Acute aortic syndrome:

Endovascular contribution

Pr Guy LESECHE Hôpital BICHAT Paris (France)

Acute aortic syndrome

Sudden chest/back pain symptoms of sharp/tearing character(« aortic pain »)

which are caused by various acute aortic diseases

Acute aortic syndrome

Intra Mural Hematoma

(IMH)Dissection (type B)

Acute aortic syndrome

Penetrating Ao Ulcer

(PAU)Traumatic aortic transection

(TAT)

Endovascular contribution

Intimal tear/disruption

Penetrating ulcer

Dissection entry tear(s)

Aortic transection

Covered stent graft to treat

the aetiological factor

Endovascular contribution: type B

dissection

– Sealing of the entry tear

– Depressurization of false lumen

– Thrombus formation in the false lumen

– Remodelling of the entire aorta

– Reconstruction of a collapsed true lumen might result in the re-establishment of side-branch flow

Fenestration and/or stenting for static or dynamic

obstruction of aortic true lumen, or vital side branches

Covered stent graft to seal entry tear

Dissection type B and Malperfusion

Vessels compromised by static

obstruction of a branch artery are

treated by endovascular stent

across the vessel origin

Dissection type B and Malperfusion

Vessels compromised by dynamic

obstruction are treated by

fenestration(create a tear in the

flap with gidewires or balloon ) with

or without stent in the aortic true

lumen

Aortic type B dissection

Severe compression of the true lumen, severe narrowing of infra renal

aorta, poor filling right renal artery, right iliac artery obstruction

Fenestration and stent placement to restore renal and right leg blood flow

Endovascular contribution: type B dissection

novel approach

Combination of covered stent and bare stent

Covered stent graft to seal proximal entry tear(s)

Bare stent to gradualy expand the true lumen

in the distal thoracic aorta while preserving branch

artery blood flow

Stenting of obstructed branch artery through large

free cell areas of the bare stent is feasible

Thoracic aortic endografting after arch debranching

Hybrid Procedures

Open proceduresprior endografting

Subclavian transposition

Z2

Direct bypass from

ascending aorta

Z0

Carotid-carotid bypass

and subclavian transposition

Z1

Endograft

landing Zone

Aortic type IA dissection

One stage Hybid procedure - Open ascending tube graft

- Great vessel transposition

- Antegrade deployement of an endoluminal

graft across arch and descending aorta

(Diethrich EB. J Endovasc Ther 2005;12:660-6)

Two stage Hybrid procedure

-Transfemoral endograft

Intra mural Hematoma

• 6-10%of all acute aortic syndromes

• Commonly defined as «dissection without intimal tear »(no communication with aortic lumen??)

IMH:Dissection without intimal tear ?

• High-resolution imaging suggest that small

plaque rupture/intimal disruption /small

ulceration may be the underlying of IMH

Plaque ulceration /intimal disruption in

a patient with intramural hematoma

Active bleeding from

the aortic lumen(TEE)

IMH : variant form or potential precursor of

Dissection

• This provide and

adequate target for

aTEVAR procedure

and prevention of

• Dissection(28-47%)

• Aneurysm / Contained

Rupture(20-45%)

Penetrating aortic ulcer

• 5-10% of acute aortic syndrome

• Ulceration of an atherosclerotic

plaque penetrating through the iel

into the aortic media

• Extensive atherosclerotic

disease,older patients(7th decade)

Penetrating aortic ulcer

Contrast-material filled,

craterlike outpouchings

of the lumen with inward

displacement of calcified

intima

PAU: segmental lesion ideal target

for endografting

Aneurysm expansion, progression

to overt dissection or rupture (40%)

Traumatic transection

-Often fatal within the first hours( ≥ 80%)

-Survivors often with multiple concomitant

injuries

-Open surgery may worsen concomitant

injuries

-Open surgery is often deliberately

postponed

-BUT 5% risk of fatal secondary aortic

rupture

Traumatic transection

Immediate endovascular treatment

prevents the risk of secondar rupture

without worsening associated lesions

Acute aortic syndrome

Acute aortic syndrome contribute significantly to

the high overall mortality from cardiovascular

disease

The emerging role of endovascular strategies is

exciting considering the sobering results of open

repair

High risk patients benefit from endovascular

stategies, but the exact role of endovascular

interventions remains to be defined as

practitioners await solid long-term data and

better devices