May 2009, the preoperative and follow-up computed tomography (CT) scans of 5 patients with acute type B aortic dissection were evaluated, and these patients had underwent stent graft implantation within 13 days of the onset of dissection (mean: 7 days; range: 3~13). The whole lumen (WL), true lumen (TL) and false lumen (FL) diameters were measured at the proximal (p), middle (m) and distal (d) third of the descending thoracic aorta. Result: The study included four men and one woman with an average age of $59.4{\pm}20.1$ years (age range: 37~79 years). The follow-up CT was performed and evaluated at 7 days and 6 months. The primary tear was completely sealed in all the patients. No paraplegia, paresis or peripheral ischemia occurred and none of the patients died. No endoleaks developed in any of the patients during follow-up. The TL diameters increased from 20.4 to 33.5 mm in the proximal third (p/3), from 19.5 to 29.8 mm in the middle third (m/3) and from 15.2 to 23.5 mm in the distal third (d/3). The FL diameters decreased from 18.7 to 0 mm in the p/3, from 15.4 to 0 mm in the m/3 and from 21.4 to 8.7 mm in the d/3. The changes in the TL diameter were statistically significant in the middle and distal aorta, and those changes in the FL diameter were not statistically significant. There was a decrease in the WL after repair, but this was not statistically Significant. In three patients, the false lumen disappeared completely on follow-up CT at 6 months. Two patients had patent false lumens and no thrombosis. Conclusion: The early results showed that endovascular repair was effective in treating acute type B aortic dissection, and endovascular repair promoted positive aortic wall changes.

배경: 급성 B형 대동맥 박리 환자들에게 시행한 혈관 내 스텐트-그라프트 치료의 초기 성적 및 대동맥 벽의 변화에 대해서 알아보고자 하였다. 대상 및 방법: 2008년 7월부터 2009년 5월까지 본원을 방문한 급성 B형 대동맥 박리 환자들을 대상으로 혈관 내 스텐트-그라프트를 13일 이전에 삽입하였다. 수술전과 수술 후 약 6개월에 혈관조영 컴퓨터 단층촬영을 시행하였고 하행 대동맥을 근위부, 중위부 그리고 원위부로 나눈 뒤 각 부위별로 진성내강과 가성내강 그리고 대동맥 전내강의 내경을 비교 분석하였다. 결과: 남녀 비는 4:1이였으며 평균나이는 $59.4{\pm}20.1$세 (37~79세)였다. 수술 전에 혈관조영 컴퓨터 단층촬영을 시행하였으며 수술 후 7일 후와 6개월에 추적검사를 시행하였다. 5명 모두에게 일차성 내막 파열(primary entry tear)의 폐쇄가 완벽하게 이루어 졌으며 신경학적 후유증이나 말초의 허혈은 관찰되지 않았고 수술로 인한 사망은 없었다. 진성내강의 변화는 근부위에서 수술 전 20.4 mm에서 33.5 mm로 증가하였으며 중위부와 원위부에서도 각각, 19.5 mm에서 29.8 mm, 15.2 mm에서 23.5 mm로 증가하였으며 (p<0.05), 가성내강의 변화는 근위부에서 18.7 mm에서 0 mm로 감소하였고 중위부와 원위부에서도 감소하는 추세로 관찰되었다. 대동맥 전내강의 변화는 수술 전 보다 수술 후 증가하였다(p<0.05). 3명의 환자에서 6개윌 후 가성내강의 완벽한 소실이 관찰되었고 2명의 환자에게서는 복부대동맥 부위에서 가성대동맥이 지속적으로 관찰되었다. 결론: 급성 B형 대동맥 박리 환자들에게 시행한 혈관 내 스텐트-그라프트의 초기 결과는 매우 효과적이였으며 스텐트-그라프트 삽입 후 대동맥 벽의 변화 역시 매우 긍정적이라 할 수 있겠다.

Keywords

References

  1. Suzuki T, Mehta RH, Ince H, et al. International registry of aortic dissection. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lesions from the International Registry of Aortic Dissection (IRAD). Circulation 2003;8(suppl 1):312-7.
  2. Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms. Circulation 1990;82:39-46.
  3. Glower DD, Fann JI, Speier RH, et al. Comparison of medical and surgical therapy for uncomplicated descending aortic dissection. Circulation 1990;82(suppl 5):39-46.
  4. Estrera AL, Miller CC 3rd, Safi HJ, et al. Outcomes of medical management of acute type B aortic dissection. Circulation 2006;114(suppl 1):384-9.
  5. Gysi J, Schaffner T, Mohacsi P, Aeschbacher B, Althaus U, Carrel T. Early and late outcome of operated and non-operated acute dissection of the descending aorta. Eur J Cardiothorac Surg 1997;11:1163-70. https://doi.org/10.1016/S1010-7940(97)00091-2
  6. Bernard Y, Zimmermann H, Chocron S, et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001;87:1378-82. https://doi.org/10.1016/S0002-9149(01)01556-9
  7. Marui A, Mochizuki T, Mitsui N, Koyama T, Kimura F, Horibe M. Toward the best treatment for uncomplicated patients with type B acute aortic dissection: a consideration for sound surgical indication. Circulation 1999;100(suppl 19):275-80.
  8. Elefteriades JA, Hartleroad J, Gusberg RJ, et al. Long-term experience with descending aortic dissection: the complication-specific approach. Ann Thorac Surg 1992;53:11-21. https://doi.org/10.1016/0003-4975(92)90752-P
  9. Schor JS, Yerliouglu ME, Galla JD, Lansman SL, Ergin MA, Griepp RB. Selective management of acute type B aortic dissection: long-term follow-up. Ann Thorac Surg 1996;61:1339-41. https://doi.org/10.1016/0003-4975(96)00105-1
  10. Bachet JE, Termignon JL, Dreyfus G, et al. Aortic dissection: prevalence, cause and results of late reoperations. J Thorac Cardiovas Surg 1994;108:199-206.
  11. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999;340:1546-52. https://doi.org/10.1056/NEJM199905203402004
  12. Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med 1999;340:1539-45. https://doi.org/10.1056/NEJM199905203402003
  13. Kato N, Hirano T, Shimono T, et al. Treatment of chronic type B aortic dissection with endovascular stentgraft placement. Cardiovasc Intervent Radiol 2000;23:60-2. https://doi.org/10.1007/s002709910010
  14. Wheatley 3rd GH, Gurbuz AT, Rodriguez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprosthesis: single center experience. Ann Thorac Surgery 2006; 81:1570-7. https://doi.org/10.1016/j.athoracsur.2005.06.068
  15. MacKenzie KS, LeGuillan MP, Steinmetz OK, Montreuil B. Management trends and early mortality rates for acute type B dissection: a 10-years single-institution experience. Ann Vasc Surg 2004;18:158-66. https://doi.org/10.1007/s10016-004-0007-8
  16. Palma JH, De Souza JA, Rodrigues Alves CM, Carvalho AC, Buffolo E. Self expandable aortic stent-graft for treatment of descending aortic dissections. Ann Thorac Surg 2002;73:1138-42. https://doi.org/10.1016/S0003-4975(02)03397-0
  17. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years' experience. Circulation 2005;111:2951-7. https://doi.org/10.1161/CIRCULATIONAHA.104.480780
  18. Gaxotte V, Thony F, Rousseau H, et al. Midterm results of aortic diameter outcomes after thoracic stent-graft implantation for aortic dissection: a multicenter study. J Endovasc Ther 2006;13:127-38. https://doi.org/10.1583/04-1416R.1
  19. Elefteriades JA, Lovoulos CJ, Coady MA, Tellides G, Kopf GS, Rizzo JA. Management of descending aortic dissection. Ann Thorac Surg 1999;67:2002-5. https://doi.org/10.1016/S0003-4975(99)00428-2
  20. Nienaber C, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009;120:2519-28. https://doi.org/10.1161/CIRCULATIONAHA.109.886408
  21. Schoder M, Czerny M, Cejna M, et al. Endovascular repair of acute type b aortic dissection: long-term follow-up of true and false Lumen diameter changes. Ann Thorac Surg 2007; 83:1059-66 https://doi.org/10.1016/j.athoracsur.2006.10.064
  22. Nienaber CA, Kische S, Zeller T, et al. Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther 2006;13:738-46. https://doi.org/10.1583/06-1923.1
  23. Schoder M, Czerny M, Cejna M, Rand T, Stadler A, Gottfried H. Endovascular repair of acute type B aortic dissection: long-term follow-up of true and false lumen diameter changes. Ann Thorac Surg 2007;83:1059-66. https://doi.org/10.1016/j.athoracsur.2006.10.064