doi: 10.1161/CIRCULATIONAHA.104.525972
(Circulation. 2005;112:I-260 – I-264.)
© 2005 American Heart Association, Inc.
Surgery for Aortic and Peripheral Vascular Disease |
How to Guide Stent-Graft Implantation in Type B Aortic Dissection?
Comparison of Angiography, Transesophageal Echocardiography, and Intravascular Ultrasound
From the Department of Cardiology, University Hospital Hamburg-Eppendorf (D.H.K., M.K., T.H., Y.V.K., O.F., C.D., G.L., T.M.), Hamburg, and the Departments of Cardiac Surgery (M.I., H.R.) and Cardiology (C.A.N., V.S., T.C.R.), University Hospital Rostock, Rostock, Germany.
Correspondence to Dr Dietmar H. Koschyk, University Hospital Hamburg-Eppendorf, Heart Center, Department of Cardiology, Martinistrasse 52, 20246 Hamburg, Germany. E-mail koschyk{at}uke.uni-hamburg.de
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Abstract |
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Background— Despite growing interest in stent-graft implantation for type-B aortic dissection, there are no established recommendations to prepare and perform an implantation procedure.
Methods and Results— We directly compared angiography (ANGIO), transesophageal echocardiography (TEE), and intravascular ultrasound (IVUS) intraprocedually before and after placement of 48 stent grafts in 42 consecutive patients (12 women, 61±11 years of age) with acute and chronic type-B aortic dissection for both usefulness and capability to guide aortic stent-graft implantation. Both IVUS and TEE are superior to ANGIO to identify multiple entries (52 and 43 versus 34; P<0.005 each), to diagnose false-lumen slow flow after stent-graft implantation (32 and 31 versus 24; P<0.005 each) and to detect incomplete stent apposition (18 and 16 versus 8; P<0.005 each). In comparison with ANGIO, guide wire position over the entire length of the aorta was documented more frequently by TEE and IVUS (40 and 42 versus 25; P<0.001 each). In 4 patients with abdominal extension of the dissection, only IVUS was able to accurately identify the false lumen over the entire length of the diseased aorta. TEE was superior to IVUS and ANGIO in the detection of endoleaks (5 versus 0 and 1; P<0.05 each). Intraprocedural ANGIO, TEE, and IVUS had been performed without complications in all patients.
Conclusions— TEE in conjunction with ANGIO appears to be advantageous and adds incremental information to safely guide stent-graft placement in type-B aortic dissection. Additional use of IVUS was found to be helpful in patients with complex anatomy and abdominal extension of the dissection.
Key Words: aorta • aneurysm • angiography • echocardiography
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Introduction |
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Endovascular stent-graft placement is an alternative treatment for aortic type-B dissection. Short-term results for stent-graft repair of acute thoracic aortic dissection are excellent, but long-term outcomes are yet not well assessed.1,2 Despite an increasing number of stent-graft implantations, the imaging guidance of an implantation procedure is not precisely defined and is the subject of ongoing discussion.3 We compared intraprocedural angiography (ANGIO), imaging by transesophageal echocardiography (TEE), and intravascular ultrasound (IVUS) for their capability to safely guide stent-graft placement in type-B aortic dissections.
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Methods |
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Patients
We compared ANGIO, TEE, and IVUS intraprocedually before and after the implantation of 48 stent grafts in 42 patients (12 women, 30 men, 61±12 years of age). All of the patients had stable type-B aortic dissection; 34 patients were not pain free under multiple antihypertensive medications; 8 patients had significant progression of the disease. The predominant risk factor was hypertension diagnosed in 35 patients (83%). All of the patients fulfilled the criteria for surgical treatment of either dissection or aneurysm, such as recurrent episodes of thoracic pain, sustained false lumen flow, and a minimum aortic diameter of 5.5 cm with a tendency to enlarge.1,2 Written informed consent was obtained from every patient, which included an explanation about alternative options, such as surgery and medical treatment. The total aortic diameter (true and false lumen) ranged between a minimum of 30.2±7.2 mm and a maximum of 46.1±6.8 mm measured by preoperative computed tomography/magnetic resonance. All of the patients underwent triple imaging using all modalities.
Aortic Stent-Graft Implantation
The technique of stent-graft implantation has been described in detail elsewhere.1,2 The stent grafts were customized according to the individual patient’s anatomy with respect to length and diameter as taken from preinterventional 3D tomographic reconstruction (Talent, Medtronic). The average length of the stent grafts was 132±20 cm. The implantation was performed under general anesthesia with surgical cutdown to the femoral artery, whereas the brachial insertion for the pigtail catheter was performed percutaneously. The stent-graft implantation was accompanied by triple imaging including intraprocedural ANGIO, TEE, and IVUS.
IVUS
IVUS has proven imaging capability not only in coronary arteries, but also in big vessels, such as the aorta.4–7 IVUS enables exact localization of the entry location between the false and true lumen and direct assessment of the effect of stent-graft placement with the detection of clot formation in the false lumen as a result of closure of the entry site with the stent graft.4,8 IVUS was performed using a phased array IVUS-catheter Vision PV Five-64 F/X, 8.2F operating at 10 MHz (Volcano), as well as a mechanical catheter, 8F, 20 MHz (CVIS, Boston Scientific Inc.). The IVUS catheter was introduced via the femoral artery after surgical cut down and advanced over a stiff 0.0035-inch guide wire in the ipsilateral femoral artery and over the same wire guiding the stent-graft instrumentation. IVUS images were obtained by a slow manual pullback from distal of the lesion until the femoral artery. All of the data were stored on S-VHS videotape and digital (phased array system) for online and offline analysis and comparison with ANGIO.
ANGIO
The procedure was performed in the catherization laboratory under sterile conditions using a HICOR digital fluoroscopy system also allowing for digital subtraction images (Siemens). Angulation of the X-ray tube reached 45° in every direction (right anterior oblique, left anterior oblique, cranial, and caudal), allowing orthogonal views. Repeat contrast injections were performed during the endovascular intervention via the pigtail catheter placed in the upper thoracic aorta via the left subclavian artery.1,2 For better visualization and accurate measurements, a radiopaque ruler was placed under the patient parallel to the aorta. Iopamidol (Solutrast 370, Bracco-Byk Gulden) was used as contrast agent.
TEE
The contribution of TEE for the diagnosis of aortic dissection and aneurysm is well established.9–12 For interventional guidance, a multiplane transesophageal probe connected to a Sonos 5500 ultrasound system (both Philips Medical System) was used (Omniplane II). The ultrasound frequency was 6.25 MHz. TEE was analyzed online, independent of angiographic results and findings. After independent determination and notification of any specific finding, the results by each imaging method were matched. TEE was recorded on a S-VHS recorder (Panasonic), as well as digitally for online and offline analysis.
Statistics
Descriptive statistics are given as mean ±SD. Continuous and categorical variables were compared using either the Student t test or McNemar test when appropriate. For comparison of TEE, ANGIO, and IVUS, the ANOVA approach was chosen. Statistical significance was considered at a P<0.05. The analysis was performed using SPSS for Windows version 10.07.
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Results |
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The results of the comparison among ANGIO, TEE, and IVUS in guiding stent-graft implantation in aortic type-B dissection are listed in the Table. Whereas the proximal entry was localized in all of the methods, the number of all entries detected by IVUS and TEE was higher than with ANGIO alone (52 and 43 versus 34; P<0.005 each). IVUS and TEE were also superior in the diagnosis of false and true lumen (42 and 39 versus 32; P<0.05 each) (Figures 1 and 2
), the assessment of slow flow in the false lumen post stent-graft implantation (32 and 31 versus 24; P<0.05 each), and incomplete stent-graft apposition (18 and 16 versus 9; P<0.05 each). IVUS alone was the best method for side-branch evaluation or interrogation (42 versus 33 and 27; P<0.05 and P<0.005; Figure 1), whereas TEE was superior to both IVUS and ANGIO in the detection of endoleaks (5 versus 0 and 1; P<0.05). In 6 of 42 patients, 2 stent grafts were implanted. Angiographic imaging, TEE, and IVUS were executed without any complications. The additional time required for the use of IVUS imaging ranged between 4 and 6 minutes; no extra time was needed for TEE and catheter ANGIO.
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Discussion |
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ANGIO, TEE, and IVUS have demonstrated a specific capability to diagnose aortic type-B dissection and to safely guide stent-graft implantation (Figures 1 through 3
).1,2,4,13–15 ANGIO is the method of first choice for the guidance of aortic stent-graft placement in aortic type-B dissection because of its ability to give the operator an immediate aortic overview, which is necessary for safe guidance (Figure 3). The exact anatomy of the aorta, including the site of the entry, is often difficult to identify on contrast ANGIO, especially when the entry is located close to the left carotid and/or subclavian artery. Because of the multiple plane access to the aorta, both IVUS and TEE offer valuable and incremental information for the implantation procedure. In a direct comparison of 48 stent-graft implantations in 42 patients, we could show that ultrasound techniques provide additional information superior to that of ANGIO, such as true and false lumen identification, detection of slow flow in the false lumen after stent-graft implantation, and the documentation of endoleaks or incomplete stent-graft apposition.4,5,7,8 With color Doppler echocardiography, TEE was superior to ANGIO and especially to IVUS in the detection of endoleaks after stent-graft implantation, a finding confirmed by others.13–15 Rapezzi et al14 assessed 7 perigraft leaks in 22 patients with TEE in comparison with only 2 with ANGIO (P=0.02). Rocchi et al15 recently reported on 13 proximal "peri-stent leaks" detected by TEE in comparison with only 6 by ANGIO in a group of 42 patients (P=0.008). The goal of stent-graft placement in aortic type-B dissection is to seal proximal entries to the false lumen, reestablish the collapsed true lumen, and resolve situations of malperfusion syndrome or ischemia.1,2,16 ANGIO, TEE, and IVUS were able to detect the main entry of the dissection, which is essential for stent-graft procedures (Figures 1 through 3). In this context, however, IVUS and TEE were able to detect significantly more secondary entries15,17 than ANGIO (52 and 43 versus 34; P<0.005 each); thus, ultrasound results led to an extension of aortic segments to be covered by implanting a second stent-graft in 6 patients, a finding often undetected by ANGIO alone.13 ANGIO alone also has difficulties in the localization of the guide wire in either the true or false lumen (Table). In 4 of 44 stent-graft implantations in our group, the guide wire had to be repositioned based on IVUS or TEE after satisfactory positioning in ANGIO. This finding is confirmed by Rocchi et al,15 where in 3 of 28 patients, guide wire repositioning was necessary after TEE. Because of the multiple plane access, TEE and IVUS provide incremental information compared with ANGIO in the measurement of aortic dimensions in all of the cases of aortic pathology.4,9,11,18 With triple imaging modalities (ANGIO, TEE, and IVUS) planned for all of the procedures, the additional time required for IVUS was <6 minutes, considering that ANGIO and TEE are compulsory. However, IVUS and TEE afford 1 additional trained person in the room participating in the procedure.
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Limitations
Because of eccentric catheter position, in some patients, parts of the arterial wall could not be visualized completely with IVUS, which may lead to overestimation of aortic diameters. Controllable IVUS catheters at the tip could overcome this technical limitation but are not yet commercially available.
With no recommendations at present for the technical performance of stent-graft placement, ANGIO, TEE, and IVUS are used at the discretion of the interventionalist. Another important consideration is the echogenic characteristics of the fabric of a given stent graft; whereas Dacron, used in this study, allows visualization beyond the fabric, other commercial fabric, such as polytetrafluoroethylene, has physical properties that limit ultrasound visualization because of absorption and reflection. With Doppler interrogation, however, stent apposition and relevant endoleaks (type I and II) will be detected by TEE, regardless of the material. The only major disadvantage of TEE is the limited access to the segment of the ascending thoracic aorta, behind the right bronchus, parts of the arch and abdominal segments beyond the celiac trunk. IVUS cannot be performed simultaneously with stent-graft placement, except if used with a second wire in the aorta, whereas TEE is uniquely suited for parallel imaging and intraprocedural monitoring.
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Conclusions |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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Guidance of aortic stent-graft implantation in type-B aortic dissection is improved by complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and IVUS. This imaging approach implies no additional risk and provides online visualization. Nevertheless, preinterventional and postinterventional computed tomography/magnetic resonance, as well as periinterventional ANGIO, will not be replaced. However, procedural complications with stent-graft implantation are likely to be avoided, because TEE and IVUS help navigate guide wires and catheters in the true lumen, which improves safety of stent-grafting and, thus, may eventually improve procedural outcomes, especially in the treatment of aortic dissection.
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References |
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1. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, Nicolas V, Pierangeli A. Non surgical reconstruction of thoracic aortic dissection by stent-graft placement. N Engl J Med. 1999; 340: 1539–1545.
2. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T, Hirano T, Takeda K, Yada I, Miller DC. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med. 1999; 340: 1546–1552.
3. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, Evangelista A, Fattori R, Suzuki T, Oh JK, Moore AG, Malouf JF, Pape LA, Gaca C, Sechtem U, Lenferink S, Deutsch HJ, Diedrichs H, Marcos-y-Robles J, Llovet A, Gilon D, Das SK, Armstrong WF, Deeb GM, Eagle KA. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000; 283: 897–903.
4. Koschyk DH, Meinertz T, Hofmann T, Kodolitsch YV, Dieckmann C, Wolf W, Knap M, Kiraly Z, Steffen W, Beythien C, Lund G, Rehders T, Nienaber CA. Value of intravascular ultrasound for endovascular stent-graft placement in aortic dissection and aneurysm. J Card Surg. 2003; 18: 471–477.[CrossRef][Medline] [Order article via Infotrieve]
5. Lee DY, Williams DM, Abrams GD. The dissected aorta: part II. Differentiation of the true from the false lumen with intravavascular Ultrasound. Radiology. 1997; 203: 32–36.
6. Chavan A, Hausmann D, Dresler C, Rosenthal H, Jaeger K, Haverich A, Borst HG, Galanski M. Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta. Circulation. 1997; 96: 2124–2127.
7. Weintraub AR, Erbel R, Görge G, Schwartz SL, Ge J, Gerber T, Meyer J, Hsu TL, Bojar R, Iliceto S. Intravascular ultrasound imaging on acute aortic dissection. J Am Coll Cardiol. 1994; 24: 495–503.[Abstract]
8. Moon MR, Dake MD, Pelc LR, Liddell R, Castro LJ, Mitchell RS, Miller DC. Intravascular stenting of acute experimental type B dissections. J Surg Res. 1993; 54: 381–388.[CrossRef][Medline] [Order article via Infotrieve]
9. Nienaber CA, Kodolitsch Y, Nicolas V, Siglow V, Piepho A, Brockhoff C, Koschyk DH, Spielmann RP. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med. 1993; 328: 1–9.
10. Nienaber CA, Kodolitsch Y, Brockhoff CJ, Koschyk DH, Spielmann RP. Comparison of conventional and transesophageal echocardiography with magnetic resonance imaging for anatomical mapping of thoracic aortic dissection. Int J Cardiac Imag. 1994; 10: 1–14.[CrossRef][Medline] [Order article via Infotrieve]
11. Erbel R, Engberding R, Daniel W, Roeland J, Visser C, Rennollet H. Echocardiography in diagnosis of aortic dissection. Lancet. 1989; I: 457–461.
12. Erbel R, Oelert H, Meyer J, Puth M, Mohr-Katoly S, Hausmann D, Daniel W, Maffei S, Caruso A, Covino FE, for the European Cooperative Study Group on Echocardiography. Effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. Circulation. 1993; 87: 1604–1615.
13. Fattori R, Caldarera I, Rapezzi C, Rocchi G, Napoli G, Parlapiano M, Favali M, Pierangeli A, Gavelli G. Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography. J Thorac Cardiovasc Surg. 2000; 120: 490–495.
14. Rapezzi C, Rocchi G, Fattori R, Caldarera I, Ferlito M, Napoli G, Pierangeli A, Branzi A. Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysm. Am J Cardiol. 2001; 87: 315–319.[CrossRef][Medline] [Order article via Infotrieve]
15. Rocchi G, Lofiego C, Biagini E, Piva T, Bracchetti G, Lovato L, Parlapiano M, Ferlito M, Rapezzi C, Branzi A, Fattori R. Transesophageal echocardiography-guided algorithm for stent-graft implantation in aortic dissection. J Vasc Surg. 2004; 40: 880–885.[CrossRef][Medline] [Order article via Infotrieve]
16. Miller DC. The continuing dilemma concerning medical versus surgical management of patients with acute type B dissections. Semin Thorac Cardiovasc Surg. 1993; 5: 33–46.[Medline] [Order article via Infotrieve]
17. Wain RA, Marin ML, Ohki T, Sanchez LA, Lyon RT, Rozenblit A, Suggs WD, Yuan JG, Veith FJ. Endoleaks after endovascular graft treatment of aortic aneurysms: classification, risk factors and outcome. J Vasc Surg. 1998; 27: 69–80.[CrossRef][Medline] [Order article via Infotrieve]
18. Maffei S, Baroni M, Terrazzi M, Piacenti M, Paoli F, Camerini E, Verunelli F, Salvatore L, Biagini A. Ambulatory follow-up of aortic dissection: comparison between computed tomography and biplane transesophageal echocardiography. Imaging. 1996; 12: 105–111.
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