| Part 1 The management of Type B Aortic Dissection:endovascular repair or open chest repairObjective:To compare the value and the clinical application of endovascular repair and open chest repair of type B aortic dissection (AD).Methods:This study retrospectively assessed 418 cases treated in our hospital for type B aortic dissection between April 2002 and January 2009, excluding re-operation or re-intervention cases, penetrating aortic ulcers (PAU), and aortic valve diseases and aortic aneurysms needed operations. Among them 299 cases received endovascular repair and 119 cases received open chest repair. There were 360 men and 58 women with the average age of 48.1±10.5 years (19～74 years), including 113(27.0%) acute-onset cases,164 (39.2%) sub-acute-onset cases and 141(33.7%) chronic cases. All cases, according to the locations of primary tear, were divided into BC and BS type, and according to the positions of aortic dilatation (≥4.0 cm), were divided into B1, B2, B3 type. In the intervention group, there were 79(26.4%) BC type cases,179(59.9%) B1S type cases,20(6.7%) B2S type cases, and 21(7.0%) B3S type cases, and in surgical group, there were 25(21%) BC type cases,28 (23.5%) B1S type cases,35(29.4%) B2S type cases, and 31(26.1%) B3S type cases. According to the detailed classification, the specific management, surgery or endovascular repair procedures were selected. Patients were assessed before treatment, at treatment, and at hospital discharge and returned for follow-up visits at 1 month,6 months, and annually thereafter.Results:In intervention group,305 stent-grafts were implanted, and two stents were used in six cases. In surgery group,25 cases underwent partial or total arch replacement with stented elephant trunk operation for BC type AD,63 cases underwent routine descending aortic replacement with distal short stented for B1S and B2S type AD, and 31 cases underwent thoracic-abdominal aortic replacement for B3S type AD. The primary technical success was achieved in 99.7% patients of intervention group and 100% of surgery group, and there were no intra-operative death. The 30-day morbidity and mortality were 3.3% and 1.3% in the intervention group, and 17.6% and 2.5% in surgery group.393 cases (95.6%) obtained follow-up with the mean duration of 35.8±23.1 months, the later morbidity and mortality were 4.2% and 1.4% in intervention group and 4.5% and 4.5% in surgery group. The cumulative survival rate at 1,5,6 years were 98.2%,96.4% and 96.4% in intervention group,and 97.5%,87.4% and 87.4% in surgery group.Conclusion:Endovascular repair is an effective treatment for B type AD with encouraging short and mid-term effect and should be the preferred management for most patients, but the long-term outcomes is still unknown. For the AD involving the arch (BC type AD) and aneurismal false lumen at abdominal aorta (B3S type AD), surgery still plays an irreplaceable role. The specific management according to the detailed classification can take full advantage of endovascular repair and surgery to obtain the best effect.Part 2 Thoracic endovascular aortic repair for Type B Aortic Dissections and penetrating aortic ulcer:A 6-year experienceObjective:To evaluate the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of type B aortic dissection (AD) and penetrating aortic ulcer (PAU) to identify influential factors.Methods:From April 2002 to January 2009,346 consecutive patients, which included 307 B type ADs and 39 PAUs, underwent TEVAR. There were 304 men and 42 women with mean age 50.6±11.2 years (24～79 years). There were 23 complicated cases, including rupture and impending rupture (n=7), malperfusion of visceral organs or extremities (n=4), concomitant abdominal aortic aneurysms (n=4), and re-operation or re-intervention cases (n=8). All the cases were divided into an acute-onset group (n=89), a subacute-onset group (n=127), and a chronic group (n=130). Compare the effects of TEVAR in diffrient groups. All Morbidity and Mortality during different periods were recorded. Analyzed variables were entered into univariate (Student's t test, X2 test or Fisher's exact test) and multivariate (stepwise logistic regression) models to assess independent predictors for death following TEVAR.Results:A total of 355 Thoracic Stent-Grafts (245 imported stents and 60 domestic stents) were implanted to close the entry tears in dissections and PAUs, and 9 patients had 2 stents implanted. Another 4 bifurcation stents were implanted for excluded the abdominal aortic aneurysms in 4 cases. Primary technical success was achieved in 99.7% of patients and there was no intraoperative death.30-days mortality was 17.4%(4/23) in complicated cases and 0.6%(2/323) in other ones. The mean Follow-up period was 31.3±23.7 months.58.5% of cases achieved the complete obliteration of the false lumens in the levels of stents. The max false lumen diameters changed from 2.9±1.2cm to 1.7±1.6cm, P=0.000. Late morbidity and mortality were 4.6%(15/328) and 2.1%(7/328). The cumulative survival rate at 1,5,6 years were 97%,95% and 95%. There were 71 endoleaks (2 major endoleaks,69 minor and moderate endoleaks) in the procedures.78.3% minor and moderate endoleaks sealed and relieved spontaneously in follow-up period. The significant independent determinants of the death during peri-operation were pre-operation shock and TEVAR within 7 days after acute-onset.Conclusion:TEVAR is an effective treatment for type B AD and PAU 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 3 Complications following Thoracic Endovascular Aortic Repair for Type B Aortic Dissections and Penetrating Aortic UlcersObjective:To update our experience with thoracic endovascular aortic repair (TEVAR) for Type B aortic dissections (AD) and penetrating aortic ulcers (PAU) over a 6-year period, focusing on the occurrence and management of serious complications.Methods:From April 2002 to January 2009,346 consecutive patients, which included 307 B type ADs and 39 PAUs, underwent TEVAR. There were 304 men and 42 women with mean age 50.6±11.2 years (24～79 years). All complications occurring during different periods were recorded. Analyzed variables were entered into univariate (Student's t test, X2 test or Fisher's exact test) and multivariate (stepwise logistic regression) models to assess independent predictors for major complications following TEVAR.Results:The 30-day morbidity and mortality were 2.6%(9/346) and 1.7%(6/346) respectively. The mean Follow-up period was 31.3±23.7months. Late morbidity and mortality were 4.6%(15/328) and 2.1%(7/328). Serious complications included retrograde type A aortic dissection (n=5), new tears at the end of stent (n=13), Stroke (n=2), et al. There were 71 early endoleaks (2 major endoleaks,69 minor and moderate endoleaks) and 3 later endoleaks.79.7% minor and moderate endoleaks sealed and relieved spontaneously in follow-up period. Multivariate analyses by stepwise logistic regression identified the size of entry tear and the maximum diameter of thoracic false lumen as predictors of endoleak. The independent determinants of new tears at the end of stents were the size of stents. Conclusion:Although the morbidity and mortality of TEVAR for B type AD and PAU is well acceptable, There were still some serious complications threaten the patient lives. The new tear at the end of stent were the most common complication, so it ought to be paid more attentions. Regular follow-up imaging is necessary.Part 4 Aortic remodeling after Thoracic Endovascular Aortic Repair for Type B Aortic DissectionObjective:To explore the change discipline of true and false lumen at each period after thoracic endovascular aortic repair (TEVAR) in type B aortic dissection (AD).Methods:From April 2002 to January 2007,182 patients underwent TEVAR for type B AD. There were 156 men and 26 women with mean age 49.6±10.3years (24～74 years). 101 cases that followed up with CTA over 2 years were enrolled and their data derived from the CTA of were reviewed. Analyzed variables were entered into univariate and multivariate models to assess independent predictors for complete obliteration of the false lumen over 2 years after TEVAR.Results:The average false lumen diameters on the level of proximal, middle, distal of thoracic aorta and on the level of proximal and distal abdominal aorta before TEVAR were 2.49 cm,2.21cm,2.10 cm,1.59 cm and 0.99 cm, and were 0.63 cm,0.71cm,1.22 cm, 1.53 cm and 1.14cm over 2 years after TEVAR respectively. The rate of whole false lumen complete obliteration was 11.9%(12/101), and the rate of false lumen obliteration at stent level was 62.4%(63/101). The previous maximum diameter of thoracic false lumen and endoleak after TEVAR were the significant independent influential factors of false lumen obliteration of proximal and middle thoracic aorta, and the number of re-tears was independent influential factor of whole false lumen complete obliteration.Conclusion:After TEVAR, the false lumen significantly reduced and the ture lumen significantly enlarged at descending thoracic aorta. The re-tear number effects obliteration of the whole false lumen, and the management of re-tears needs further attention. Influential factors, Re-tearPart 5 Endovascular Repair for Penetrating Aortic UlcerObjective:To investigate the intermediate-term outcome and efficacy of endovascular repair for penetrating atherosclerotic ulcer (PAU), and to identify risk factors for the complications.Methods:From August 2002 to January 2009,46 patients (43 men and 3 women) with a mean age of 57.7±12.6 years were treated for PAUs in the descending thoracic aorta. Among them, concomitant B type AD were seen in 7 cases.41 patients presented with symptomatic PAUs. Clinical and imaging follow-up was performed in all patients using CT angiography (CTA). The diameters of PAU were measured. Analyzed variables were entered into univariate and multivariate models to assess independent predictors for complication after thoracic endovascular aortic repair (TEVAR).Results:The diameter changes of PAUs measured on CTA imaging before operation showed statistical significance in 11 patients. Comparison of PAU's sizes between proximal thoracic aorta and other locations had statistical differences. Primary technical success was achieved in all patients. The 30-day morbidity and mortality were 8.7%(4/46) and 4.3%(2/46) respectively. The follow-up period was 27.4±19.7 months. The follow-up morbidity and mortality were all 4.5%(2/44). The cumulative survival rates at 1,5 and 6 years were both 90.0%. The significant independent determinants of complications were un-absorption of intramural hematoma within 3 mothns after TEVAR.Conclusion:Acute PAU showed more malignant nature and progression. PAU on the proximal thoracic aorta had more invasive. TEVAR might be an effective treatment for PAU over the medium term. Assiduous serial follow-up imaging after TEVAR is mandatory to detect early and late complications.
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