Endovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of True and False Lumen Diameter Changes

DOI: 10.1016/j.athoracsur.2006.10.064 2007;83:1059-1066 Ann Thorac Surg

H. Sodeck, Roman Gottardi, Christian Loewe and Johannes Lammer Maria Schoder, Martin Czerny, Manfred Cejna, Thomas Rand, Alfred Stadler, Gottfried

True and False Lumen Diameter ChangesEndovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of

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ndovascular Repair of Acute Type B Aorticissection: Long-Term Follow-Up of True and Falseumen Diameter Changesaria Schoder, MD, Martin Czerny, MD, Manfred Cejna, MD, Thomas Rand, MD,lfred Stadler, MD, Gottfried H. Sodeck, MD, Roman Gottardi, MD,hristian Loewe, MD, and Johannes Lammer, MD

epartments of Angiography and Interventional Radiology, Cardio-Thoracic Surgery, and Emergency Medicine, Medical
niversity of Vienna, Vienna, Austria
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Background. The aim of this study was to determinehe technical success after endovascular treatment ofcute type B aortic dissections and to evaluate true andalse lumen diameter changes at long-term follow-up.

Methods. Twenty-eight patients with acute type B-issection who were treated by stent graft repair pre-ented with rupture (n � 1), contained rupture (n � 2),ompromised branch vessels (n � 14), pleural effusionn � 11), rapid aortic diameter progression (n � 5),ersistent pain (n � 3), refractory hypertension (n � 10),nd an aortic diameter of more than 4 cm (n � 4). Takingnto account the perfusion status of the false lumen,iameter changes were monitored in the thoracic aorta at

he level of the stented segment (L1), distal to the stentraft (L2), and at the level of the celiac trunk (L3).Results. Severe complications in 9 patients (32%) re-

ulted in 3 deaths for a 30-day mortality rate of 10.7%.

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iuertel 18-20, A-1090 Vienna, Austria; e-mail: [email protected].

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rimary sealing of the entry tear was achieved in 86%. Atll levels, the true lumen diameter increased significantlyfter stent graft placement. At the 1-year follow-up, thealse lumen in L1 was thrombosed in 90% and the meanifference of diameter reduction was highly significant.n L2, complete false lumen thrombosis occurred in 60%ith a significant diameter decrease. In L3, the false

umen thrombosed in only 22%, and the mean differencef false lumen diameter increase reached significance athe 2-year follow-up.

Conclusions. Ninety percent of patients were treateduccessfully with thrombosis of the false lumen in thetented segment. False lumen perfusion distal to the stentraft resulted in diameter increase in several patientseaving these segments an area of concern.

(Ann Thorac Surg 2007;83:1059–66)
© 2007 by The Society of Thoracic Surgeons
ntil recently, acute uncomplicated Stanford type Bdissections were preferably managed by conserva-

ive medical treatment; however, complications includ-ng rupture, visceral or lower limb ischemia, refractoryypertension, continuing pain, and aortic diameter pro-ression occur in 5% to 20% of patients during the acutehase [1–5]. Furthermore, a considerable number ofatients without acute complications experience dissec-

ion-related adverse events during the chronic phase thatemain a treatment challenge [2, 3, 5]. A more aggressiveurgical approach is therefore advocated by some au-hors [6]. Despite technical advances, the surgical mor-ality rate in complicated acute dissections remains 14%o 31% [4, 7–10], with a remarkable increase in patientsith end-organ ischemia [7, 10–12].Closure of the primary entry tear by endovascular

epair may lead to thrombosis of the false lumen withemodelling of the true lumen in the acute and chronicetting. Furthermore, lowering the pressure in the false

ccepted for publication Oct 24, 2006.

ddress correspondence to Dr Schoder, Department of Angiography andnterventional Radiology, Medical University of Vienna, Waehringer

umen may restore the perfusion in the compromisedortic branch vessels. In recent years, encouraging tech-ical results after endovascular repair of acute type Bissection have been reported [13–21]; however, reportsn the true and false lumen changes after endovascularherapy during a longer-term follow-up remain limited13, 20, 22, 23].

The purpose of this study was to assess the clinicalutcome and technical success in endovascular repair ofcute type B aortic dissections. The significance of true andalse lumen diameter changes in the thoracic and abdomi-al aorta was also evaluated at the long-term follow-up.

aterial and Methods

atient Populationrom March 2000 to June 2005, 5 women and 23 men withcute type B aortic dissections were treated by stent graftepair. Mean age of patients was 57 years (range, 33 to 83ears). All patients stated an acute onset of chest pain atdmission. One patient was hemodynamically instablend 1 patient had paraplegia.Endovascular repair of thoracic aortic diseases was

ntroduced at Medical University of Vienna as an alter-

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1060 SCHODER ET AL Ann Thorac SurgENDOVASCULAR REPAIR OF ACUTE TYPE B DISSECTION 2007;83:1059–66

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ative treatment to surgical repair in high-risk patients in996. The local Institutional Review Board gave approvalnd consent for this retrospective study. Written in-ormed consent was obtained from all conscious patients.n one unconscious patient, the treatment decision was

ade collaboratively with cardiothoracic surgeons andnterventional radiologists.

Confirmation of dissection was based on contrast-nhanced computed tomography (CT) angiographyCTA) using a multidetector scanner (Somatom Volume

able 1. Clinical and Anatomic Characteristics in 24 Patients

Pt No. Dissection-Associated Complications

1 Compromised celiac artery, pleural effusion, dissectiosuperior mesenteric artery

2 Rupture, hemodynamic instability, compromised coetrunk, SMA, right RA with kidney infarction, left ilartery

3 Pleural effusion, severe continuing pain4 Pleural effusion, refractory hypertension

5 Pleural effusion, refractory hypertension, compromisiliac artery

6 Pleural effusion, refractory hypertension

7 Primary paraplegia, pleural effusion, compromised Racute renal failure

8 Rapid diameter progression

9 Refractory hypertension, continuing pain0 Refractory hypertension, continuing pain, rapid diam

progression1 Contained rupture, compromised iliac artery

2 Rapid expansion of the false lumen; compromised SMRAs, both iliac arteries; acute renal failure

3 Pleural effusion, rapid diameter progression4 Compromised SMA

5 Compromised RA6 Pleural effusion, refractory hypertension7 Compromised left iliac artery8 Contained rupture, compromised RAs, acute ischemi

right lower limb, hypertension9 Compromised celiac trunk, SMA, left accessory rena

artery (partial infarction left kidney), and right iliaartery; ileus; acute renal failure

0 Pleural effusion, rapid diameter progression1 Compromised celiac artery

2 Compromised left RA, iliac arteries3 Pleural effusion, rapid diameter progression4 Hypertension, compromised left RA

L � endoleak; RA � renal artery; SMA � superior mesenteric artery.


oom; Siemens, Erlangen, Germany). CT scanninganged from the supraaortic vessels to the commonemoral arteries. Routine post acquisition image process-ng from each CT scan included three-dimensional re-onstructions consisting of multiplanar reformationsMPR), curved planar reconstructions (CPR), and a max-mum intensity projection (MIP).

Dissections extended down into one (n � 10, 36%) oroth iliac arteries (n � 11, 39%), to the renal arteries

n � 3, 13%), to the superior mesenteric artery (SMA; n �

h Complicated Acute Type B Dissection

Procedural Outcome, AdditionalProcedures

Follow-Up(days)

Uneventful 1072

Death due to rerupture during surgicalevacuation of right-sided hemothorax

3

Uneventful 1489Primary EL at entry tear, spontaneous

sealing within 1 year1440

Uneventful 1671

Incomplete, transient paraplegia,cerebrospinal fluid drainage

1331

Ischemia left upper limb after LSAoverstenting, LSA transposition,temporary hemodialysis

1032

Retrograde type A dissection, surgicalreplacement of ascending aorta

1152

Uneventful 730Uneventful 1192

Permanent paraplegia, heparin-inducedthrombocytopenia, prolonged intubation,temp. hemodialysis

1082

Temp hemodialysis; retrograde type Adissection on day 9 after stent graftprocedure, death due to pericardialtamponade

9

Uneventful 851Stenting SMA; primary EL at entry tear,

proximal overstenting, otherwiseuneventful

824

Uneventful 721Uneventful 762Uneventful 781Right leg amputation, hemodialysis, death

due to cardiorespiratory insufficiency20

Stenting iliac artery, primary EL at entrytear; resection of necrotic small boweland right-sided hemicolectomy;temporary hemodialysis

567

Uneventful 497Stenting celiac artery, primary EL at entry

tear, otherwise uneventful40

Stenting RA, uneventful 120Uneventful 108Stenting RA, uneventful 164

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1061Ann Thorac Surg SCHODER ET AL2007;83:1059–66 ENDOVASCULAR REPAIR OF ACUTE TYPE B DISSECTION

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, 4%), or were limited to the thoracic aorta (n � 3, 13%).he primary intimal tear was located just distal to the leftubclavian artery in 26 (93%) patients, whereas in 2atients, the entry tear was in the middle third of theescending aorta. The false lumen was patent in all pa-

ients. Thirty branch vessels were compromised by eithern exclusively dynamic process (n � 17) or a combination ofdynamic and a static process. In 12 patients (42.9%), eitherne branch vessel (renal artery in 10, celiac trunk in 1) orwo branch vessels (renal artery and superior mesentericrtery) originated from the false lumen.

Twenty-four symptomatic patients with more thanne complication were selected for endovascular ther-py because of rupture (n � 1), contained rupture (n �), compromised branch vessels (n � 14), pleuralffusion (n � 11), rapid aortic diameter progression (n

5), persistent pain (n � 3), and refractory hyperten-ion (n � 10). Specific patient characteristics with

ig 1. A 70-year old woman with acute renal failure caused by acutehows the entry tear located close to the left subclavian artery (LSA).C) Remarkable true lumen expansion after implantation of two Talenow in the abdominal branches and iliac arteries after stent grafting.

issection related complications are listed in Table 1. 2


our clinically asymptomatic patients demonstratingn aortic diameter of more than 40 mm and markedompression of the true lumen were treated to preventurther aortic dilation. Owing to the severity of theirymptoms, 9 patients (32%) required emergent (withinours) stent graft implantation after CT diagnosis of ancute type B dissection. Another 11 patients werereated within 7 days. Mean time to treatment was 101ours (range, 1 to 312 hours).

ndovascular Prosthesis and Procedurell patients were treated with commercially available

tent grafts. A Talent endoprosthesis (Medtronic, Sun-ise, FL) was used in 18 patients, and the Thoracicxcluder (W. L. Gore & Assoc, Flagstaff, AZ) stent graftystem was used in 10. The diameter of the stent graftas calculated from the largest diameter of the proxi-al anchoring zone, and an oversizing factor of 10% to

B aortic dissection. (A) Angiogram before stent graft implantationompromised visceral, renal, and iliac arteries by a dynamic process.oprostheses with overstenting of the LSA. (D) Restoration of blood

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All procedures were performed in an angiosuite thats equipped with digital subtraction angiography (Mul-istar T.O.P., Siemens, Erlangen, Germany). All pa-ients were under general anesthesia. Antibiotic pro-hylaxis was administered intravenously in all patientsefore the procedure. In patients without rupture, 5000U of heparin sodium was given after the access sitecommon femoral or external iliac artery) was surgi-ally exposed.

A 5F pigtail catheter was positioned into the ascendingorta through right-sided percutaneous brachial accesso perform an angiogram before stent graft deployment.aining access to the true lumen from the iliac route

equired adjunctive maneuvers in 2 patients. Approach-ng from the true lumen via brachial access, a pigtailatheter was advanced down to the aortic bifurcation.ubsequently, a 260-cm-long steerable hydrophilicuidewire (Terumo Europe N.V., Leuven, Belgium) wasdvanced to the iliac artery and snared with an Amplatzooseneck snare (ev3, Plymouth, MN). A diagnostic cath-ter was then introduced from the femoral site over thehrough-and-through wire up to the aortic arch to facil-tate placement of the superstiff guidewire (Back-up

eier, Boston Scientific, Natick, MA).After deployment of the device, an angiogram was

erformed to evaluate the position of the stent graftelative to supraaortic arch vessels, to confirm closure ofhe proximal entry tear, to ascertain the true lumeniameter along the aorta, and to document the perfusiontatus of the branch vessels.

ollow-up ImagingTA examinations were routinely performed withindays after the procedure, at 3, 6, and 12 months, and

early thereafter. To assess the extent of the dissection,he diameter of the true and false lumen, and the perfu-ion status of the false lumen and the branch vessels, thentire aorta and the iliac arteries were included.

tatistical Analysisontinuous variables are expressed as means and �

tandard deviation. For exact analysis of diameterhanges of the true and false lumen, preprocedural andollow-up CT examinations were reevaluated. Measure-

ents were obtained at the same levels perpendicular tohe line of the intimal flap and at the maximum diametern three selected aortic segments: stented aortic segmentL1), thoracic aorta distal to the stent graft (L2), and thebdominal aorta at the level of the celiac trunk (L3).Diameter changes were evaluated for significance

etween the preprocedural and first postprocedural im-ges. For statistical analysis of diameter changes forong-term follow-up, a 1-year and 2-year CTA examina-ion was required. Differences of aortic measurementsere tested for significance using the �2 test for propor-

ions. Significance level was set at p � 0.05. Statisticalnalysis was performed using SPSS 13 statistical software
SPSS Inc, Chicago, IL). (

esults

echnical Resultsn 7 patients, complete overstenting of the left subclavianrtery (LSA) was required to close the entry tear. Tovoid vertebrobasilarly symptoms after intentional cov-ring of the LSA, transposition was performed in 4atients with a dominant left vertebral artery before thetent graft procedure. The LSA was partially covered in9 patients, and 2 patients could be treated with anchor-ng of the stent graft distal to the LSA. Eight patients werereated with 1 endoprosthesis, 18 patients with 2, and 2atients with 3. Length of the covered aortic segment was0 to 21 cm. Deployment of the stent grafts was successfuln all patients; however, in 4 patients (14.3%), the entryear could not be sealed during the first procedure.

Proximal overstenting led to sealing of the entry tear inpatient, and in the second patient, the perfusion of the

alse lumen from the entry tear decreased steadily andas sealed completely at the 1-year follow-up. Twoatients (patient 19 and 21) with partial covering of theSA demonstrated residual flow into the false lumen

rom the proximal entry tear at the last follow-up. For

ig 2. Box plots show the differences of (A) true and (B) false lumeniameter changes between the preprocedural computed tomographymaging and the 1-year follow-up at the level of the stented segment
L1).


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urther proximal overstenting, transposition of the leftommon carotid artery would be necessary in these 2atients. One of these patients refused further interven-

ions, and the second patient has a stable thoracic aorticiameter. Consequently, these patients remain underlose observation.

Expansion of the true lumen after stent graft deploymentesulted in a satisfactory perfusion of compromised vesselsn 83% (Fig 1). Additional stenting was necessary in five17%) arteries (2 visceral arteries, 2 renal arteries, 1 iliacrtery) to alleviate persistent obstruction of the true lumeny extension of the intimal flap beyond a vessel’s origin.

urvival and Complicationsevere complications in 9 (32%) patients resulted in 3eaths for 30-day mortality rate of 10.7%. One patientied from hemorrhage from a ruptured aortic dissectionuring surgical evacuation of the hemothorax. The sec-nd patient died from pericardial tamponade after aetrograde type A dissection on day 9. The third patientied as a result of cardiac and respiratory insufficiencyssociated with dissection-related acute ischemic compli-ations of the leg, followed by a massive reperfusionyndrome that required leg amputation. The survival ratet 1, 2, and 3 years was 89.3%.Further serious complications in the 25 surviving pa-

ients were spinal cord ischemia in 2 (7.1%). In patient 11,ho sustained permanent paraplegia, the LSA was com-letely overstented and the stent graft covered Th-8istally. In patient 6, who had incomplete transientaraplegia, the LSA was partially covered and the deviceas fixed distally at the level of the ninth thoracolumbar

ertebrae. Intentional occlusion of the LSA led to isch-mia of the left upper limb requiring secondary transpo-ition of LSA in 1 patient. A retrograde type A dissectionhat developed in another patient was treated success-ully with surgery. Dissection-related infarction of thentestines required a partial small bowel resection and aight-sided hemicolectomy in one patient. Temporaryemodialysis was necessary in 3 patients who had dis-

able 2. Mean Differences of Diameter Changes of the False-Year Follow-Upa

Thrombosed False Lumen

1 Year p Value 2 Year

1 (n) 18/20 14/14False lumen �11.6 � 8.2 �0.0001 �12.0 � 8.1Max diameter �4.3 � 7.9 0.36 �5.1 � 8.5

2 (n) 12/20 9/14False lumen �8.2 � 10.4 0.02 �5.7 � 11.2Max diameter �0.6 � 5.7 0.73 �0.9 � 6.6

3 (n) 4/18 4/13False lumen �8.5 � 8.0 0.12 �9.8 � 7.4Max diameter �1.3 � 5.9 0.698 �0.5 � 8.1

Data are presented in mm � standard error of the mean.

ection-related acute renal failure. d


ollow-Up Analysis of the True and False Lumenean CT follow-up of surviving patients was 859 � 546

ays (range, 40 to 2107 days). The first postprocedural CTxamination was completed in 25 patients. Twenty pa-

ig 3. Box plots show the differences of (A) true and (B) false lumeniameter changes between the preprocedural computed tomographymaging and the 1-year follow-up in the thoracic aorta at the level

n and the Maximal Aortic Diameter at the 1-Year and

Patent False Lumen

p Value 1 Year p Value 2 Year p Value

2/20 0/14�0.0001 �1.0 � 5.7 0.844

0.42 �4.5 � 2.1 0.2058/20 5/14

0.17 �1.4 � 6.5 0.58 �6.2 � 5.2 0.0550.699 �4.9 � 3.8 0.0084 �9.4 � 3.4 0.0061

14/18 9/130.08 �2.9 � 4.9 0.058 �5.8 � 6.9 0.0370.91 �4.5 � 2.8 0.001 �7.6 � 5.1 0.002

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ients were available for the 1-year CT follow-up analysis,nd 14 patients had CT examinations at 24 months, 8 at6, 4 at 48, and 2 at 60 months.

1-STENTED THORACIC AORTIC SEGMENT. At the first postproce-ural CT, a complete thrombosis of the false lumen waseen in 15 (60%) patients. The mean difference of trueumen diameter increase was highly significant (p �.0001) between the preprocedural and postproceduraleasurements (Fig 2, Table 2).Twelve month follow-up images demonstrated total

hrombosis of the false lumen in 18 patients (90%) alongith complete reabsorption of the thrombus in 9 (50%).he mean true lumen diameter between the initial post-rocedural CTA and 1-year follow-up increased further

n 16 patients (80%) and was stable in 4 (20%). Theiameter of the false lumen increased in 1 patient (5%)ith a patent false lumen. The mean false lumen diam-

ter in the remaining 19 patients (95%) decreased.

2-THORACIC AORTIC SEGMENT DISTAL OF THE STENT GRAFT. Athe first postprocedural CT a complete thrombosis of thealse lumen was observed in 5 patients (20%) and the

ig 4. Box plots show the difference of (A) true (B) and false lumeniameter changes between the preprocedural computed tomographymaging and the 1-year follow-up at the level of the celiac trunk

rL3).


ean difference of true lumen diameter increase wastatistically significant (p � 0.0005; Fig. 3, Table 2).

At the 1-year follow-up, a complete thrombosis of thealse lumen was observed in 12 patients (60%), withomplete reabsorption of the thrombus in 4 (20%). Theean true lumen diameter between the first and 1-year

ollow-up increased in 14 patients (70%), was stable in 420%), and slightly decreased in 2 (10%). Conversely, thealse lumen decreased in 10 patients (50%), was stable in

(15%), and increased in 7 (35%) in whom the falseumen was patent.

3-ABDOMINAL AORTA-LEVEL OF CELIAC ARTERY. At the firstostprocedural CT, none of the 22 patients demonstratedthrombosis of the false lumen; however, the true lumen

howed a statistically significant mean difference of di-meter increase (p � 0.0009; Fig 4, Table 2).At the 1-year follow-up, thrombosis of the false lumen

ccurred in 4 (22%) of 18 patients and the thrombus wasissolved completely in one. The mean true lumen diam-ter between follow-up examinations increased furthern 11 patients (61%), was stable in 4 (22%), but slightlyecreased in 3 (17%). Conversely, the false lumen de-reased only in 6 (33%), and was stable in 2 (11%). In 10atients (56%), the diameter of the patent false lumen

ncreased.

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he current indications for intervention in acute type Bissections involve rupture or signs of impending rup-

ure, rapid diameter progression malperfusion of abdom-nal or peripheral vessels, persisting pain, and uncontrol-able hypertension, and 24 (85.7%) of our patients methese criteria. Medical management of uncomplicatedcute dissections remains the preferable treatment mo-ality. However, several studies showed that adversevents during the clinical course were strongly correlatedith a patent false lumen and a maximal thoracic aorticiameter of 40 mm or more [2, 3, 5]. Both predictive

ndicators were present in the 4 asymptomatic patients.n addition, these patients had a marked compression ofhe true lumen that led us to undertake urgent stent graftepair.

The effectiveness of surgical or endovascular repair forortic dissection is dependent on closure of the entry tear,eexpansion of the true lumen, and clotting of the falseumen. Our experience, as well as that in other studies [13,5, 16, 18, 19, 21, 24], indicates that stent graft repair is anffective approach even in the emergent treatment of pa-ients with a complicated acute type B dissection. In addi-ion to relief of acute symptoms, stent graft placement mayrevent aneurysmal degeneration of the thoracic aorta by

hrombus formation in the false lumen.The in-hospital mortality rate in this patient series was

0.7%, which is similar to the 7% to 20% reported initerature [13, 16, 18, 19, 24, 25]. Although these datandicate a superior survival compared with surgery, theerious condition of this category of patients is also
eflected in a complication rate of up to 36% as reported


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y Kato and colleagues [25] and in the 30% occurrence inur patients, corresponding to the study by Eggebrechtnd colleagues [20].As a procedure-related complication, we observed per-anent paraplegia in 1 (3.6%) patient. This compares

avorably with reported rates in patients who underwenturgery [8, 9, 26]. Another serious procedure-relatedomplication was a retrograde type A dissection occur-ing in 2 patients who were treated with a Talent endo-rosthesis with a free flow design on the proximal cage,esulting in one death. The cause may be related to theimited flexibility of the currently available devices thatroduce forced wall stress at the outer curvature leading

o intimal injuries, which is also reported in previousxperiences [24, 27, 28].Intentional overstenting of the LSA without previous

evascularization is described as a feasible and well-olerated procedure in a few series [17, 21, 29, 30].

owever, 1 of our 3 patients with complete LSA occlu-ion, without previous revascularization, sustained acuterm ischemia that necessitated LSA transposition. Non-erious ischemic arm symptoms in 13.6% of patients werelso reported in the study of Görich and associates [29].oreover, in the series of Tiesenhausen and colleagues

31], 3 (37.5%) of 8 patients with partial or completecclusion of the LSA sustained vertebrobasilar symp-oms. As reported in the literature, bilateral vertebralrtery occlusion, which can be also simulated by over-tenting of a dominant LSA and an additional severelytenotic or hypoplastic right vertebral artery, causedrreversible neurologic problems in 23% of patients [32].herefore, to rule out patients for whom LSA revascu-

arization might be essential, both the carotid andertebral arteries should be evaluated before inten-ional overstenting.

Branch vessels may be compromised by a dynamic ortatic obstruction, or a combination of both [13, 33]. In atudy by Dake and colleagues [13], restoration of bloodow was sufficient after stent graft repair in all branchessels that were compromised exclusively by a dynamicrocess. In vessels also affected by a static component,eployment of an uncovered stent within the true lumenf the obstructed artery was necessary in 60% of theatients. In accordance with this, all our patients with aynamic obstruction of arteries could be treated by stentrafting alone. An additional stent deployment was nec-ssary in five vessels (17%) with an obstruction caused byirect extension of the flap beyond the vessel’s origin.

nfradiaphragmatic vessels originating from the falseumen did not suffer from malperfusion after occlusion ofhe entry tear. An adequate blood supply was providedy existing natural fenestrations of the intimal flap allow-

ng communication between the true and false lumen,hich has also been shown in other series [13, 34].Recent studies have reported patient outcome during the

hronic phase in type B dissections that have only beenreated with medical therapy [2, 5]. Akutsu and associatesoncluded [2] that patients with a thrombosed false lumenad a significantly better outcome in terms of dissection-
elated death and dissection-related events in the chronic

hase. In addition, they found that a higher incidence ofissection-related death in patients with the most dilatedortic segment located at the distal arch. Marui and col-eagues [5] reported that during the chronic phase, thevent-free rate at 1 year was 97% in type B dissections withthrombosed false lumen and an aortic diameter of less

han 40 mm. Conversely, dissections with a patent falseumen and an aortic diameter of 40 mm or more had anvent-free rate of only 43% at the same instant. With respecto these findings, the advantage of endovascular treatmentf acute type B dissections is not limited to treatment ofomplications, but might also prevent adverse events dur-ng the chronic phase.

Primary closure of the entry tear after stent grafting waseported in 89% to 100% [16, 17, 19, 21, 24, 35] and waschieved in 85.7% of our patients. In our series, completehrombosis of the false lumen in the stented aortic segmentL1) as well as in the thoracic aorta distally to the stent graftL2) was observed in 90% and 60%, respectively. A signifi-ant reduction of the false lumen diameter was alsochieved in these patients. In dissections with a patent falseumen in L2, the false lumen increased without reachingtatistical significance at the 2-year follow-up. However, theaximal aortic diameter increased significantly over the

ame time period.Thrombosis of the false lumen occurred in the abdom-

nal aorta (L3) in 22% of our patients, a rate consistentith the findings of other studies that reported false

umen thrombosis in the abdominal aorta in 0% to 10%13, 20, 36]. This circumstance can be explained by theresence of reentries, as mentioned previously. In con-

rast to the results of Czermak and associates [23], whoound no substantial volume change in the abdominalorta, we showed that the mean difference of diameterncrease of a patent false lumen was remarkable at the3 level at the 1-year follow-up and reached statisticalignificance at the 2-year follow-up. There was a clearendency for diameter decrease at this level with ahrombosed false lumen.

A limitation of this study is the small sample size, whichid not allow us to draw final conclusions from our results.owever, closure of the entry tear and stabilization of the

rue lumen presents a promising alternative treatment toonventional surgery for relief of life-threatening dissectionelated complications. Furthermore, aortic segments with ahrombosed false lumen had no substantial diameterhanges during the follow-up period. False lumen perfu-ion distal of the stent graft resulted in substantial diameterncrease in several of our patients leaving these segmentsn area of great concern.

edtronic sponsored a research grant for the Department ofngiography and Interventional Radiology.

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DOI: 10.1016/j.athoracsur.2006.10.064 2007;83:1059-1066 Ann Thorac Surg

H. Sodeck, Roman Gottardi, Christian Loewe and Johannes Lammer Maria Schoder, Martin Czerny, Manfred Cejna, Thomas Rand, Alfred Stadler, Gottfried

True and False Lumen Diameter ChangesEndovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of

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Endovascular Repair of Acute Type B Aortic Dissection: Long-Term Follow-Up of True and False Lumen Diameter Changes