Clinic Study Of Interventional Therapy On Aortic Disease

Part 1 Transluminal Stent-grafl Placement for the Treatment of Type BAortic DissectionsObjective: To evaluate the safety and effectiveness of transluminal stent-graflplacement (TSGP) for the treatment of type B aortic dissection (AD) and to identifyinfluential factors.Methods: From April 2002 to January 2007, 213 patients underwent TSGP for AD, including classic Stanford type B dissection (n=190) and penetrating aortic ulcer(n=23) with intramural hematoma (n=40). There were 158 men and 22 women withmean age 51 years in acute stage (n=64), sub-acute stage (n=66) and chronic stage(n=83). 32.2 percent of abdominal branch-vessels and iliac arteries were involved.Analyzed variables were entered into univariate (Student's t test, X2 test or Fisher'sexact test) and multivariate (stepwise logistic regression) models to assessindependent predictors for complication and death following TSGP.Results: Primary technical success was achieved in 94.4% of patients. 86.2% ofischemic branch-vessels were improved. The 30-day morbidity and mortality were4.7% and 2.7% respectively. Follow-up period ranged from 1 to 57 months and was94.2%. Late morbidity and mortality were both 2.1%. 52.7% of type B AD achievedthe complete obliteration of the false lumens in the levels of stent and 93.8% hadcomplete thrombosis of the thoracic aortic false lumen. 35 patients with early minorendoleaks sealed spontaneously, 6 patients of them unchanged, 1 patient increased. 7patients with middle endoleaks were relieved, and 1 patient of them unchanged. Lateendoleaks occurred in 2 patients. The diameter of abdominal false lumen enlarged in8.7% of patients. The cumulative survival rate at 1, 2, 4 years were 96.6%, 95.6% and93.1%. The significant independent determinants of middle endoleak were previous tear size, the maximum diameter of thoracic false lumen and over middle aortic valveregurgitation. Procedure during acute stage might increase the risk of 30-daymorbidity and mortality. The complete obliteration of thoracic false lumen was abeneficial prognostic factor.Conclusion: TSGP is an effective treatment for type BAD in short and middle-term.To avoid operation during acute stage if allowed might be helpful for patients.Regular follow-up imaging is necessary.Part 2 Changes in True and False Lumen after Transluminal Stent-graftPlacement for Type B Aortic Dissection: Midterm ResultsObjective: To analysis and explore the change discipline and tendency of true andfalse lumen before and at each period after transluminal stent-graft placement (TSGP)in type B aortic dissection at different stages.Methods: From April 2002 to January 2007, 213 patients underwent TSGP for type BAD. 88 patients of them with classic type B aortic dissections were follow-up over 2years (mean 36.2±8.2 months) by contrast enhanced CT. The patients were dividedinto 34 acute-onset, 24 sub-acute-onset and 30 chronic dissections. Measurements ofthe true lumen, false lumen and whole aorta diameters were conducted on the level ofproximal, middle and distal of stents, diaphragmatic surface of left ventricle, celiacartery, left renal artery and inferior mesenteric artery. Each diameter were statisticalanalysis before and at each period (within 1 month, ranging from 1 to 6 month, 6 to12 month and 12 to 24 month, over 2 years) after TSGP. Analyzed variables wereentered into univariate (Student's t test, X2 test or Fisher's exact test) and multivariate(stepwise logistic regression) models to assess independent predictors for completeobliteration of the false lumen over 2 years after TSGP. Descriptive levels (P) lessthan 0.05 were considered significant. Results: The average false lumen diameters on the level of proximal, middle anddistal of stents, diaphragmatic surface of left ventricle before TSGP were 2.25, 2.22, 2.09 and 2.01 cm in the acute dissection group, 2.39, 2.36, 2.22 and 2.25 cm in thesub-acute dissection group, and 2.86, 2.73, 2.70 and 2.78 cm in the chronic dissectiongroup, respectively. The false lumen diameters over 2 years after TSGP were 0.51, 0.54, 0.54 and 1.05cm in the acute dissection group, 0.38, 0.31, 0.34 and 0.61cm inthe sub-acute dissection group, and 0.99, 1.11, 1.15 and 2.01 cm in the chronicdissection group, respectively. But the false lumen diameter of the distal abdominalaorta was increased to＞5mm in 7 patients. Minor and medium endoleak were 16 and3 cases respectively within 1 month after TSGP, but both 2 cases over 2 years. Therates of false lumen complete obliteration of proximal and middle thoracic aorta were68.6%, 80% and 39.3% respectively in the acute-onset, sub-acute and chronicdissection groups. The significant independent influential factors of false lumencomplete obliteration were previous maximum diameter of thoracic false lumen andendoleak after TSGP.Conclusion: The rate of false lumen complete obliteration was higher in acute andsub-acute cases than in chronic cases. The occurring time was also earlier after TSGP.We should pay more attention to the diameter of abdominal aorta at follow up.Part 3 Tranluminal Stent-graft Placement for Penetrating Aortic Ulcer inthe Descending Thoracic Aorta: Early and Mid-term ResultsObjective: To summarize the clinical experience and effectiveness of transluminalstent-graft placement (TSGP) of penetrating atherosclerotic ulcer (PAU) in thedescending thoracic aorta and to identify risk factors for the complications.Methods: From August 2002 to January 2007, 28 patients with PAU accepted TSGP.There were 27 men and 1 woman with mean age 57 years. Aortic concomitant diseases included type B aortic dissection (n=7), aortic pseudoaneurysm (n=3) andabdominal aortic aneurysm (n=1). The diameters of ostium, depth and length aboutPAU before TSGP were measured and. Analyzed variables were entered intounivariate (Student's t test, X2 test or Fisher's exact test) and multivariate (stepwiselogistic regression) models to assess independent predictors for complication afterTSGP. Descriptive levels (P) less than 0.05 were considered significant.Results: The diameters of PAU based on previous two-time CT before TSGP showedstatistical significance in 8 patients. Comparison of diameters between proximalthoracic aorta and other locations had statistical differences. Primary technical successwas achieved in all patients, 2 of them were implanted with 2 stents. The 30-daymorbidity and mortality were 14.3% (4/28) and 7.1% (2/28) respectively, includingtype A AD developing (n=2, one died, another to surgery), aortic pseudoaneurysm atproximal stent (n=1, died), and new PAU occurred at distal thoracic aorta. Within thefollow-up average 18.7 months, 1 patient occurred type A AD and 1 patient died forlung cancer. Total clinical success rate was 85.7%. The cumulative survival rates at 1and 3 years were both 88.1%. The significant independent determinants ofcomplications were un-absorption of intramural hematoma within 3 mothns afterTSGP.Conclusion: Acute PAU showed more malignant nature and progression. PAU on theproximal thoracic aorta had more invasive. TSGP might be an effective treatment forPAU over the medium term. Assiduous serial follow-up imaging after TSGP ismandatory to detect early and late complications.Part 4 Treatment of Aortic Pseudoaneurysm with Interventional ProcedureObjective: To evaluate the feasibility and effectiveness of interventional therapy onaortic pseudoaneurysm. Methods: 25 patients (20 men and 5 woman), aged 19～77 years (mean, 50.2±15.3years) were treated with interventional procedure for aortic pseudoaneurysm locatedin the thoracic aorta (n=23) and abdominal aorta (n=2) by CT or MRI scan with theaverage diameter was (41.1±16.4) mm×(37.2±19.2) mm. Etiologies of thepseudoaneurysms included traumatic rupture of the aorta(n=9), Behcet's disease(n=2), artherosclerosis (n=4), leakage after surgery (n=1), infected aorta (n=1) and unclearreasons(n=8). 20 patients were treated by endovascular stent-grafts, and the other 4patients who were not were suitable for stent-graft placement, were applied withAmplazter devices including VSD occluder (n=1), PDA occluder (n=2) and vascularplug (n=1) respectively to excluded aneurysms.Results: Primary technical success was achieved in 96.0% of patients. Instantangiography revealed medium endoleak (n=1) and minor endoleaks (n=2). The formerwas added a cuff, then endoleak decreased. There were no adverse complication anddeath during perioperation. Within the follow-up average 20.7 months, 1 patient withartherosclerosis occurred new intimal entry, and then died due to lung cancer 5months later after TSGP. CT scans demonstrated complete thrombosis of theaneurysm in other patients.Conclusion: Our results suggested that endovascular stent-graft placement andclosure with Amplatzer occluder were effective treatments for aortic pseudoaneurysm.But long-term results require further observation.Part 5 The Initial Experience of Covered Cheatham-Platinum Stent forTreatment of Aortic CoarctationObjective: To evaluate the early results of covered Cheatham-Platinum (CP) stentimplantation for coarctation of aorta (CoA) in adolescents and adults.Methods: From August 2005 to August 2006, 8 patients with CoA underwent covered CP stent implantations. There were 5 men and 3 women with mean age (19.1±6.0)years. All patients had right upper limb systolic hypertension, while the lower limbblood pressures could not be measured except 1 patient. The concomitant diseaseincluded patent ductus arteriosus (PDA) (n=1), moderate aortic stenosis associatedwith bicuspid valves (n=1), aortic arch hypoplasia (n=1) and severe mitralregurgitation with mitral valve prolapse (n=1). All patients were diagnosed by CTcontrast-scans. The stent and balloon were selected according to the data of CT andDSA examinations. The covered CP stent onto the catheter balloon was delivered tothe lesion through 14-Fr long sheath, and then stent was deployed by expanding theballoon. Perclose device was applied to the femoral artery after the operation.Results: Interventional procedure was successful in all cases without major adverseevents. The mean peak systolic pressure gradient across the CoA site decreased from(63.8±17.6) mmHg to (6.5±11.8) mmHg. The mean minimum aortic diameterincreased from (4.8±1.4) mm to (18.0±2.6) mm. The PDA had completely closed.Blood pressure was recovered in all patients except one. At a follow-up period of 3 to10 months, all patients were clinically well, and the aortic coarctation was dilatedsuccessfully to an acceptable diameter. 1 patient with aortic arch hypoplasiaunderwent bare CP stent implantion 9 month later, and then the peak systolic pressuregradient across the CoA site decreased from 35 mmHg to 10 mmHg.Conclusions: Covered CP stents are useful in adolescents and adults with native CoAat short-terms. But long-term results require further observation.