Endovascular Treatment of Residual Type A Aortic Dissection Preserving Patency of Supra-Aortic Vessels by Implantation of the Djumbodis System. No More Surgery for the Aortic Arch?

ABSTRACT: A persistent distal false lumen perfusion—residual type A aortic dissection—is found in 50% to 100% of patients following ascending aorta replacement. Complications of persistent or newly developed dissection of the distal aorta are often fatal and require reoperation, leading to a higher morbidity and mortality rate for these patients than with primary surgery. Thus, many efforts have been done to treat this aortic disease by an endovascular approach. Unfortunately, patency of the supra-aortic vessel still remains an unresolved issue. The present report describes the case of a patient with a residual type A aortic dissection persisting after ascending aorta replacement, successfully treated by implantation of a new endovascular device, the Djumbodis^® Dissection System, a bare stent with sufficiently large mesh to join the dissected layers without occluding main vital branches such as supra-aortic arteries.

J INVASIVE CARDIOL 2011;23(11):E251-E253

Key words: aortic arch, aortic dissection

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Acute type A aortic dissection (AAAD) remains one of the most serious cardiovascular conditions with a mortality rate of about 50% within the first 48 hours.¹ Thus, the prompt emergency surgical approach by replacement of the dissected ascending aorta is fundamental to save the patient’s life.² Although operative outcomes for this acute disease have improved, a persistently high hospital mortality rate still persists.³ Unfortunately, after the first operation, subsequent aortic events might occur because in many cases, the distal intimal tear cannot be removed and the false lumen frequently remains patent, causing the residual type A aortic dissection. This might lead to progressive descending aortic dilation until its fatal rupture.^4,5

Because of this, persistent or newly developed dissection of the distal aorta requires reoperation. Unfortunately, a higher morbidity and mortality rate than with primary surgery has been described for these patients.⁶ To overcome these fundamental limitations due to reoperation, several attempts have been made to treat residual type A aortic dissection by an endovascular treatment. However, these efforts have not had a significant clinical impact.^7,8

The Djumbodis^® Dissection System (DDS) (Saint Come Chirurgie) is an open, bare stent, specifically designed and approved for aortic dissections (both type A and B, but not suited for aneurysms) that can be used in conjunction with the classic replacement of the ascending aorta and/or the Bentall procedure. Since the DDS is an open stent, and its mesh is sufficiently large, it does not obstruct any collateral flows such as supra-aortic arteries in the aortic arch, renal and mesenteric arteries in the abdomen. Thus it is ideally suited for the treatment of dissections in the aortic arch, isthmus, and descending thoracic and abdominal aortas.

We describe a case of a patient with a residual type A aortic dissection persisting after ascending aorta replacement, successfully treated by DDS implantation. This endovascular treatment avoided a high-risk complex redo open surgery with circulatory arrest.

Case Report. A 72-year-old male was admitted for a residual type A aortic dissection persisting after ascending aorta replacement by conventional surgery performed 5 years before. He had developed a residual type A aortic dissection at the distal anastomosis of the conventional graft, involving the arch and the descending thoracic aorta (Figure 1A). A dangerous median growth rate of more than 5 mm was observed during the last year. Two hypothetical surgical strategies could be chosen for the treatment of this patient: a conventional surgery redo with deep hypothermic circulatory arrest (DHCA) or a hybrid treatment consisting of a preventive aortic vessel revascularization through redo-sternotomy followed by thoracic endovascular aortic repair (TEVAR). Because of the high risk of bleeding and neurological complications associated with the previously mentioned procedures, we decided to avoid surgical solutions and attempt an endovascular transfemoral approach.

The DDS consists of an uncovered stent, pre-mounted on a low pressure (0.3 bars) balloon catheter whose length ranges between 70 cm and 120 cm. The stent has 3 available lengths (40 cm, 90  cm, and 140 mm). The balloon compliance allows the stent opening to conform to the aortic anatomy, thus joining the dissected layers without occluding the main vital branches (Figure 2). 

The DDS (140 mm) was introduced through the femoral artery over a 0.035-mm Lunderquist guidewire (Cook Medical). The device was carefully positioned to overlap the distal border of the conventional graft previously implanted in the ascending aorta. Thus, it was implanted in the aortic arch below the supra-aortic vessels that were preserved patent. Because the patient had widespread dissection involving the whole thoracic aorta, we positioned two covered stent grafts (Medtronic) distal to the left subclavian artery, one of which overlapped to the previously implanted DDS (Figure 1B). 

A significant exclusion of the residual type A aortic dissection and a satisfactory aortic reshaping was documented by intraoperative angiography. No complications were observed. The mean hospital stay was less than 3 days. At 1 and 6 months follow-up, CT scan confirmed a significant exclusion of the false lumen in short axis view and a very satisfying reshaping of the arch and descending thoracic aorta in the 3-dimensional reconstruction (Figures 1 and 2).

Discussion. The residual patent false lumen following surgery still remains a controversial issue for the evaluation of long-term results in patients treated for the type A aortic dissection.^2-4 Surgical treatment is advocated only for patients who develop life-threatening complications or with a growth rate of patent false lumen of more than 5 mm/yr.⁹ Unfortunately, reoperation in these patients is complicated by high morbidity and mortality rates compared with primary surgery especially when arch is involved.¹⁰ Moreover, patients unfit for conventional open surgical repair but eligible for hybrid approach with an endovascular stent graft, require complex adjunctive open debranching of supra-aortic vessels.¹¹ Thus, many efforts have been made to obtain an endovascular treatment of AAAD to avoid surgery and its complications. Patients with type B aortic dissection treated with endovascular stenting have shown promising results.^8,12 On the contrary, similar results have not been confirmed for treatment of type A dissection.^13-15 The main limitation of treating aortic arch is represented by supra-aortic vessels. Other groups have successfully used covered stent grafts to treat acute type A dissections, but the stent landing zone did not involve supra-aortic vessels.^15,16 Another hypothetical approach was to use fenestrated and branched stent grafts but worldwide experiences with these devices seem to be scarce. Finally, other reports have described similar treatment attempts but, despite initially successful stent graft treatment, patients still developed severe complications.^17,18

The Djumbodis^® System, is an “open” stent, with sufficiently large mesh making it ideally suitable for treatment of dissections in the aortic arch, as it does not obstruct any collateral flow such as supra-aortic vessels. This DDS, specifically designed to treat residual type A aortic dissection or type B dissection with retrograde extension, might be the ideal solution, allowing treatment of this aortic disease using an endovascular approach since, in addition to compressing the false lumen, it appears to successfully preserve blood flow of the supra-aortic vessels. Consequently, it should overcome one of the principal limitations associated with endovascular treatment of residual type A aortic dissection, by preserving the patency of vital aortic side branches.

The DDS impact on true and false aortic lumen evolution has been recently evaluated in patients with AAAD.¹⁹ In particular, placement of the Djumbodis prosthesis did not confer any additional surgical benefit and did not contribute to reducing the incidence of postoperative false lumen patency in patients with AAAD in comparison with conventional surgery. However, in that study, the prosthesis was implanted using a surgical technique, which required profound hypothermia, extracorporeal circulation, and opening of the aorta to insert the Djumbodis balloon catheter in the true lumen. In addition, patients treated in that study had an aortic dissection not extending beyond the aortic arch and, more important, not involving the supra-aortic vessels. In the present report, the Djumbodis was implanted percutaneously, thus not requiring hypothermic circulatory arrest, and cardiopulmonary bypass below the supra-aortic vessels that were preserved patent. Of course, further studies are needed to evaluate the clinical outcome of patients with these aortic diseases at long-term follow-up.

Conclusion

In conclusion, endovascular treatment of type A aortic dissection surely is an evolving tool. The Djumbodis System, for its unique characteristics, might represent an attractive new device to perform a “pure endovascular” management, especially in high-risk type A dissection cases, older and with more co-pathologies at presentation, where open surgical repair is not feasible.

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From the Department of Internal Medicine, Cardiovascular and Immunological Sciences, University of Naples “Federico II,” Naples, Italy.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted March 9, 2011, provisional acceptance given March 15, 2011, final version accepted March 21, 2011.
Address for correspondence: Plinio Cirillo, MD, PhD, University of Naples “Federico II,” Department of Internal Medicine, Cardiovascular and Immunulogical Sciences, via Sergio Pansini 5 Naples, 80131 Italy. Email: pcirillo@unina.it