Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement

Background The treatment of thoracic aortic dissection is guided by prognos tic and anatomical information. Proximal dissection requires surgery, but t he appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis. Methods We prospectively evaluated the safety and efficacy of elective tran sluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surger y in 12 matched controls. In all 24 patients, aortic dissection was diagnos ed by magnetic resonance angiography. In each group, the dissection involve d the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resec tion was undertaken or a custom-designed endovascular stent-graft was place d by unilateral arteriotomy. Results Stent-graft placement resulted in no morbidity or mortality, wherea s surgery for type B dissection was associated with four deaths (33 percent , P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 mo nths. Transluminal placement of the stent-graft prosthesis was successful i n all patients, with no leakage; full expansion of the stents was ensured b y balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, an d thrombosis of the false lumen was confirmed in all 12 patients after a me an of three months by magnetic resonance imaging. There were no deaths or i nstances of paraplegia, stroke, embolization, side-branch occlusion, or inf ection in the stent-graft group; nine patients had postimplantation syndrom e, with transient elevation of C-reactive protein levels and body temperatu re plus mild leukocytosis. All the patients who received stent-grafts recov ered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04). Conclusions These preliminary observations suggest that elective, nonsurgic al insertion of an endovascular stent-graft is safe and efficacious in sele cted patients who have thoracic aortic dissection and for whom surgery is i ndicated. Endoluminal repair may be useful for interventional reconstructio n of thoracic aortic dissection. (N Engl J Med 1999;340:1539-45.) (C)1999, Massachusetts Medical Society.