The Case of Aortic Dissection

The pathophysiology, management and prognosis of aortic dissection are different from those of aortic an-eurysm. Untreated aortic dissection has a high mortality [4]. Recently, a consensus has evolved regarding the acceptable management of aortic dissections. For the acute Stanford type A dissection immediate surgery is recom-

Fig. 5.4.5a-f Endovascular aneurysm repair (EVAR) for TAA with involvement of supra-aortic arteries - hybrid management. a, b Intraoperative angiography before and after stent graft placement. c, d CT scan before and after stent graft placement. e, f 3D CT reconstruction 1 and 6 months (after subclavian artery transposition) after endografting

Fig. 5.4.5a-f Endovascular aneurysm repair (EVAR) for TAA with involvement of supra-aortic arteries - hybrid management. a, b Intraoperative angiography before and after stent graft placement. c, d CT scan before and after stent graft placement. e, f 3D CT reconstruction 1 and 6 months (after subclavian artery transposition) after endografting mended, whereas the management of acute Stanford type B dissection depends on its clinical manifestation [42]. Surgical intervention is only indicated in cases of impending rupture, visceral and lower limb ischaemia, therapy-resistant hypertension and continued pain [27]. EVAR has emerged as a less invasive alternative technique for the management of complicated aortic type B dissection. EVAR significantly reduces the morbidity and mortality rates in comparison to open repair [43]. The choice of stent graft is particularly important for patients with aortic dissection. It is recommended to implant stent grafts with high flexibility and low rigidity. Customized stent grafts should be used when covering up to 20 cm of the dissected aorta [33]. In order to avoid retrograde aortic dissection, the placement of stent grafts with bare stents, hooks and barbs should be avoided. The graft over-sizing should not exceed 8-10 % of the aortic diameter. Retrograde dissections are reported in up to 10% of dissection patients after EVAR [39]. The placement of stent graft in the true lumen is not simple and demands tran-soesophageal echocardiography (TEE) monitoring and/

or intravascular ultrasonography (IVUS) application. If it does not occur spontaneously, sufficient refenestration of the false lumen percutaneously is technically challenging.

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