This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chavan, A. Articles by Galanski, M. Search for Related Content PubMed PubMed Citation Articles by Chavan, A. Articles by Galanski, M.

(Circulation. 1997;96:2124-2127.)
© 1997 American Heart Association, Inc.

Articles

Intravascular Ultrasound–Guided Percutaneous Fenestration of the Intimal Flap in the Dissected Aorta

A. Chavan, MD, DMRD; D. Hausmann, MD; C. Dresler, MD; H. Rosenthal, MD; K. Jaeger, MD; A. Haverich, MD; H. G. Borst, MD; ; M. Galanski, MD

From the Departments of Diagnostic Radiology (A.C., H.R., M.G.), Cardiology (D.H.), Thoracic and Cardiovascular Surgery (C.D., A.H., H.G.B.), and Anesthesiology (K.J.), Hannover Medical School, Germany.

Correspondence to Ajay Chavan, MD, DMRD, Department of Diagnostic Radiology, Hannover Medical School, Carl Neuberg Str 1, 30625 Hannover, Germany.

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
Background Aortic dissection with branch obstruction is associated with high morbidity and mortality. Fenestration of the dissection flap to relieve distal vessel ischemia is at present largely performed surgically. The surgical mortality and morbidity are high, because most patients are poor candidates for anesthesia or surgery.

Methods and Results Nine percutaneous fenestrations (one with additional stenting of the infrarenal true aortic lumen) were performed under local anesthesia in seven patients with aortic dissection. The presenting symptoms were abdominal angina or claudication. By the transfemoral approach, the intimal flap was initially punctured with a needle-catheter combination through which a guidewire was placed across the dissection flap. The fenestration was carried out with a balloon catheter introduced over the guidewire. The procedure was performed under on-line guidance with intravascular ultrasound imaging. The procedure was performed successfully and without complications in all patients. After intervention, symptoms resolved in all seven patients.

Conclusions Intravascular ultrasound–guided percutaneous fenestration of the intimal flap in symptomatic aortic dissections with distal vessel involvement is a technically feasible and safe procedure that can effectively relieve the patient's symptoms.

Key Words: dissection, aortic • fenestration • ultrasonics

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
Treatment of acute type A aortic dissections is primarily surgical.^{1 2 3} Intervention may also be necessary to relieve distal-vessel ischemia causing abdominal angina, renal insufficiency, or claudication.¹ Surgical morbidity and mortality in patients with branch-vessel involvement is high.^{3 4} In analogy to the surgical fenestration often performed in such patients,^{2 3 4 5 6 7} we performed nine percutaneous fenestrations in seven patients. We illustrate the method of percutaneous fenestration using intravascular ultrasound (IVUS) imaging and evaluate its clinical outcome. With the help of our patients, we confirm the safety and efficacy of this procedure as reported by other authors.^{8 9 10 11 12 13}

	Methods

Top Abstract Introduction Methods Results Discussion References

 
Seven male patients (age, 41 to 65 years; mean, 55 years; Table) with chronic aortic dissection (3 type A, 4 type B) and abdominal angina (1 patient) or claudication (6 patients) underwent percutaneous fenestration under local anesthesia with an anesthetist on standby. Informed consent was obtained. The follow-up period ranged from 3 to 23 months (average, 14.4 months). A contrast spiral CT examination of the aorta was initially carried out to determine the orientation of the intimal flap and to rule out luminal thrombi at the fenestration site. All patients had arterial cannulas for continuous monitoring of arterial blood pressure, a wide-lumen central venous line and peripheral venous cannulas (16-gauge) for rapid blood transfusion if necessary. Compatible cross-matched blood was kept in readiness. As sedation we used propofol in dosages of 1 to 3 mg · kg^-1 · h^-1 IV as continuous infusion.

View this table: [in this window] [in a new window]   Table 1. Patient Data of the Seven Patients Subjected to Percutaneous Fenestration

After diagnostic angiograms of the two lumina and the branch vessels (Fig 3a and 3b) had been obtained, a 6.2F, 12.5-MHz IVUS catheter (Sonicath, Boston Scientific Corp) was introduced transfemorally into the aorta over a 0.025-in guidewire (Fig 1a). From the opposite femoral artery (9F sheath), a Ross transjugular liver-access needle-catheter combination (William Cook Europe) was introduced over a 0.035-in stiff guidewire (Amplatz Super Stiff, Boston Scientific Corp), and its tip was positioned at the level of the transducer on the IVUS catheter (Fig 1a). While the needle was advanced, its tip was always kept covered and protected by the outer catheter (Fig 1a). Under IVUS guidance, the needle was rotated and its tip positioned against the center of the dissection flap so that it did not point toward the free aortic wall (Fig 2a). After the guidewire was removed and the outer catheter retracted, the flap was perforated with the needle by a quick, short thrust. The intraluminal position of the needle tip now in the second lumen was confirmed with IVUS (Fig 2b), and the outer catheter was advanced over the needle from one lumen into the other. After an angiogram was performed with the catheter tip in the second lumen, the stiff guidewire was reintroduced and the needle-catheter combination removed, leaving the guidewire placed across the intimal flap. A balloon catheter with a balloon diameter of 15 mm (Vas-cath Inc) was advanced over this guidewire and positioned across the intimal flap. Inflation of the balloon created the desired fenestration. A "waisting" of the balloon during inflation indicated satisfactory balloon position (Fig 1b). The outcome of the procedure was controlled by a flush aortogram (Fig 3c and 3d) and with IVUS imaging after an agitated mixture containing 19 mL normal saline and 1 mL air was injected at the level of the fenestration (Fig 2c and 2d). True and false lumen manometry was carried out in two patients (Table, patients W.H. and S.W.). In two patients, small preexisting reentries above the aortic bifurcation were widened with a balloon catheter. One patient (Table, W.H.) underwent stenting of the true lumen of the infrarenal aorta 4 months after fenestration with a 5-cm-long stent that was expanded to a diameter of 18 mm (Palmaz stent, Johnson & Johnson). The previous fenestration was also widened with a 20-mm balloon.

View larger version (125K): [in this window] [in a new window]   Figure 3. Patient M.G., Table. a and b, Flush aortograms of two lumina before fenestration. a, Opacification of right renal artery and branches of celiac trunk (arrows) and of superior mesenteric artery (arrowheads) is from right-sided true lumen. b, Left-sided false lumen supplies only left kidney. c, Early and d, late phases of flush aortogram of left-sided lumen after fenestration showing satisfactory flow of contrast medium from one lumen into other (small arrow, c) with opacification not only of left renal artery (large arrow, c) but also of other abdominal vessels (arrowheads, c and d). As left common iliac artery was not adequately opacified from either of two lumina after high fenestration, patient's claudication did not improve significantly. A second fenestration carried out just above aortic bifurcation 3 weeks later led to resolution of symptoms.

View larger version (110K): [in this window] [in a new window]   Figure 1. Patient M.G., Table. a, Intravascular ultrasound catheter is in true lumen (arrowhead) with tip of needle in false lumen (large arrow) positioned against membrane at level of transducer; note that tip of needle is still protected by outer catheter (small arrow). b, Balloon catheter positioned across membrane after membrane puncture; "waisting" of balloon during inflation (arrow) was considered a reliable sign of satisfactory balloon position.

View larger version (156K): [in this window] [in a new window]   Figure 2. Patient M.G., Table. IVUS imaging during procedure. a, Tip of needle positioned against membrane before membrane was punctured (arrow). b, Needle lying across membrane after puncture (arrow). c, After fenestration, opening created in membrane is well visualized (arrow). d, Satisfactory flow of contrast from one lumen into other (arrow). TL indicates true lumen; FL, false lumen.

	Results

Top Abstract Introduction Methods Results Discussion References

 
Technical Results
Altogether, 10 procedures—7 high fenestrations (between the 12th thoracic vertebra and the 2nd lumbar vertebra), 2 low fenestrations (above the aortic bifurcation), and 1 stenting of the infrarenal true lumen—were successfully carried out without complications in 7 patients (Table). In patient W.H. (Table), the peak systolic pressures in the true and false lumina before fenestration were 150 and 160 mm Hg, respectively, and did not change significantly after the fenestration. The patient required stenting of the true lumen 4 months later before his symptoms resolved. In patient S.W. (Table), the peak systolic pressure in the false lumen fell from 121 mm Hg prefenestration to 103 mm Hg postfenestration; the corresponding true lumen pressures were 103 and 98 mm Hg, respectively, before and after the procedure. His symptoms resolved after the fenestration.

Clinical Results
In one patient, abdominal angina resolved after the fenestration. In four of the other six patients suffering from claudication, numbness, or leg pain, the symptoms disappeared after just one fenestration (Table). In one patient (Table, M.G.), no significant relief of symptoms was observed after the first fenestration at the level of the celiac trunk. After a second fenestration above the aortic bifurcation, his claudication resolved. In the last patient (Table, W.H.), the walking distance improved only moderately, from 1000 to 1500 m after fenestration at the level of the renal arteries. After infrarenal stenting of the narrowed true lumen, his claudication disappeared.

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
Acute type A dissection involving the coronary arteries or the supra-aortic vessels is always repaired promptly for fear of proximal aortic rupture and often results in spontaneous resolution of organ malperfusion even distally.^{1 2 3 5} Intervention or reintervention is required in the type A and type B dissections to relieve persistent distal vessel ischemia causing mesenteric infarction, abdominal angina, acute onset of hypertension, renal insufficiency, or claudication; this intervention may even be life saving.¹ Fenestration of the intimal flap^{2 3 4 6 7} and/or surgical replacement of an aortic segment^{1 3 14} are the most common operations performed in such cases. The presence of aortic-branch obstruction clearly increases morbidity and mortality,¹ with surgical mortality being as high as 30% to 51%,^{3 4} because most patients are poor candidates for anesthesia or surgery. We performed nine percutaneous fenestrations (one with additional stenting of the infrarenal true aortic lumen) without complications under local anesthesia. Because spiral CT scans were available in all cases, we were able to reliably differentiate between the true and false lumina by combining the CT, angiographic, and IVUS findings. In situations in which the true lumen was compressed to a sliver by the false lumen, we injected an agitated mixture of normal saline and a little air to identify the true lumen when necessary. The dissection flap and the needle tip could be well visualized in all cases. All patients could be mobilized the day after the procedure.

Four of the seven patients responded favorably to just one fenestration performed between the levels of the celiac trunk and the renal arteries. In two further patients with claudication (Table, M.G. and W.H.), the symptoms of claudication did not improve significantly after an initial high fenestration. In one of them (Table, M.G., and Fig 3), who had left leg claudication, an initial fenestration at the level of the celiac trunk did not result in clinical improvement. In retrospect, only a high fenestration with the intention of decompressing the false lumen and improving the perfusion of the true lumen of the left common iliac artery could not have been expected to cause clinical improvement, because the left common iliac artery was not adequately opacified from either of the two lumina after the first procedure. A second fenestration above the aortic bifurcation that improved local blood flow across the dissection flap into the left common iliac artery resulted in resolution of symptoms. The second patient (Table, W.H.) improved clinically only after stenting of the narrowed true lumen of the infrarenal aorta and widening of the fenestration with a 20-mm balloon. The seventh patient with claudication (Table, S.W.), who underwent one fenestration at the level of the renal arteries and one above the aortic bifurcation, also responded well clinically. Thus, it appears that just one fenestration (with a 15-mm balloon) to decompress the false lumen may not be adequate in relieving symptoms; it may be necessary to resort to a second fenestration further downstream to provide local blood flow across the intimal flap¹⁵ or to measures such as stenting of the true lumen to keep it patent.¹²

To the best of our knowledge, 20 cases of percutaneous fenestration in patients with aortic dissection have been reported.^{8 9 10 11 12 13 16 17 18 19 20 21} Six of these patients underwent stenting of the true aortic lumen in addition to the fenestration.^{11 12 13} No major complications occurred. Three of these 20 patients died of causes not related to the procedure.^{9 10 18} The remaining patients responded well clinically, as did our seven patients. All our patients had chronic dissections. However, this procedure has also been performed successfully in the acute and subacute setting, with immediate clinical improvement in most cases.^{8 9 10 11 16 17 18 21} On the basis of our data and the data in the literature, percutaneous fenestration in symptomatic aortic dissections with distal vessel obstruction appears to be a technically feasible and safe procedure associated with a low complication rate. Most of the patients respond well symptomatically, thus obviating the need for surgical relief of the obstruction. Additional measures such as stent implantation in the true lumen may be necessary for complete relief of symptoms in some cases.

Received May 27, 1997; revision received July 22, 1997; accepted July 25, 1997.

	References

Top Abstract Introduction Methods Results Discussion References

 
1. Borst HG, Heinemann MK, Stone CD, eds. Surgical Treatment of Aortic Dissection. New York, NY: Churchill Livingstone; 1996.

2. Fann JI, Sarris GE, Mitchell RS, Shumway NE, Stinson EB, Oyer PE, Miller CD. Treatment of patients with aortic dissection presenting with peripheral vascular complications. Ann Surg. 1990;212:705-713.[Medline] [Order article via Infotrieve]

3. Heinemann MK, Buehner B, Schaefers HJ, Jurmann MJ, Laas J, Borst HG. Malperfusion of the thoracoabdominal vasculature in aortic dissection. J Card Surg. 1994;9:748-757.[Medline] [Order article via Infotrieve]

4. Cambria RP, Brewster DC, Gertler J, Moncure AC, Gusberg R, Tilson D, Darling RC, Hammond G, Megerman J, Abbott WM. Vascular complications associated with spontaneous aortic dissection. J Vasc Surg. 1988;7:199-209.[Medline] [Order article via Infotrieve]

5. Laas J, Heinemann M, Schaefers HJ, Daniel W, Borst HG. Management of thoracoabdominal malperfusion in aortic dissection. Circulation. 1991;84(suppl III):III-20-III-24.

6. DeBakey ME, McCollum CH, Crawford ES, Morris GC, Howell J, Noon GP, Lawrie G. Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery. 1982;92:1118-1134.[Medline] [Order article via Infotrieve]

7. Elefteriades JA, Hammond GL, Gusberg RJ, Kopf GS, Baldwin JC. Fenestration revisited: a safe and effective procedure for descending aortic dissection. Arch Surg. 1990;125:786-790.[Abstract/Free Full Text]

8. Williams DM, Brothers TE, Messina LM. Relief of mesenteric ischemia in type III aortic dissection with percutaneous fenestration of the aortic septum. Radiology. 1990;174:450-452.[Abstract/Free Full Text]

9. Williams DM, Andrews JC, Marx V, Abrams GD. Creation of reentry tears in aortic dissection by means of percutaneous balloon fenestration: gross anatomic and histologic considerations. J Vasc Interv Radiol. 1993;4:75-83.[Medline] [Order article via Infotrieve]

10. Walker PJ, Dake MD, Mitchell RS, Miller DC. The use of endovascular techniques for the treatment of complications of aortic dissection. J Vasc Surg. 1993;18:1042-1051.[Medline] [Order article via Infotrieve]

11. Peterson AH, Williams DM, Rodriguez JL, Francis IR. Percutaneous treatment of a traumatic aortic dissection by balloon fenestration and stent placement. AJR Am J Roentgenol. 1995;164:1274-1276.[Free Full Text]

12. Slonim SM, Nyman U, Semba CP, Miller DC, Mitchell SR, Dake MD. Aortic dissection: percutaneous management of ischaemic complications with endovascular stents and balloon fenestration. J Vasc Surg. 1996;23:241-253.[Medline] [Order article via Infotrieve]

13. Slonim SM, Nyman U, Semba CP, Miller DC, Mitchell SR, Dake MD. True lumen obliteration in complicated aortic dissection: endovascular treatment. Radiology. 1996;201:161-166.[Abstract/Free Full Text]

14. Miller DC. The continuing dilemma concerning medical versus surgical management of acute type B dissections. Semin Thorac Cardiovasc Surg. 1993;5:33-46.[Medline] [Order article via Infotrieve]

15. Williams DM, Lee DY, Hamilton BH, Marx VM, Narasimham DL, Kazanjian SN, Prince MR, Andrews JC, Cho KJ, Deeb GM. The dissected aorta, III: anatomy and radiologic diagnosis of branch-vessel compromise. Radiology. 1997;203:37-44.[Abstract/Free Full Text]

16. Faykus MH, Hiette P, Koopot R. Percutaneous fenestration of type I aortic dissection for relief of lower extremity ischaemia. Cardiovasc Intervent Radiol. 1992;15:183-185.[Medline] [Order article via Infotrieve]

17. Saito S, Arai H, Kim K, Aoki N, Tsurugida M. Percutaneous fenestration of dissecting intima with a transseptal needle: a new therapeutic technique for visceral ischaemia complicating acute aortic dissection. Cathet Cardiovasc Diagn. 1992;26:130-135.[Medline] [Order article via Infotrieve]

18. Kato N, Sakuma H, Takeda K, Hirano T, Nakagawa T. Relief of acute lower limb ischaemia with percutaneous fenestration of intimal flap in a patient with type III aortic dissection: a case report. Angiology. 1993;44:755-759.

19. Schild HH, Düber C, Grebe P, Hake U, Oelert H, Thelen M, Meyer J. Transvaskuläre Fensterung eines disseziierenden Aortenaneurysmas. Fortschr Geb Rontgenstrahlen Neuen Bildgeb Verfahr. 1994;161:164-167.

20. Farber A, Gmelin E, Heinemann M. Transfemorale Fensterung und Stentimplantation bei aorto-iliakaler Dissektion. Vasa. 1995;24:389-391.[Medline] [Order article via Infotrieve]

21. Görge G, Erbel R. Intravasaler Ultraschall zur Steuerung der perkutanen Fenestration einer Aortendissektionsmembran. Dtsch Med Wochenschr. 1996;121:1598-1602.[Medline] [Order article via Infotrieve]

This article has been cited by other articles:

				K.-M. Lai and P. Coleman Endovascular Repair of Abdominal Aortic Aneurysm With Chronic Dissection Using an Intravascular Ultrasound-Guided Reentry Catheter Vascular and Endovascular Surgery, October 1, 2008; 42(5): 462 - 465. [Abstract] [PDF]

				H. E. Garrett Jr and B. A. Wolf Management of Acute Infrarenal Aortic Occlusion Secondary to Type A Dissection Ann. Thorac. Surg., April 1, 2006; 81(4): 1500 - 1502. [Abstract] [Full Text] [PDF]

				D. H. Koschyk, C. A. Nienaber, M. Knap, T. Hofmann, Y. V. Kodolitsch, V. Skriabina, M. Ismail, O. Franzen, T. C. Rehders, C. Dieckmann, et al. How to Guide Stent-Graft Implantation in Type B Aortic Dissection?: Comparison of Angiography, Transesophageal Echocardiography, and Intravascular Ultrasound Circulation, August 30, 2005; 112(9_suppl): I-260 - I-264. [Abstract] [Full Text] [PDF]

				G. G. Hartnell and J. Gates Aortic Fenestration: A Why, When, and How-to Guide RadioGraphics, January 1, 2005; 25(1): 175 - 189. [Abstract] [Full Text] [PDF]

				P. T. O'Gara, A. J. Greenfield, N. A. Afridi, and S. L. Houser Case 12-2004 - A 38-Year-Old Woman with Acute Onset of Pain in the Chest N. Engl. J. Med., April 15, 2004; 350(16): 1666 - 1674. [Full Text] [PDF]

				S. D. Moffatt and R. S. Mitchell Endovascular Stent Management of Thoracic Aneurysms and Dissections Card. Surg. Adult, January 1, 2003; 2(2003): 1191 - 1204. [Full Text]

				R. H. Mehta, P. T. O'Gara, E. Bossone, C. A. Nienaber, T. Myrmel, J. V. Cooper, D. E. Smith, W. F. Armstrong, E. M. Isselbacher, L. A. Pape, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era J. Am. Coll. Cardiol., August 21, 2002; 40(4): 685 - 692. [Abstract] [Full Text] [PDF]

				D. L. Packer, C. L. Stevens, M. G. Curley, C. J. Bruce, F. A. Miller, B. K. Khandheria, J. K. Oh, L. J. Sinak, and J. B. Seward Intracardiac phased-array imaging: methods and initial clinical experience with high resolution, under blood visualization: Initial experience with intracardiac phased-array ultrasound J. Am. Coll. Cardiol., February 6, 2002; 39(3): 509 - 516. [Abstract] [Full Text] [PDF]

				R. H. Mehta, T. Suzuki, P. G. Hagan, E. Bossone, D. Gilon, A. Llovet, L. C. Maroto, J. V. Cooper, D. E. Smith, W. F. Armstrong, et al. Predicting Death in Patients With Acute Type A Aortic Dissection Circulation, January 15, 2002; 105(2): 200 - 206. [Abstract] [Full Text] [PDF]

				J. Sailer, P. Peloschek, T. Rand, M. Grabenwoger, S. Thurnher, and J. Lammer Endovascular Treatment of Aortic Type B Dissection and Penetrating Ulcer Using Commercially Available Stent-Grafts Am. J. Roentgenol., December 1, 2001; 177(6): 1365 - 1369. [Abstract] [Full Text] [PDF]

				M. A. Passman, W. A. Marston, M. A. Farber, L. V. Owens, F. S. Sandhu, P. F. Jaques, and B. A. Keagy Percutaneous Balloon Fenestration and Endovascular Stent Placement for Type B Acute Aortic Dissection with Renal Ischemia: A Case Report Vascular and Endovascular Surgery, September 1, 2000; 34(5): 459 - 465. [Abstract] [PDF]

				P. G. Hagan, C. A. Nienaber, E. M. Isselbacher, D. Bruckman, D. J. Karavite, P. L. Russman, A. Evangelista, R. Fattori, T. Suzuki, J. K. Oh, et al. The International Registry of Acute Aortic Dissection (IRAD): New Insights Into an Old Disease JAMA, February 16, 2000; 283(7): 897 - 903. [Abstract] [Full Text] [PDF]

				C. A. Nienaber, R. Fattori, G. Lund, C. Dieckmann, W. Wolf, Y. von Kodolitsch, V. Nicolas, and A. Pierangeli Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent-Graft Placement N. Engl. J. Med., May 20, 1999; 340(20): 1539 - 1545. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chavan, A. Articles by Galanski, M. Search for Related Content PubMed PubMed Citation Articles by Chavan, A. Articles by Galanski, M.