Endovascular Treatment of Aortic Diseases
Diseases of the aorta include a wide spectrum of acute and chronic conditions ranging from aortic aneurysms and malformations to acute aortic syndromes (AAS), including acute aortic dissection (AD), intramural haematoma (IMH), penetrating aortic ulcer (PA
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Andreas Mitsis and Christoph A. Nienaber
82.1 Introduction Aortic diseases include a wide spectrum of arterial diseases such as aortic aneurysms, acute aortic syndromes (AAS), including acute aortic dissection (AD), intramural haematoma (IMH), penetrating aortic ulcer (PAU) and traumatic aortic injury (TAI), pseudoaneurysm, atherosclerotic and even inflammatory conditions affecting the aorta as well as congenital abnormalities such as coarctation of the aorta. Some cases have well-determined genetic underpinnings, while many others however develop in the context of risk conditions and chronic arterial hypertension. With open surgery as the standard of care for many aortic pathologies, we see today a shift to combinations of open and endovascular interventions (hybrid procedures) and eventually to full endovascular procedures for many of the above conditions.
82.2 Acute Aortic Dissection Acute aortic syndromes (AAS) are defined as emergency conditions with various manifestations of a fear of disruption of the intima and A. Mitsis · C. A. Nienaber (*) Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Trust and Cardiovascular Department, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK e-mail: [email protected]; [email protected]
media of the aortic wall, leading to IMH, PAU or dissection of the medial layer (AD) and the formation of a true lumen (TL) and a false lumen (FL). As the blood continues to flow between layers of the aortic wall, the intimal flap can extend in both an antegrade and a retrograde direction from the site of the initial tear and can progress to involve side-branch arteries. Despite technological improvements, aortic dissection remains a life-threatening condition and requires special treatment [1]. The estimated incidence is 2.6–3.5 cases per 100,000 people per year [2, 3]. However, this figure may underestimate the true incidence as hospital-based reports do not account for preadmission deaths [4]. Indeed, a prospective analysis of 30,412 middle-aged men and women with 20 years of follow-up reported 15 cases per 100,000 patient-years at risk for aortic dissection, with a 67.5% male preponderance [5]. In those 65–75 years of age, the incidence may even be as high as 35 cases per 100,000 people per year (Fig. 82.1) [6].
82.2.1 Classification Aortic dissections are classified according to anatomical location by the Stanford and DeBakey classification. DeBakey’s nomenclature is based on the anatomic site of the intimal tear and the extent of the resulting dissection. In a type I dissection, the intimal tear originates in
© Springer-Verlag GmbH Austria, part of Springer Nature 2019 O. H. Stanger et al. (eds.), Surgical Management of Aortic Pathology, https://doi.org/10.1007/978-3-7091-4874-7_82
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A. Mitsis and C. A. Nienaber
1172 50 45
Rate per 100,000 population
40 35 30 Men
25
Women Total
20 15 10 5 0 85 85 Type A
85
Type B
Total
Age (years)
Fig. 82.1 Incidence of aortic dissection separated in proximal an
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