Endovascular repair of acute type B aortic

dissection: Early and mid-term results

Shang Dong Xu, MD,a Fang Jiong Huang, MD,a Jin Fei Yang, MD,a Zhi Zhong Li, MD,b
Xue Yong Wang, MD,c Zhao Guang Zhang, MD,a and Jia Hui Du, MD,d Beijing, China

Objective: To evaluate early and mid-term results of endovascular repair of acute type B aortic dissection by stent graft.
Methods: From June 2001 to May 2005, 63 patients with acute type B aortic dissection underwent stent graft
implantation. The study included 59 men and 4 women with an average age of 50.4 ⴞ 11.4 years (range, 31-80 years).
Four patients underwent stent-graft implantation in the acute phase. Fifty-nine patients with acute type B dissection
underwent stent-graft implantation 2 weeks after the onset of dissection. All patients were followed up from 1 to 47
months (average, 11.7 ⴞ 10.6 months). The clinical data of the patients were analyzed.
Results: The primary tear was incompletely sealed in three cases. The incidence of incomplete seal was 4.8%. Ascending
aortic dissection occurred in three cases. One occurred during operation. The other two occurred at 1 day and 10 months
after stent-graft implantation. Two patients died within 30 days after operation. One died of rupture of the ascending
aortic dissection. The other one died of acute renal failure. The 1-month mortality was 3.2%. Four patients underwent a
second stent-graft implantation before discharge. One year after stent-graft implantation, complete thrombosis of the
false lumen in the thoracic aorta was achieved in 98.4% of patients, and the maximum diameter of the descending aorta
decreased 11.2% ⴞ 7.3%. Three patients died within the follow-up time. Mortality during the follow-up period was 4.8%.
One patient died of peptic ulcer hemorrhage. Another one died of rupture of the ascending aortic dissection. The third
one died of unknown reasons. The actuarial survival curve by the Kaplan-Meier method showed a 4-year survival rate of
89.4%.
Conclusions: Early and mid-term results showed that endovascular repair was effective in treatment of acute type B aortic
dissection. With the enrichment of doctors’ experience and refinement of the device, better results are expected in the
future. ( J Vasc Surg 2006;43:1090-5.)

There has been debate over the proper treatment of
acute type B aortic dissection. Medical treatment is the first
line of management of acute type B dissection. Surgical
repair is reserved for those who have organ or extremity
malperfusion, impending rupture, persistent pain, or re-
fractory blood pressure. However, both of them have lim-
itations. Surgical treatment of acute type B aortic dissection
has high mortality and morbidity, especially in patients with
heart, lung, or kidney dysfunction.1 With medical treat-
ment, the descending aorta of 20% to 28% of patients with
chronic stable type B dissection will dilate and 18% will
eventually rupture during a period of 40 to 50 months.2,3
Since the introduction of endovascular repair by Dotter4 in
1969, the technique has progressed dramatically. Endovas-
cular repair is safe and effective in selected patients who
have thoracic aortic dissection and for whom surgery is
indicated.5 We therefore hypothesized that endografting
for the treatment of thoracic aortic dissection may offer a
benefit compared with medical or conventional treatment.
We performed our first case in 2001. From June 2001 to
From the aCardiac Surgery Division, bEmergency Division, cAnesthesiology
Division, dRadiology Division, Beijing Institute of Heart, Lung & Vascu-
lar Diseases, Capital University of Medical Science, Beijing Anzhen Hos-
pital, Beijing 100029, China
Competition of interest: none.
Reprint requests: Shang Dong Xu, MD, Beijing Anzhen Hospital, Cardio-
vascular Division, An Zhen Li, Chao Yang District, Beijing 100029, China
(e-mail: xushangdong@vip.sina.com).
0741-5214/$32.00
Copyright © 2006 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2005.12.070
1090
May 2005, 63 patients with acute type B aortic dissection
received stent-graft implantation in our center. The results
were analyzed below.
MATERIALS AND METHODS
Patients. The patients’ clinical data were collected,
and a database was set up by using SPSS 11.0 software
(SPSS Inc, Chicago, Ill). All data were expressed as mean ⫾
SD. Patient characteristics are listed in Table I. If the
patient met the anatomic requirements, stent-graft implan-
tation was considered. Anatomic inclusion criteria included
the following: (1) the landing zone’s diameter was less than
38 mm, (2) the access route permitted the delivery system
to pass through, (3) and there was no aberrant right sub-
clavian artery. During the same period, a total of five
patients were excluded. Three received medical treatment
because of cost problems. Two patients received surgery
because of an aberrant right subclavian artery. If the pa-
tients did not have organ or extremity ischemia, signs of
impending rupture (pleural fluid), persistent pain, or refrac-
tory blood pressure, stent-graft implantation was performed 2
weeks after the onset of the disease, until it become a chronic,
stable one. Four patients underwent stent-graft implanta-
tion within the acute stage. Two of them had contained
ruptures. The other two had pleural fluid, refractory blood
pressure, and continuous back pain. The other 59 patients
were admitted to our hospital in the acute phase but
underwent stent-graft implantation 2 weeks after the onset
of dissection.
JOURNAL OF VASCULAR SURGERY
Volume 43, Number 6 Xu et al 1091

Table I. Patients’ clinical data

Variable Data

Sex
Male 59 (93.7%)
Female 4 (6.3%)
Age (y)
Range 31-80
Mean ⫾ SD 50.4 ⫾ 11.4
Symptom
Back pain 63 (100.0%)
Hoarseness 1 (1.6%)
Shock 2 (3.2%)
Cause of dissection
Hypertension 54 (85.7%)
Hypertension ⫹ atherosclerosis 6 (9.5%)
Marfan syndrome 2 (3.2%)
Unknown 1 (1.6%)
Contained rupture 2 (3.2%)
Left hemothorax 1 (1.6%) Fig 1. Three domestic stent grafts in the Chinese market (from
Hematoma in superior Mediastinum 1 (1.6%) left to right): Aegis (Microport, Shanghai, China), Ankura (Life-
Aortic incompetence 2 (3.2%)
tech, Shenzhen, China), and Griking (Grikin, Beijing, China).
Polycystic kidney 2 (3.2%)
Renal insufficiency 2 (3.2%) Griking does not have a connecting bar, and the whole piece is
Renal failure (need dialysis) 2 (3.2%) tapered.
Descending aorta dimension (mm)
Range 32-65
Mean ⫾ SD 43.4 ⫾ 8.2 used in 10 patients. Blood pressure was monitored by right
Distance from LSCA to primary tear (mm) radial artery cannulation. A 5F sheath was inserted into the
Range 0-40 left radial artery or surgically exposed left brachial artery. A
Mean ⫾ SD 18.7 ⫾ 11.9
Duration between ST implantation and onset
calibrated 5F pigtail catheter was introduced into the as-
of dissection cending aorta through the left subclavian artery (LSCA).
⬍2 wk 4 (6.3%) The unilateral femoral artery was exposed by surgical dis-
2 wk to ⬍1 mo 59 (93.7%) section. A 6F sheath was inserted. A 6F pigtail catheter was
LSCA, Left subclavian artery; ST, stent graft. introduced into the ascending aorta through the femoral
artery. Angiography was performed. Usually two projec-
tions, one left anterior oblique (60°) and one anteroposte-
Preoperative examination. All patients received mag- rior, were used. The 6F pigtail catheter must be confirmed
netic resonance angiography (MRA) or computed tomog- in the true lumen. The precise location of the primary tear
raphy angiography (CTA). The landing zone diameter was was identified. By using the calibrated pigtail catheter, the
measured on MRA or CTA scan. diameter of the landing zone was measured. The data were
Stent graft. Five types of stent-graft systems have compared with the figure obtained from the MRA or CTA.
been used. Talent (Medtronic Inc, Minneapolis, MN) was The average of the two figures was regarded as the diameter
used in 3 patients, Vasoflow (Vascore, Suzhou, China) was of the landing zone. A stent graft with a larger diameter
used in 4 patients, Aegis (Microport, Shanghai, China) was (usually 10%-20%) was chosen.
used in 27 patients, and Griking (Grikin, Beijing, China) Before the deployment of the stent graft, heparin
was used in 28 patients. Ankura (Lifetech, Shenzhen, 1 mg/kg or 125 IU/kg was given intravenously. Through
China) was used in one patient. All stent grafts have a metal the pigtail catheter, an extra-stiff guidewire was threaded
skeleton covered by a polyester graft fabric or polytetrafluo- into the ascending aorta. A transverse or a longitude arte-
roethylene graft. Fig 1 shows three types of domestic stent riotomy was made on the femoral artery. The delivery
grafts in the Chinese market. Domestic stent grafts were system was introduced over the super-stiff guidewire to the
different from foreign ones. For example, Griking does not appropriate position. After the systolic blood pressure had
have a connecting bar, and the whole piece is tapered. It is been decreased to less than 100 mm Hg and the heart rate
more flexible and adapts to the anatomy of the aorta. All had been decreased to less than 90/min, the stent graft was
delivery systems contain a sheath and a pushing rod. deployed under fluoroscopy. Angiography was performed
Stent-graft implantation. Stent-graft implantation again. Fig 2 shows the angiographies of a patient with type
was performed in the catheter laboratory by a team of a B dissection before and after stent-graft implantation. If the
cardiovascular surgeon, interventional cardiologist, radiol- primary entry was incompletely sealed, a cuff was added.
ogist, and anesthetist. All operations were elective except Three stent grafts were implanted in 1 patient, 2 stent grafts
two emergent cases with contained rupture. General anes- in each of 11 patients, and 1 stent graft in each of the
thesia was used in 14 patients. Epidural anesthesia at the L2 remaining 51 patients. If the distance between the primary
or L3 level was used in 39 patients. Local anesthesia was tear and the opening of the LSCA was less than 2 cm, partial
 JOURNAL OF VASCULAR SURGERY
1092 Xu et al June 2006

Fig 2. Aortography during the procedure of a patient with a type

B dissection. Left: aortography before stent-graft implantation.
Right: aortography after stent-graft implantation.
Fig 4. Computed tomographic angiography of a patient with
type B dissection. Left: before stent-graft implantation. Right:
three-dimensional reconstruction 1 week after stent-graft implan-
tation.

Table II. Early results

Variable n %

Mortality 2 3.2
Incomplete seal 3 4.8
Type A dissection 2 3.2
Cerebral infarction 1 1.6
Renal insufficiency 2 3.2
Renal failure 2 2.5
Fever (⬎37.5°C) 51 81.0
Fig 3. Aortography during the procedure of a patient with Stan- Femoral artery damage 1 1.6
ford B dissection. Left: aortography after stent-graft implantation. False aneurysm of LBA 1 1.6
The opening of the left subclavian artery was covered by the stent Transient left arm ischemia 1 1.6
graft. A moderate leak still existed. Right: aortography after an Operation time (h) 2.5
occluder was added in the left subclavian artery. Minimal leak was Blood loss (mL) 80
left. Hospital stay length (d) 10
LBA, Left brachial artery.
or total occlusion of the LSCA was considered. The prox-
imal covered end of the stent graft would surpass the
opening of the LSCA. The opening of the LSCA was totally Follow-up. CTA was conducted before discharge and
occluded by the stent graft in 16 patients. In two of them, at least once a year after the operation (Fig 4).
angiography showed that there was still some blood enter-
ing the false lumen through the primary tear. We suspected RESULTS
that the blood was from the LSCA. After an occluder Early results. Early results are listed in Table II. In
(Lifetech) in LSCA was added, minimal leakage remained three cases, the primary tears were incomplete sealed. The
(Fig 3). incidence of incomplete seal was 4.8%. In other patients,
Postoperative care. All patients were transferred to the primary tears were sealed completely. There were two
the intensive care unit after the operation. The systolic ascending aortic dissections. One occurred during the pro-
blood pressure was decreased to less than 120 mm Hg by cedure after balloon dilation. Fortunately, the patient was
sodium nitroprusside. Respiration assistance was usually still alive 3 years later. The false lumen in the ascending
withdrawn after the patient became fully awake. Oral med- aorta was partially thrombosed. Another patient had as-
icine was given to control blood pressure. Intravenous cending aortic dissection 1 day after stent-graft implanta-
antibiotics were given for 3 days. No anticoagulant was tion. The patient died of cardiac tamponade 1 day after
used. stent-graft implantation. One patient died of hyperpotasse-
Second stent-graft procedure. CTA showed reentry mia because of acute renal failure despite dialysis. Two
distal to the stent graft in the descending aorta in four patients died within 30 days after the operation. The mor-
patients 1 week after stent-graft implantation. They under- tality rate was 3.2%. One patient had cerebral infarction
went a second stent-graft implantation before discharge. during the operation. The reason was unclear. Femoral
Combined procedure. One patient received aortic artery damage occurred in one patient with a small femoral
valve replacement 2 weeks after stent-graft implantation. A artery during the procedure. Angioplasty with a patch was
bioprosthetic valve was used. needed. No paraplegia occurred after the procedure. The
JOURNAL OF VASCULAR SURGERY
Volume 43, Number 6
Fig 5. Computed tomographic angiography (CTA) of a patient
with type B dissection 1 week and 1 year after stent-graft implan-
tation. Top: CTA 1 week after stent-graft implantation. Bottom:
CTA 1 year after stent-graft implantation. This shows the expan-
sion of the true lumen and disappearance of the false lumen.
LSCA was totally occluded in 16 patients. One patient had
transient left arm ischemia on the first postoperative day.
After treatment of low-molecular-weight heparin and pa-
paverine, the patient recovered 4 hours after the onset of
the symptom. No left upper extremity ischemia or brain
steal phenomena occurred in the other patients.
Follow-up. All patients were followed up for 1 to 47
months (average, 11.7 ⫾ 10.6 months). In three patients
with an incomplete seal of the tear, the false lumen was
partially thrombosed 1 week after stent-graft implantation,
and this was found by CTA. The three patients were fol-
lowed up closely. One year later, CTA showed that the pri-
mary entry sealed spontaneously in two patients. The false
lumen in the third patient was partially thrombosed. The
diameter of the descending aorta remained unchanged. One
year after stent-graft implantation, complete thrombosis of
the false lumen in the thoracic aorta was confirmed in 98.4%
of patients. CTA during follow-up showed expansion of the
true lumen and a decrease or disappearance of the false
lumen in most patients (Fig 5). One year after the proce-
dure, the maximum diameter of the descending aorta was
38.0 ⫾ 6.8 mm, 5.4 ⫾ 4.5 mm, or 11.2% ⫾ 7.3% less than
the diameter before stent-graft implantation. One patient
had repeated back pain 1 year after operation. No reason
was found. After aspirin therapy, the pain disappeared.
Three patients died during follow-up. Mortality during the
follow-up period was 4.8%. One had ascending aortic dis-
section 10 months after the procedure. The patient died 2
months later. Another patient died of hemorrhage of a
peptic ulcer. The third one died of unknown reasons. The
actuarial survival curve by the Kaplan-Meier method
showed a 4-year survival rate of 89.4% (Fig 6).
Xu et al 1093
Fig 6. Survival curve of all patients (n ⫽ 63) by the Kaplan-Meier
method with a 4-year survival rate of 89.4%.
DISCUSSION
The stent graft has shown good results in treatment of
complicated acute type B dissection.6 Should asymptom-
atic acute type B dissection be treated with stent grafts
instead of medicine? Some authors have gotten very good
results with medical therapy. Hsu et al7 reported a 5-year
survival rate of 98.9% ⫾ 1.1%. However, results of some
other ones were not so good. Juvonen et al2 and Genoni
et al3 reported that the descending aorta of 20% to 28% of
patients with chronic stable type B dissection will dilate and
that 18% will eventually rupture during a period of 40 to 50
months. Dialetto et al8 reported that with an average
follow-up of 18.1 ⫾ 16.9 months, the mortality was 14.3%,
and an aneurysmal dilatation of the descending aorta was
seen in 28.5% patients. The reason we treat asymptomatic
acute type B dissection with a stent graft is simple. A
dissected aorta is a diseased, weakened aorta. Akutsu et al9
reported that the patency of the false lumen was an inde-
pendent risk factor for dissection-related death and for a
dissection-related event. Also, it is hard to tell whose de-
scending aorta will dilate and whose will not in the future,
so why should we leave them at risk? Our study showed that
1 year after endovascular repair, complete thrombosis of
the false lumen in the thoracic aorta was achieved in 62
(98.4%) patients. The maximum diameter of the descend-
ing aorta decreased 11%, and the 4-year survival rate was
nearly 90%. All these show that endovascular repair is
effective. Prospective randomized trials comparing medical
therapy and stent grafting are needed to obtain a final
conclusion on which one is better.
Although stent-graft implantation is a kind of mini-
mally invasive therapy, sometimes it can cause deadly com-
plications. Ascending aortic dissection is no doubt the most
severe one. We encountered it in three patients; two of
them died. It occurred during the procedure and 1 day and

1094 Xu et al
10 months after the operation. There are four possible
reasons. The first one is procedure related. The tips of the
guidewire and the delivery system could cause damage to
the aortic intima. The use of a balloon was a risk factor. The
second reason may be related to the design of the stent
graft. The newly developed tears were at the proximal end
of the stent graft in the first two cases, and all types of stent
grafts we used have a bare spring at the proximal end for
anchoring. The bare spring contacts with the aortic intima
directly and tightly. The pulsation of the aorta may cause
friction between the two, and as a result, intima damage
may develop. The third reason was size related. The larger
the stent graft, the greater the radial force it gives to the
aortic wall. The fourth reason may be related to congenital
weakness of the aortic wall. It is common sense that the
aortic wall is fragile in patients with Marfan syndrome. We
have two patients with Marfan syndrome who underwent
stent-graft implantation. One of them developed ascending
aortic dissection 10 months later and died. Because the
newly developed tear was not at the proximal end of the
stent graft, we cannot say that the ascending aortic dissec-
tion was caused by the stent graft. Still, a more aggressive
operation (aortic root replacement plus arch replacement
plus stented elephant trunk) at the first time may be a better
choice.10 Congenital weakness of the aortic wall must also
be considered in patients who have no obvious cause of
dissection. Stent-graft implantation in such patients must
be performed very cautiously.
Once ascending aortic dissection occurs, emergent sur-
gical treatment should be performed as soon as possible.11
This is the lesson we have learned. When we encountered
retrograde dissection in the first patient, we chose the
wait-and-see policy. One week later, CTA showed a throm-
bosed false lumen in the ascending aorta. The patient is still
alive. This gave us a wrong concept: that retrograde dissec-
tion could thrombose spontaneously. The fate of the other
two patients told us that immediate ascending aorta plus
arch/half arch replacement was the only choice.
Incomplete sealing of the primary tear is a common
complication. Three of 63 patients with aortic dissection
had an incomplete seal of the tear. The incidence was 4.8%.
The shorter the distance between the opening of the LSCA
and the primary tear, the greater the chance of incomplete
seal. Although the opening of the LSCA was partially or
totally sealed, a small volume of blood still entered the false
lumen through the primary tear. Palma et al12 reported an
incidence of incomplete seal of 7.1%. All the patients with
incomplete seal underwent conversion to surgery. We think
that this may be too aggressive. We chose a wait-and-see
policy. Fortunately, the false lumens of two out of three
patients with incomplete seal were completely thrombosed.
The false lumen in the third patient was partially throm-
bosed. The diameter of the dissecting aneurysm did not
increase. This may be due to the hemodynamic change in the
false lumen. The blood pressure and blood velocity in the
false lumen are related to the blood volume that enters the
false lumen. When a large entry is turned into a small one,
the blood volume that enters the false lumen decreases
JOURNAL OF VASCULAR SURGERY
June 2006
dramatically, and the blood pressure and blood velocity in
the false lumen may decrease simultaneously. This may
explain the thrombus formation in the false lumen. Close
follow-up should be performed for these patients.
One patient experienced cerebral infarction during the
procedure. Two reasons may exist: (1) shedding of atheroscle-
rotic plaque or (2) low blood pressure during the procedure.
When an acute aortic dissection becomes a chronic one,
it always has reentry. The reentry or reentries may be
located in the descending aorta, abdominal aorta, or iliac
artery. In all cases, except when the reentry is in the
descending aorta, it is left open. In most cases, the reentry
or reentries are very close to the visceral arteries. It is
impossible to seal it with a stent graft. Buffolo et al13 agree.
By MRA or CTA, we evaluated all visceral arteries in each
patient and found that most visceral arteries arose from the
true lumen. The most common artery that arises from the
false lumen is the right or left renal artery. Because there is
communication between the true and false lumens, we do
not worry about visceral ischemia after the primary tear is
sealed. No visceral organ ischemia occurred after stent-graft
implantation in our group. In our experience, in some cases
the false lumen in the abdominal aorta will still exist, but the
diameter of the abdominal aorta seldom increases.
Two patients had renal insufficiency, and two patients
had acute renal failure before operation. The reasons may
be as follows:
1. Chronic renal insufficiency. Most patients had hyperten-
sion, and chronic hypertension can itself cause renal
insufficiency.
2. Hypovolemic shock, most often seen in patients who
had contained rupture.
3. Contrast material used in MRA or CTA may cause
damage to renal function. Contrast medium used in the
procedure may aggravate renal damage. Two patients
had renal insufficiency after the procedure. Two patients
with acute renal failure continued dialysis. One died of
hyperpotassaemia despite dialysis.
The opening of the LSCA was totally sealed in 16
patients. One patient had transient left arm ischemia on the
first postoperative day. There was no left arm ischemia or
steal phenomenon in the other patients.
The choice of the stent graft depends on the diameter
of the proximal landing zone. We used to choose a stent
graft with a diameter 20% larger than the landing zone at
the beginning. Then we realized that the larger the size, the
larger the radial force it gave to the aortic wall. Although we
have no scientific data to support our approach, our expe-
rience suggests that oversizing of 10% is sufficient to
achieve sealing and landing.
Another problem we faced was how to place the extra-
stiff guidewire into the true lumen. Because there was
always reentry in the abdominal aorta or iliac artery, when
the guidewire advanced up the aorta, it could enter the false
lumen. If this happens, we introduce an exchange guide-
wire through the LSCA and all the way down to descending
aorta, abdominal aorta, iliac artery, and femoral artery. The
JOURNAL OF VASCULAR SURGERY
Volume 43, Number 6
exchange guidewire is pulled out of femoral artery through
arteriotomy. Then the exchange guidewire is replaced by an
extra-stiff guidewire. Angiographies of at least two projec-
tions are used to confirm that the extra-stiff guidewire is in
the true lumen.
Anesthesia was very important. Effective analgesia and
steady blood pressure control are keys to the success of the
operation. At an earlier period, we used general anesthesia.
A very smooth process could be achieved, and it was very
easy to control the blood pressure. Then we had a patient
who experienced cerebral infarction during the operation.
We did not know when it happened. We realized that the
patient’s conscious state should be monitored during the
process. Then we turned to local anesthesia and found that
some patients could not tolerate the pain. At last, we turned
to epidural anesthesia and found a very smooth process.
Epidural hematoma may occur when heparin is used. Be-
cause the dose was very limited (1 mg/kg), no one had
epidural hematoma in our group.
CONCLUSIONS
Early and mid-term results showed that endovascular
repair was effective in treatment of acute type B aortic dissec-
tion. Endovascular repair is still in its early stage. With the
enrichment of doctors’ experience and refinement of the de-
vice, better results are expected. Endovascular repair may
be the first choice in treatment of type B dissection in the
future.
AUTHOR CONTRIBUTIONS
Conception and design: SDX, FJH, ZGZ, JHD
Analysis and interpretion: SDX
Data collection: JFY, ZZL, XYW
Writing the article: SDX
Critical revision of the article: FJH
Final approval of the article: ZGZ, JHD
Statistical analysis: SDX
Obtained funding: ZGZ, JHD
Overall responsibility: SDX
Xu et al 1095
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Submitted Jul 15, 2005; accepted Dec 25, 2005.