Aortic dissections remain complicated management issues both in the acute setting and in the chronic setting. Acute problems revolve around malperfusion syndromes or rupture, whereas chronic issues progress from the development of aneurysms in the residual dissected aorta. Endovascular approaches to dealing with these difficult situations are being used more frequently to treat acute issues in type B dissections and prevent secondary complications in type A dissections that may require significant intervention in the future. This article discusses the endovascular approaches employed in the care of acute dissections with particular attention toward the anesthetic considerations involved in these challenging cases.
DakeMDKatoNMitchellRS. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340:1546-1552.
2.
SvenssonLGKouchoukosNTMillerDC. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008;85:S1-S41.
3.
SpittellPCSpittellJAJrJoyceJW. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc. 1993;68:642-651.
4.
SayedSThompsonMM. Endovascular repair of the descending thoracic aorta: evidence for the change in clinical practice. Vascular. 2005;13:148-157.
5.
SafiHJMillerCC3rdEstreraAL. Chronic aortic dissection not a risk factor for neurologic deficit in thoracoabdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2002;23:244-250.
6.
VerdantA. 1988: Surgery of the descending thoracic aorta: spinal cord protection with the gott shunt. Updated in 1995. Ann Thorac Surg. 1995;60:1151-1152.
7.
VerdantACossetteRPageABaillotRDontignyLPageP. Aneurysms of the descending thoracic aorta: three hundred sixty-six consecutive cases resected without paraplegia. J Vasc Surg. 1995;21:385-390.
8.
SvenssonLG. Aortic surgery, coarctation of the aorta, and aortic dissection. Curr Opin Cardiol. 1993;8:254-261.
9.
CoselliJSLeMaireSAConklinLDAdamsGJ. Left heart bypass during descending thoracic aortic aneurysm repair does not reduce the incidence of paraplegia. Ann Thorac Surg. 2004;77:1298-1303.
10.
CriadoFJClarkNSBarnatanMF. Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg. 2002;36:1121-1128.
11.
StoneDHBrewsterDCKwolekCJ. Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006;44:1188-1197.
12.
BavariaJEAppooJJMakarounMSVerterJYuZFMitchellRS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg. 2007;133:369-377.
13.
FairmanRMCriadoFFarberM. Pivotal results of the medtronic vascular talent thoracic stent graft system: the valor trial. J Vasc Surg. 2008;48:546-554.
14.
MatsumuraJSCambriaRPDakeMDMooreRDSvenssonLGSnyderS. International controlled clinical trial of thoracic endovascular aneurysm repair with the zenith tx2 endovascular graft: 1-year results. J Vasc Surg. 2008;47:247-257.
15.
ButhJHarrisPLHoboR. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European collaborators on stent/graft techniques for aortic aneurysm repair (Eurostar) registry. J Vasc Surg. 2007;46:1103-1110.
16.
RamirezGO’NeillWMJrLambertRBloomerHA. Cholesterol embolization: a complication of angiography. Arch Intern Med. 1978;138:1430-1432.
17.
BraekkenSKReinvangIRussellDBrucherRSvennevigJL. Association between intraoperative cerebral microembolic signals and postoperative neuropsychological deficit: comparison between patients with cardiac valve replacement and patients with coronary artery bypass grafting. J Neurol Neurosurg Psychiatry. 1998;65:573-576.
18.
HamonMGomesSOppenheimC. Cerebral microembolism during cardiac catheterization and risk of acute brain injury: a prospective diffusion-weighted magnetic resonance imaging study. Stroke. 2006;37:2035-2038.
19.
ThompsonMMSmithJNaylorAR. Microembolization during endovascular and conventional aneurysm repair. J Vasc Surg. 1997;25:179-186.
20.
MartinMMorisCHeviaS. Intimal dehiscence during endovascular treatment of thoracic aortic dissection. Int J Cardiol. 2007;114:e1-e2.
SafiHJMillerCC3rdHuynhTT. Distal aortic perfusion and cerebrospinal fluid drainage for thoracoabdominal and descending thoracic aortic repair: ten years of organ protection. Ann Surg. 2003;238:372-380.
24.
GrieppRBErginMAGallaJD. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg. 1996;112:1202-1213.
25.
WynnMMMellMWTeferaGHochJRAcherCW. Complications of spinal fluid drainage in thoracoabdominal aortic aneurysm repair: a report of 486 patients treated from 1987 to 2008. J Vasc Surg. 2009;49:29-34.
26.
SvenssonLGStewartRWCosgroveDM3rd. Intrathecal papaverine for the prevention of paraplegia after operation on the thoracic or thoracoabdominal aorta. J Thorac Cardiovasc Surg. 1988;96:823-829.
27.
KhanSNStansbyG. Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. Cochrane Database Syst Rev. 2004;(1):CD003635.
28.
GallaJDErginMASadeghiAMLansmanSLDantoJGrieppRB. A new technique using somatosensory evoked potential guidance during descending and thoracoabdominal aortic repairs. J Card Surg. 1994;9:662-672.
WooEYMcGarveyMJacksonBMBavariaJEFairmanRMPochettinoA. Spinal cord ischemia may be reduced via a novel technique of intercostal artery revascularization during open thoracoabdominal aneurysm repair. J Vasc Surg. 2007;46:421-426.
31.
SloanTBJamesonLC. Electrophysiologic monitoring during surgery to repair the thoraco-abdominal aorta. J Clin Neurophysiol. 2007;24:316-327.
32.
GueritJMVerhelstRRubayJKhouryGMattaADionR. Multilevel somatosensory evoked potentials (SEPs) for spinal cord monitoring in descending thoracic and thoraco-abdominal aortic surgery. Eur J Cardiothorac Surg. 1996;10:93-103.
33.
LeeWAMartinTDGravensteinN. Partial right atrial inflow occlusion for controlled systemic hypotension during thoracic endovascular aortic repair. J Vasc Surg. 2008;48:494-498.
34.
DiethrichEB. A safe, simple alternative for pressure reduction during aortic endograft deployment. J Endovasc Surg. 1996;3:275.
35.
DorrosGCohnJM. Adenosine-induced transient cardiac asystole enhances precise deployment of stent-grafts in the thoracic or abdominal aorta. J Endovasc Surg. 1996;3:270-272.
36.
WeigandMAMotschJBardenheuerHJ. Adenosine-induced transient cardiac arrest for placement of endovascular stent-grafts in the thoracic aorta. Anesthesiology. 1998;89: 1037-1038.
37.
BelardinelliLLindenJBerneRM. The cardiac effects of adenosine. Prog Cardiovasc Dis. 1989;32:73-97.
38.
PlaschkeKBocklerDSchumacherHMartinEBardenheuerHJ. Adenosine-induced cardiac arrest and eeg changes in patients with thoracic aorta endovascular repair. Br J Anaesth. 2006;96:310-316.
39.
FangTDLippmannMKakazuC. High-dose adenosine-induced asystole assisting accurate deployment of thoracic stent grafts in conscious patients. Ann Vasc Surg. 2008;22:602-607.
40.
PornratanarangsiSWebsterMWAlisonPNandP. Rapid ventricular pacing to lower blood pressure during endograft deployment in the thoracic aorta. Ann Thorac Surg. 2006;81:e21-e23.
HataMTanakaYIgutiASaitoHIshibashiTTabayashiK. Endovascular repair of a descending thoracic aortic aneurysm: a tip for systemic pressure reduction. J Vasc Surg. 1999;29:551-553.
43.
NishikimiNUsuiAIshiguchiTMatsushitaMSakuraiTNimuraY. Vena cava occlusion with balloon to control blood pressure during deployment of transluminally placed endovascular graft. Am J Surg. 1998;176:233-234.
44.
HalsteadJCMeierMEtzC. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2007;133:127-135.
45.
KirschMSoustelleCHouelRHillionMLLoisanceD. Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2002;123:318-325.
46.
LaiDTRobbinsRCMitchellRS. Does profound hypothermic circulatory arrest improve survival in patients with acute type A aortic dissection?Circulation. 2002;106:I218-I228.
47.
YanoHIshimaruSKawaguchiSObitsuY. Endovascular stent grafting of the descending thoracic aorta after arch repair in acute type A dissection. Ann Thorac Surg. 2002;73:288-291.
48.
JazayeriSTatouEGomezMC. Combined treatment of aortic type A dissection: ascending aorta repair and placement of a stent in the descending aorta. Heart Surg Forum. 2003;6:387-389.
49.
ParkKHLimCChoiJH. Midterm change of descending aortic false lumen after repair of acute type I dissection. Ann Thorac Surg. 2009;87:103-108.
50.
YehCHChenMCWuYCWangYCChuJJLinPJ. Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection. Chest. 2003;124:989-995.
51.
ImmerFFKrahenbuhlEHagenU. Large area of the false lumen favors secondary dilatation of the aorta after acute type A aortic dissection. Circulation. 2005;112:I249-I252.
52.
SongJMKimSDKimJH. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol. 2007;50:799-804.
53.
GeirssonABavariaJESwarrD. Fate of the residual distal and proximal aorta after acute type A dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg. 2007;84:1955-1964.
54.
BachetJTermingnonJLGoudotB. Late reoperations in patients with aortic dissection. J Card Surg. 1994;9:740-746.
55.
BachetJETermignonJLDreyfusG. Aortic dissection. Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg. 1994;108:199-205.
56.
ZiererAVoellerRKHillKEKouchoukosNTDamianoRJJrMoonMR. Aortic enlargement and late reoperation after repair of acute type A aortic dissection. Ann Thorac Surg. 2007;84:479-486.
57.
KimuraNTanakaMKawahitoKYamaguchiAInoTAdachiH. Influence of patent false lumen on long-term outcome after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2008;136:1160.e3-1166.e3.
58.
FleckTHutschalaDCzernyM. Combined surgical and endovascular treatment of acute aortic dissection type A: preliminary results. Ann Thorac Surg. 2002;74:761-765.
59.
TsagakisKTossiosPKamlerM. The Debakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition. Eur J Cardiothorac Surg. In press.
60.
UchidaNIshiharaHShibamuraHKyoYOzawaM. Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type A aortic dissection. J Thorac Cardiovasc Surg. 2006;131:862-867.
61.
JakobHTsagakisK. Debakey type I dissection: when hybrid stent-grafting is indicated?J Cardiovasc Surg (Torino). 2010;51:633-640.
62.
PochettinoABrinkmanWTMoellerP. Antegrade thoracic stent grafting during repair of acute Debakey I dissection prevents development of thoracoabdominal aortic aneurysms. Ann Thorac Surg. 2009;88:482-489.
63.
NienaberCARousseauHEggebrechtH. Randomized comparison of strategies for type B aortic dissection: the investigation of stent grafts in aortic dissection (instead) trial. Circulation. 2009;120:2519-2528.
64.
UmanaJPMillerDCMitchellRS. What is the best treatment for patients with acute type B aortic dissections—medical, surgical, or endovascular stent-grafting?Ann Thorac Surg. 2002;74:S1840-S1843.
65.
VerhoyeJPMillerDCSzeDDakeMDMitchellRS. Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting. J Thorac Cardiovasc Surg. 2008;136:424-430.
66.
BarnesDMWilliamsDMDasikaNL. A single-center experience treating renal malperfusion after aortic dissection with central aortic fenestration and renal artery stenting. J Vasc Surg. 2008;47:903-910.
67.
MakarounMSDillavouEDWheatleyGHCambriaRP. Five-year results of endovascular treatment with the Gore tag device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008;47:912-918.
68.
GoMRChoJSMakarounMS. Mid-term results of a multicenter study of thoracic endovascular aneurysm repair versus open repair. Perspect Vasc Surg Endovasc Ther. 2007;19:124-130.
69.
CambriaRPCrawfordRSChoJS. A multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta. J Vasc Surg. 2009;50:1255-1264.
70.
EggebrechtHBoseDGasserT. Complete reversal of paraplegia after thoracic endovascular aortic repair in a patient with complicated acute aortic dissection using immediate cerebrospinal fluid drainage. Clin Res Cardiol. 2009;98:797-801.
71.
JonkerFHSchlosserFJMollFL. Outcomes of thoracic endovascular aortic repair for aortobronchial and aortoesophageal fistulas. J Endovasc Ther. 2009;16:428-440.
72.
JonkerFHHeijmenRTrimarchiSVerhagenHJMollFLMuhsBE. Acute management of aortobronchial and aortoesophageal fistulas using thoracic endovascular aortic repair. J Vasc Surg. 2009;50:999-1004.
73.
BozinovskiJCoselliJS. Outcomes and survival in surgical treatment of descending thoracic aorta with acute dissection. Ann Thorac Surg. 2008;85:965-970.
74.
SzetoWYMcGarveyMPochettinoA. Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection. Ann Thorac Surg. 2008;86:87-93.
75.
KhoynezhadAGuptaPKDonayreCEWhiteRA. Current status of endovascular management of complicated acute type B aortic dissection. Future Cardiol. 2009;5:581-588.
76.
CriadoFJAbul-KhoudoudO. Endograft repair of acute aortic dissection. Promises and challenges. J Cardiovasc Surg (Torino). 2005;46:107-112.
77.
MoonMCPablo MoralesJGreenbergRK. Complicated acute type B dissection and endovascular repair: indications and pitfalls. Perspect Vasc Surg Endovasc Ther. 2007;19:146-159.
DialettoGCovinoFEScognamiglioG. Treatment of type B aortic dissection: endoluminal repair or conventional medical therapy?Eur J Cardiothorac Surg. 2005;27: 826-830.
80.
WhiteRAMillerDCCriadoFJ. Report on the results of thoracic endovascular aortic repair for acute, complicated, type B aortic dissection at 30 days and 1 year from a multidisciplinary subcommittee of the society for vascular surgery outcomes committee. J Vasc Surg. 2011;53:1082-1090.
81.
HartnellGGGatesJ. Aortic fenestration: a why, when, and how-to guide. Radiographics. 2005;25:175-189.
82.
DebakeyMEHenlyWSCooleyDACrawfordESMorrisGC. Surgical treatment of dissecting aneurysm of the aorta analysis of seventy-two cases. Circulation. 1961;24:290-303.
83.
PradhanSElefteriadesJASumpioBE. Utility of the aortic fenestration technique in the management of acute aortic dissections. Ann Thorac Cardiovasc Surg. 2007;13:296-300.
84.
WilliamsDMBrothersTEMessinaLM. Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum. Radiology. 1990;174:450-452.
85.
WuestWGoltzJRitterCYildirimCHahnDKickuthR. Fenestration of aortic dissection using a fluoroscopy-based needle re-entry catheter system. Cardiovasc Intervent Radiol. 2011;34(suppl 2):S44-S47.
86.
ParkKBDoYSKimSSKimDKChoeYH. Endovascular treatment of acute complicated aortic dissection: long-term follow-up of clinical outcomes and ct findings. J Vasc Interv Radiol. 2009;20:334-341.
87.
GaxotteVThonyFRousseauH. Midterm results of aortic diameter outcomes after thoracic stent-graft implantation for aortic dissection: a multicenter study. J Endovasc Ther. 2006;13:127-138.
