Accepted Manuscript Aortic dissection with acute malperfusion syndrome: Endovascular fenestration by the funnel technique Anne Vendrell, MD, Julien Frandon, MD, Mathieu Rodiere, MD, Olivier Chavanon, MD PhD, Jean-Philippe Baguet, MD PhD, Ivan Bricault, MD PhD, Bastien Boussat, MD, Gilbert Raymond Ferretti, MD PhD, Frédéric Thony, MD PII:

S0022-5223(15)00507-3

DOI:

10.1016/j.jtcvs.2015.03.056

Reference:

YMTC 9483

To appear in:

The Journal of Thoracic and Cardiovascular Surgery

Received Date: 8 January 2015 Revised Date:

18 March 2015

Accepted Date: 30 March 2015

Please cite this article as: Vendrell A, Frandon J, Rodiere M, Chavanon O, Baguet J-P, Bricault I, Boussat B, Ferretti GR, Thony F, Aortic dissection with acute malperfusion syndrome: Endovascular fenestration by the funnel technique, The Journal of Thoracic and Cardiovascular Surgery (2015), doi: 10.1016/j.jtcvs.2015.03.056. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT 1

Title Page:

2 3

Manuscript type: Original Research Article

4

Title: Aortic dissection with acute malperfusion syndrome: Endovascular fenestration by the

6

funnel technique

RI PT

5

Authors name:

9

Anne VENDRELL, MD

M AN U

8

SC

7

10

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

11

CHU de Grenoble

12

Julien FRANDON, MD

14

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

15

CHU de Grenoble

TE D

13

EP

16

Mathieu RODIERE, MD

18

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

19

CHU de Grenoble

20

AC C

17

21

Olivier CHAVANON, MD PhD

22

Clinique Universitaire de Chirurgie Cardio-Thoracique

23

CHU de Grenoble

24 25

Jean-Philippe BAGUET, MD PhD

1

ACCEPTED MANUSCRIPT 26

Service de Cardiologie

27

Clinique des Eaux Claires – Groupe Hospitalier Mutualiste

28

Ivan BRICAULT, MD PhD

30

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

31

CHU de Grenoble

32

Bastien BOUSSAT, MD

34

Université Joseph Fourier, Laboratoire TIMC-IMAG

35

CHU de Grenoble

36

M AN U

33

SC

RI PT

29

Gilbert Raymond FERRETTI, MD PhD

38

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

39

CHU de Grenoble

40

TE D

37

Frédéric THONY, MD

42

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

43

CHU de Grenoble

45 46 47

AC C

44

EP

41

Relationship with industry: No relation

Conflicts of interests: None

48 49 50

2

ACCEPTED MANUSCRIPT Correspondence to:

52

Anne VENDRELL, MD

53

Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM

54

CHU de Grenoble, BP 10217, 38043 GRENOBLE Cedex 09 (France)

55

Tel: 00 334.76.76.52.41

56

[email protected]

Fax : 00 334.76.76.88.30

57

Total word count: 2537 excluding abstracts and references

SC

58

M AN U

59

60

61

66

67

68

EP

65

AC C

64

TE D

62

63

RI PT

51

69

70

71

3

ACCEPTED MANUSCRIPT 72

Structured Abstract:

73

Objective: To analyze the short- and long-term results of an original aortic fenestration

75

method using the funnel technique during aortic dissection complicated by malperfusion

76

syndrome.

RI PT

74

77

Methods: The funnel technique consists in the deployment of an uncovered aortic stent graft

79

placed from the false to the right lumen through an intimal flap aortic fenestration made by

80

balloon angioplasty. Twenty-eight patients presenting with an aortic dissection (type A n=19,

81

type B n=9) were treated for malperfusion syndrome due to dynamic compression (16 renal,

82

17 bowel, and 13 lower limb ischemia) using the aforementioned technique, and were

83

followed-up at short (30 days) and long term (mean 55 ± 40 months). Eight patients had

84

severe ischemia upon arrival (6 bowel, 7 renal, 3 lower limb ischemia).

M AN U

TE D

85

SC

78

Results: Technical success was achieved in 27 of 28 patients (96%) and ischemic symptoms

87

have disappeared in 25 of 28 patients (89%) at short term. Five patients presented

88

postprocedure complications: four minor and one major with arterial thrombosis which

89

caused technical failure (3.6%). The 30-day mortality rate was 7% (n=2), related to bowel

90

ischemia complications. At long-term, 21 patients had a stable thoracic aortic diameter (91%).

AC C

91

EP

86

92

Conclusion: The funnel technique in cases of malperfusion syndrome following aortic

93

dissection safely improves the clinical outcome at short and long term, and could represent an

94

interesting alternative in the management of patients. The hemodynamic efficiency of this

95

technique may account for a lower mortality in our series.

96

4

ACCEPTED MANUSCRIPT 97

Word count: 232 words

98

Key words: Aortic dissection, Aortic fenestration, Stent, Malperfusion

99

RI PT

100

101

102

SC

103

M AN U

104

105

106

110

111

112

113

EP

109

AC C

108

TE D

107

114

115

116

5

ACCEPTED MANUSCRIPT

Ultramini Abstract:

118

The funnel technique is a novel aortic fenestration method using a stent graft through the

119

intimal flap for patients with malperfusion syndrome. Among the 28 patients treated, the

120

clinical success rate was 89% (n=25) and the 30-day mortality rate was 7% (n=2), with only

121

one self-limited major complication.

RI PT

117

122

Word count: 48 words

SC

123 124

M AN U

125

126

127

131

132

133

EP

130

AC C

129

TE D

128

134

135

136

137

6

ACCEPTED MANUSCRIPT 138

Units of measurement: None

139

140

RI PT

141

142

SC

143

M AN U

144

145

146

150

151

152

153

EP

149

AC C

148

TE D

147

154

155

156

7

ACCEPTED MANUSCRIPT 157

Abbreviations:

AD: Aortic dissection

160

MPS: Malperfusion syndrome

161

FT: Funnel technique

162

LL: Lower limbs

163

MOF: Multiple organ failure

SC

159

RI PT

158

164

M AN U

165

166

167

171

172

173

174

EP

170

AC C

169

TE D

168

175

176

177

8

ACCEPTED MANUSCRIPT 178

Text:

179

Introduction:

181

Acute aortic dissection (AD) is a rare but serious disease1, inducing a high mortality rate

182

(50%) at 48 hours2,3. The Stanford classification of AD4 differentiates type A requiring

183

surgical management5, from type B treated medically6.

184

Malperfusion syndrome (MPS) due to a reduced flow in the aortic branch vessels, is the

185

second most common complication (20-50%) of AD7 after cardiac complications8 and causes

186

higher mortality (51% versus 29% in survivors patients)9–11. Two ischemic mechanisms have

187

been described12: dynamic compression due to an aortic true lumen collapse and static

188

compression related to direct extension of AD into an aortic branch.

189

In cases of dynamic compression MPS, closing the primary entry tear of the dissection by

190

using a covered stent is the recommended treatment13–16. When this is unfeasible, aortic

191

fenestration (AF) has been proposed as an alternative technique17–20; however, high

192

postprocedural complications (11–20%) and mortality rates (17–34%) have been reported.

193

In our center, a new and original AF technique consisting of an uncovered aortic stent graft

194

insertion between the false and the right lumen called the “funnel technique” (FT) was

195

performed on selected patients. The aim of this study was to assess the safety and efficacy of

196

this technique at short- and long-term follow-up.

198

SC

M AN U

TE D

EP

AC C

197

RI PT

180

199 200 201 202

9

ACCEPTED MANUSCRIPT 203

Methods:

204

Study design:

206

The local Institutional Review Board (N°5891) approved this retrospective study. Relevant

207

and follow-up data were collected and reviewed, using the medical files and imaging exams

208

of included patients.

209

From January 1, 2000 to December 31, 2013 all consecutive patients presenting renal,

210

digestive and/or lower limbs (LLs) ischemia due to dynamic compression MPS following

211

type A or B AD admitted to our center received this new procedure. These patients could not

212

be treated by thoracic aortic stent graft because of anatomic constraints, as entry tear in the

213

aortic segment II or next to the supra aortic trunks.

214

Diagnosis of MPS was based on clinical, biological, and/or radiological features, according to

215

the following criteria:

SC

M AN U

-

Renal ischemia: uncontrolled arterial hypertension, defined as blood systolic pressure

TE D

216

RI PT

205

>120 mmHg despite two intraveinous antihypertensive therapy, variation of serum

218

creatinine ≥ 44 µmol/L or decreased glomerular filtration rate >25%21, evidence of

219

renal malperfusion on the CT scan in the non-severe forms; anuria in the severe forms; -

non-severe forms; sensorimotor deficit in the severe forms;

221 222 223 224

LL ischemia: absent pulse, claudication, cool limb, low flow in the iliac arteries in the

-

AC C

220

EP

217

Bowel ischemia: abdominal pain, diarrhea in the non-severe forms; bowel tract bleeding, high lactates level, and/or lack of enhancement of bowel wall on CT scan in severe forms.

225

The pre-operative CT scan also confirmed the dynamic compression, with the collapse of the

226

true lumen, and the absence of concomitant disease which could explain the symptoms.

227

These different types of ischemia and their severity are described in Table 1.

10

ACCEPTED MANUSCRIPT 228

MPS could occur immediately during the dissection, postoperatively, or later. The time from

229

diagnosis to treatment varied from 3 hours to 72 hours.

230

Procedure:

232

A pre-procedure contrast enhanced CT-scan was systematically performed to determine the

233

orientation of the intimal flap and the fenestration target, located 4 cm above the celiac trunk.

234

All procedures were performed by two interventional radiologists with more than 10 years

235

experience (FT, MR), under fluoroscopic guidance. Initial anteroposterior and lateral

236

angiography in the true lumen was first done under local anesthesia, through a femoral sheath,

237

to confirm the dynamic compression and identify the flap orientation. In a curved 5F catheter

238

positioned 4 cm above the coeliac trunk facing the intima, a rigid 0.014 Spartacore®

239

guidewire (Abbott Vascular, Santa Clara, CA, USA) was introduced in the reverse position

240

(hard end first) pushed through the flap and advanced in the false lumen. The fenestration

241

opening was then enlarged by using an 18 mm diameter balloon (Boston Scientific, Natick,

242

MA, USA) after changing the introducer for a 10-F sheath and replacing the guidewire with a

243

0.035 inch guidewire (Terumo, Yamanashi, Japan). An uncovered self-expanding steel stent

244

(Wallstent, Boston Scientific, Natick, MA, USA) or nitinol stent (Memotherm, Bard

245

Angiomed, Wachhausstrasse, Germany) of 18 mm to 24 mm diameter and 40-60 mm long,

246

was then deployed from the false lumen toward the true lumen through the opening created,

247

with its distal end placed above the ostium of celiac trunk.

248

The final angiography was then performed in the false lumen above the fenestration, and had

249

to confirm satisfactory flow in the true lumen (increased caliber, rapid and intense

250

enhancement) and the aortic branches. Upstream of the stent, the true aortic lumen was

251

expected to be collapsed by the stent (Figures 1, 2, 3 and 4).

AC C

EP

TE D

M AN U

SC

RI PT

231

11

ACCEPTED MANUSCRIPT 252

If the angiographic result was inadequate, an additional subrenal fenestration without stenting

253

or peripheral stenting of side branches was discussed.

254

For the following 6 months, patients received an antiplatelet treatment, except those treated

255

with oral anticoagulants.

RI PT

256

Definitions:

258

Technical success was defined as a normal blood flow velocity in the stent, the true lumen

259

and the aortic branches, with a normal perfusion of end-organs on the final angiogram, in

260

either a single procedure (primary technical success) or two procedures, whether or not

261

simultaneous (secondary technical success).

262

Clinical success was defined when clinical symptoms disappeared and biological parameters

263

normalized between D+1 and D+30.

264

The main evaluation criterion was clinical success. The secondary evaluation criteria were

265

mortality and complication rate at short term (between D+1 and D+30); onset of late

266

complications and evolution of thoracic aorta diameter at long term.

M AN U

TE D

267

SC

257

Patients were followed up by MRI or CT at Day + 10, 6 months, 12 months, and then every

269

2 years. The mean duration of follow-up was defined as the time between the initial imaging

270

study and the last available images. The thoracic aorta was measured on the same levels in the

271

axial plane. Increase aortic diameter was defined by a diameter greater than 60 mm or

272

progressing more than 4 mm/year. Data were summarized using the mean and the median

273

(25-75% interquartile range). The Kaplan-Meier technique was used to perform a survival

274

curve. Growth rates for aortic diameter were estimated with linear regression using a linear

275

mixed-effects model. Linear mixed-effect regression analysis using follow-up time, the

AC C

EP

268

12

ACCEPTED MANUSCRIPT 276

localization of primary entry tear, the involvement of ascending aorta, age and pre-existing

277

hypertension was carried out. The significance threshold was set at p≤0.05.

278 279

Results:

RI PT

280 281

Population:

283

Within thirteen years, 379 patients were admitted to our center for AD (type A n=259, type B

284

n=120). Among patients presenting with type A, 247/259 (95.4%) underwent surgical aortic

285

replacement and 12/259 (4.6%) died before the surgery. All patients with type B AD were

286

treated medically. Sixty-nine of 379 patients (18.2%) presented dynamic compression MPS,

287

treated with either thoracic endovascular aortic repair (TEVAR) (n=41) or AF by the funnel

288

technique (n=28).

289

Of the 28 treated by FT, 19 patients presented type A AD and underwent emergency cardiac

290

surgery (14 aorto-aortic tubes, 4 Bentall procedures, and 1 hemiarch replacement), always

291

performed first regardless of the severity of MPS. Nine patients presented type B AD.

292

Patients’ characteristics and ischemic territories are summarized in table 2.

293

Eight out of 28 patients (29%) presented severe ischemia: mesenteric (n=6), renal (n=7), or

294

lower limb (n=3).

295

Additional stenting for concomitant static compression was necessary in 13/28 patients: renal

296

(n=7), superior mesenteric (n=5), and iliac (n=5).

AC C

EP

TE D

M AN U

SC

282

297 298

Recanalization:

299

Primary technical success was 86% (24/28), secondary technical success 96% (27/28), with

300

no intraprocedural complications. Three patients required a second subrenal AF: one patient

13

ACCEPTED MANUSCRIPT during the same procedure because of insufficient flow in the iliac arteries on the final

302

angiogram, two patients later because of recurrence of their ischemic symptoms at D2 and

303

D15.

304

Clinical success was achieved in 25 of 28 patients (89%). Two patients (7%) with severe

305

ischemia (1 renal and bowel ischemia, 1 all three sites), treated with cardiac surgery and then

306

AF at D0 died before D30: the first at D2 of multisystem organ failure, the second of septic

307

shock ending in death at D14.

308

One patient was considered as technical and clinical failure, and major complication because

309

of worsening of a right LL ischemia at the end of the procedure, related to the onset of a

310

thrombosis of the common femoral artery on the sheath. He was treated with embolectomy

311

and femoro-femoral bypass resulting in good postoperative evolution.

M AN U

SC

RI PT

301

312

Severe ischemia:

314

Six out of 8 patients with severe ischemia survived. Of the 4 survivors with mesenteric

315

ischemia, all patients evolved favorably, 3 of whom required bowel resection. Dialysis was

316

reversible after AF for the 5 patients with severe renal ischemia. Of the two patients with

317

severe LL ischemia, both improved after fenestration, although one of them required a

318

femoral bypass as previously described. Table 3 summarizes the characteristics of the patients

319

with severe ischemia.

EP

AC C

320

TE D

313

321

Complications:

322

Five patients presented complications. The major complication was described above. Of the

323

four minor complications, 3 were related to the puncture point (arterial thrombosis resolved

324

with medical treatment; hematoma and infection resolved with antibiotics). The last

325

complication was an aortic stent fracture on a nitinol stent discovered on the follow-up CT at

14

ACCEPTED MANUSCRIPT 326

D10, with no clinical or biological repercussions and was treated by placing a second stent

327

within the fractured one.

328

Follow-up:

330

During the follow-up, three patients were lost to follow-up after hospitalization and three had

331

died (Figure 5): two at one year of follow-up, the first after surgical replacement of the

332

descending aorta and the second of a brain tumor; the third of fissuration of a descending

333

thoracic aorta aneurysm at nine years of follow-up. Of the 23 patients followed up, one

334

proximal fracture of a nitinol stent was detected on the 2 years follow-up CT with no

335

consequences. No recurrence of ischemia was observed.

336

Aortic diameter increased significantly over time (p= 0.0038) at a mean rate of 1.46 mm/year.

337

Two patients had a significant increased aortic thoracic diameter (9%) and needed a surgical

338

treatment. No risks factors among the localisation of entry tear, the involvement of ascending

339

aorta, the age or pre-existing hypertension were identified.

340

Concerning the 41 patients treated by TEVAR (type B n= 34, type A n=7), six patients died

341

and three presented endoleaks with recirculation of the false lumen (type II n=2, type I n=1).

342

These patients were treated by an embolization of the endoleaks and presented a good clinical

343

outcome.

345

SC

M AN U

TE D

EP

AC C

344

RI PT

329

346

Discussion:

347

The current recommended treatment for MPS caused by dynamic compression is to close the

348

primary entry tear of AD by a covered thoracic stent graft14,16,22,23. However, when it is not

349

possible, AF can resupply the true lumen at the abdominal level by creating a communication

350

between the two lumens. Two techniques of AF have been described: fenestration with

15

ACCEPTED MANUSCRIPT balloon angioplasty19,20,24,25 and the scissor technique26. These series were done in 34

352

patients17 and 40 patients20. Our technique is new and original because it enlarges the surface

353

area of the re-entry orifice in the true lumen with an endoaortic stent positioned between the

354

two lumens, which increases flow and pressure in the true lumen and reduces them in the

355

false, thus improving the efficacy of fenestration.

356

RI PT

351

AF has been described as both a reliable (100% technical success) and effective technique,

358

with clinical success between 70% and 93% at D+3017,20 versus 60% for surgery22. This series

359

also shows that AF using the funnel technique is effective (89% clinical success).

360

With balloon angioplasty AF, the 30-day mortality rate was 17–25%, with an approximately

361

20% complication rate19,20,25. The scissor technique has shown 30% mortality at D+30 with

362

roughly 10% complications17. Mortality in our series was much lower (7%) and the morbidity

363

rate was equivalent (18%).

364

Patients with severe ischemia account for 14% to 26% with a 33% to 66% mortality

365

rate17,20,27. In our series, the severe ischemia rate was higher with 29%, with a lower mortality

366

rate (25%). The mortality rate with the FT therefore does not stem from the population

367

presenting globally less severe MPS, but probably from a more effective reapplication of

368

pressure in the true lumen. This results in the disappearance of the clinical symptoms and the

369

reversion of the acute ischemic lesions, preventing the onset of multi-organ failure. In the

370

present study, only two patients (7%) died of multi-organ failure despite the AF, whereas this

371

unfavorable outcome seems more frequent in the other series (15-25%)17,20.

AC C

EP

TE D

M AN U

SC

357

372 373

We did not observe stent malposition or stent migration during grafting, nor injury of the

374

aortic wall or stent thrombosis at the long term. Two fractures of stents were discovered

375

inadvertently, both asymptomatic and involving nitinol stents (Memotherm Bard Angiomed,

16

ACCEPTED MANUSCRIPT Wachhausstrasse, Germany). We have since decided to use only steel self-expandable

377

Wallstents (Boston Scientific, Natick, MA, USA), with no new complications discovered to

378

date. No collapse of the stent had been observed, probably due to the placement of the stent

379

between the two lumens, which decreased pressure in the false lumen. Massman et al28 had

380

described this type of complication in 4 of 14 patients treated by an uncovered aortic stent

381

graft in the true lumen: this collapse could be due to the persistent pressure in the false lumen,

382

which allowed the compression of the true lumen and the dilatation of the false lumen at long

383

term.

SC

RI PT

376

384

Three patients underwent an additional fenestration because the first was deemed insufficient.

386

In these patients, an 18 mm diameter stent was selected for a mean 30 mm diameter aorta in

387

the fenestration area. Finally, this stent diameter was considered too small for the size of the

388

false lumen. Since this time, we have used stents with a larger diameter so that the re-entry

389

orifice in the true lumen is at least two-thirds the total diameter of the aorta, thus ensuring that

390

flow is greater than 50% between the true and false lumen. This is not always possible

391

because the maximal diameter of a wallstent is 24mm.

TE D

EP

392

M AN U

385

Over the long-term, decreased pressure in the false lumen seems to protect against the

394

aneurysmal aortic evolution, since 91% of our patients (15 type A and 6 type B) presented a

395

stable aortic diameter. The only one factor involved in the growth aortic diameter was the

396

follow up-time, with a mean progression of 1.46mm/year, which we considered as natural

397

evolution. As reported in the literature, the natural progression of AD is characterized by

398

dilatation of the descending thoracic aorta in 20–50% of cases29 and up to 83% in the

399

segment-by-segment study of the aorta30,31. This confirms the hypothesis postulating that

400

blood pressure is reduced within the false lumen upon reapplication of pressure in the true

AC C

393

17

ACCEPTED MANUSCRIPT 401

lumen, thus avoiding progression toward aneurysm. Midulla et al.17 have reported the same

402

observation.

403

The small number of patients treated was the main limitation of this study. Further studies, as

405

best comparative and multicentric, would be necessary to confirm the efficacy and safety of

406

this new procedure. Another limitation was a recruitment bias concerning bowel ischemia as

407

some patients have not been treated by the FT because of their gravity or the onset of death

408

before the treatment.

SC

RI PT

404

409

M AN U

410 411

Conclusion:

413

Aortic fenestration by the funnel technique, in patients with MPS during aortic dissection is

414

an effective technique (clinical success: 89%) associated with low morbidity (30-day

415

mortality: 7%; major complications: 3.6%). Over the long-term, no ischemic recurrence was

416

observed, and decreasing the applied pressure of the false lumen seems to protect from

417

increase aortic thoracic diameter. The hemodynamic efficiency of this technique may account

418

for a lower mortality in our series but this result has to be confirmed.

420 421

EP

AC C

419

TE D

412

422

423

424

18

ACCEPTED MANUSCRIPT 425

References:

426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473

1.

Golledge J, Eagle KA. Acute aortic dissection. Lancet. 2008;372(9632):55-66.

2.

Asfoura JY, Vidt DG. Acute aortic dissection. Chest. 1991;99(3):724-729.

RI PT

3. Mészáros I, Mórocz J, Szlávi J, Schmidt J, Tornóci L, Nagy L et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117(5):1271-1278. 4. Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg. 1970;10(3):237-247.

SC

5. Debakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES, Beall AC Jr. Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg. 1965;49:130-149.

M AN U

6. Wheat MW, Palmer RF, Bartley TD, Seelman RC. Treatment of dissecting aneurysms of the aorta without surgery. J Thorac Cardiovasc Surg. 1965;50:364-373. 7. Swee W, Dake MD. Endovascular management of thoracic dissections. Circulation. 2008;117(11):1460-1473. 8. Rodiere M, Thony F, Michoud M, Frandon J, Ferretti G. Acute visceral ischaemia, early complication of the aortic syndrome: how to detect and manage it?. Presse Med. 2011;40(1 Pt 1):54-61.

TE D

9. Di Eusanio M, Trimarchi S, Patel HJ, Hutchinson S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145(2):385-390.

EP

10. Cambria RP, Brewster DC, Gertler J, Moncure AC, Gusberg R, Tilson MD, et al. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg. 1988;7(2):199-209.

AC C

11. Jonker FHW, Patel HJ, Upchurch GR, Williams DM, Montgomery DG, Gleason TG, et al. Acute type B aortic dissection complicated by visceral ischemia. J Thorac Cardiovasc Surg. 2014. 12. Williams DM, Lee DY, Hamilton BH, Marx MV, Narasimham DL, Kazanjian SN, et al. The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise. Radiology. 1997;203(1):37-44. 13. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, Von Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999;340(20):1539-1545. 14. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340(20):1546-1552. 19

ACCEPTED MANUSCRIPT 15. Nienaber CA, Zannetti S, Barbieri B, Kirsche S, Scharek W, Rehders TC, et al. INvestigation of STEnt grafts in patients with type B Aortic Dissection: design of the INSTEAD trial--a prospective, multicenter, European randomized trial. Am Heart J. 2005;149(4):592-599.

RI PT

16. Botsios S, Schuermann K, Maatz W, Keck N, Walterbusch G. Complicated acute type B dissections: a single-center experience with endovascular treatment. Thorac Cardiovasc Surg. 2010;58(5):280-284. 17. Midulla M, Renaud A, Martinelli T, Koussa M, Mounier-Vehier C, Prat A, et al. Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up. J Thorac Cardiovasc Surg. 2011;142(1):66-72.

SC

18. Beregi J-P, Haulon S, Otal P, Thony F, Bartoli JM, Crochet D, et al. Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study. J Endovasc Ther Off J Int Soc Endovasc Spec. 2003;10(3):486-493.

M AN U

19. Patel HJ, Williams DM, Meerkov M, Meekov M, Dasika NL, Upchurch GR Jr, et al. Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: implications for thoracic aortic endovascular repair. J Thorac Cardiovasc Surg. 2009;138(2):300-308. 20. Slonim SM, Miller DC, Mitchell RS, Semba CP, Razavi MK, Dake MD. Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg. 1999;117(6):1118-1126.

TE D

21. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care Lond Engl. 2004;8(4):R204R212.

EP

22. Fattori R, Tsai TT, Myrmel T, Cooper JV, Trimarchi S, Li J, et al. Complicated acute type B dissection: is surgery still the best option?: a report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc Interv. 2008;1(4):395-402. 23. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120(25):2519-2528.

AC C

474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523

24. Kos S, Gürke L, Jacob AL. A novel fenestration technique for abdominal aortic dissection membranes using a combination of a needle re-entry catheter and the “cheese-wire” technique. Cardiovasc Intervent Radiol. 2011;34(6):1296-1302. 25. Chavan A, Hausmann D, Dresler C, et al. Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta. Circulation. 1997;96(7):2124-2127. 26. Beregi JP, Prat A, Gaxotte V, Delomez M, McFadden EP. Endovascular treatment for dissection of the descending aorta. Lancet. 2000;356(9228):482-483.

20

ACCEPTED MANUSCRIPT 27. O’Donnell S, Geotchues A, Beavers F, Akbari C, Lowery R, Elmassry S, et al. Endovascular management of acute aortic dissections. J Vasc Surg. 2011;54(5):1283-1289. 28. Massmann A, Kunihara T, Fries P, Schneider G, Buecker A, Schäfers H-J. Uncovered stent implantation in complicated acute aortic dissection type B. J Thorac Cardiovasc Surg. 2014;148(6):3003-3011.

RI PT

29. Trimarchi S, Jonker FHW, van Bogerijen GHW, et al. Predicting aortic enlargement in type B aortic dissection. Ann Cardiothorac Surg. 2014;3(3):285-291. 30. Tolenaar JL, van Keulen JW, Jonker FHW, Tolenaar JL, Moll FL, Czerny M, et al. Morphologic predictors of aortic dilatation in type B aortic dissection. J Vasc Surg. 2013;58(5):1220-1225.

SC

524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541

31. Sueyoshi E, Sakamoto I, Hayashi K, Yamaguchi T, Imada T. Growth rate of aortic diameter in patients with type B aortic dissection during the chronic phase. Circulation. 2004;110 (11 Suppl 1):II256-II261.

M AN U

542 543

544

548

549

550

551

EP

547

AC C

546

TE D

545

552

553

554

21

ACCEPTED MANUSCRIPT 555

Tables:

556 557

Table 1: Different types of ischemia and their severity: Definition

N

Severe

Lower limb ischemia Non-severe

560 561 562 563

Anuria

Renal malperfusion

SC

Variation of serum creatinine ≥ 44 µmol/L or decreased glomerular filtration rate >25%

Abdominal pain, diarrhea Bowel tract bleeding

Absent pulse, claudication, cool limb Sensorimotor deficit

High lactates level

9

7 11

Lack of enhancement of bowel wall

6

Low flow in iliac arteries

10 3

AC C

559

Uncontrolled arterial hypertension

Radiological

EP

Severe 558

Biological

M AN U

Severe Bowel ischemia Non-severe

Clinical

TE D

Renal ischemia Non-severe

RI PT

Ischemia territories

564 565 566

22

ACCEPTED MANUSCRIPT 567

Table 2: Population caracteristics: Characteristic

Value

Male

9

Female

19

56 (47-63)

Type A dissection

19

Type B dissection

9

SC

Median age (Y)

Three sites : Renal/Mesenteric/Lower Limb Two sites :

5

TE D

Renal/Lower Limb

AC C

Mesenteric Lower Limb

569

EP

Mesenteric/Lower Limb

Renal

4

10

Renal/Mesenteric

One site

M AN U

Ischemic Territories

568

RI PT

Sex

3 2 14 5 5 4

570 571 572

23

ACCEPTED MANUSCRIPT

Table 3: Treatment and evolution of patients with severe ischemia: Severe

ischemia N Bowel

sites

Bowel

resection monitoring 2

1

1

Renal/Bowel

2

1

2

1

1

Renal

1

Bowel

2

Lower limbs

1

1 1

2

1

M AN U EP AC C

584

1

TE D

578

583

1

1

577

582

RI PT

1

576

581

complications

2

575

580

Death Alive

Renal/Bowel/LL

574

579

Dialysis Major

SC

573

585

586

587

24

ACCEPTED MANUSCRIPT 588

Figures legends:

589

Figure 1: 71-years-old patient admitted for acute type B AD with severe bowel ischemia

591

(bowel tract bleeding and high lactate level) due to dynamic compression and dissection of

592

the superior mesenteric artery. Angio CT-scan on axial views (A, B), sagittal (C) and coronal

593

reformations (D), showing thoraco-abdominal type B AD, with large primary entry tear

594

located in the aortic arch (arrowhead); compression of the true lumen (TL) by the false lumen

595

(FL) in the abdominal aorta, decreasing blood flow in the abdominal arteries.

SC

RI PT

590

M AN U

596

Figure 2: Illustration of the funnel technique: A, B: Illustration showing the dynamic

598

compression: the true lumen is collapsed by the large false lumen. C, D: AF with balloon

599

angioplasty of the fenestration opening and deployment of the stent graft across the false and

600

the true lumen.

601

TE D

597

Figure 3: Aortic fenestration using the funnel technique in the same patient. A: Angiogram

603

showing a collapsed true lumen (TL). The right renal artery and the intercostal arteries

604

originate from the true lumen (arrowsheads). B: Angiogram of the false lumen (FL) after

605

insertion of a catheter through the intimal perforation, showing the celiac trunk, the left renal

606

artery, the superior and inferior mesenteric arteries (white arrows). Only the first part of the

607

superior mesenteric artery is supplied by the false lumen. D: Final angiogram with injection in

608

the false lumen (FL): The blood flow in the true lumen (TL) has been restored by the stent

609

graft (asterisk) with good patency of both renal arteries (solid arrows), the celiac trunk

610

(splenic and hepatic arteries) and the superior mesenteric artery (dashed arrows).

AC C

EP

602

611

25

ACCEPTED MANUSCRIPT Figure 4: Follow-up CT at D2 in the same patient in axial views (A, B), sagittal reformations

613

(C) and VRT reformations (D) showing the stent graft (asterisk) within the true lumen (TL)

614

and the false lumen (FL) and the good patency of the aortic branchs. Another stent has been

615

placed in the superior mesenteric artery in the same procedure because of static compression

616

(arrowhead). Ischemic symptoms have disappeared after the procedure and the patient have

617

evolved favorably.

618

Figure 5: Survival rate after treatment by the funnel technique.

SC

619 620

M AN U

621 622 623 624

629 630 631 632

EP

628

AC C

627

TE D

625 626

RI PT

612

633 634 635 636

26

ACCEPTED MANUSCRIPT 637

Central picture:

638

Figure 4

639

The funnel technique: uncovered aortic stent graft between the false and the true lumen.

RI PT

640 641

Central Message:

643

The funnel technique is a novel aortic fenestration method using a stent graft through the

644

intimal flap for patients with malperfusion syndrome. Among the 28 patients treated, the

645

clinical success rate was 89% (n=25) and the 30-day mortality rate was 7% (n=2), with only

646

one self-limited major complication.

647

M AN U

SC

642

Perspective:

649

The funnel technique in patients with malperfusion syndrome during aortic dissection seems

650

to be a better treatment considering his efficacy and low rate of morbidity compared to the

651

other aortic fenestration techniques. This method could become an interesting alternative to

652

the covering of the primary entry tear when this is unfeasible, because it protects from the

653

ischemic recurrence at short term. At long term, it also permits to decrease pressure in the

654

false lumen, which protect from potential thoracic aortic dilatation, which occur in 20-50% of

655

cases.

EP

AC C

656

TE D

648

657

27

ACCEPTED MANUSCRIPT

Figures :

AC C

EP

TE D

M AN U

SC

RI PT

Figure 1 :

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

Figure 2 :

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

Figure 3 :

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

Figure 4 :

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

Figure 5 :

Aortic dissection with acute malperfusion syndrome: Endovascular fenestration via the funnel technique.

To analyze the short- and long-term results of an original aortic fenestration method using the funnel technique during aortic dissection complicated ...
1MB Sizes 0 Downloads 9 Views