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