Eur Radiol (2009) 19: 488–494DOI 10.1007/s00330-008-1141-4 VASCULAR-INTERVENTIONAL

Ajay ChavanHerbert RosenthalLars LutheStefanie PfingstenIngo KutschkaJerry EasoSiegfried PiepenbrockOtto DapuntAxel HaverichMichael Galanski

Received: 14 April 2008Revised: 14 July 2008Accepted: 18 July 2008Published online: 9 August 2008# European Society of Radiology 2008

Percutaneous interventions for treatingischemic complications of aortic dissection

Abstract The aim of this study was toevaluate the role of percutaneousinterventions in treating ischemiacomplicating aortic dissection. Forty-five patients with ischemia compli-cating aortic dissection were treatedby balloon fenestration, true lumenstenting, angioplasty, or thrombolysis.Clinical and laboratory examinationswere performed before and after in-tervention, and at the end of follow-up(median 37 months). Eighteen dissec-tions were acute, 9 sub-acute, and 18chronic. Mesenterohepatic ischemiaresolved in 16 of 18 patients; lactate

and SGOT values fell from 2.89 to1.23 mmol/L (p=0.006) and from165.9 to 59.7 U/L (p=0.034), respec-tively. In patients with renal ischemia,creatinine levels fell from 360.1 to196.3 μmol/L (p=0.007) accompa-nied by a significant reduction inblood pressure. Limb-threateningischemia resolved in three of fourpatients; in 21 claudicants, the meanwalking distance improved from 272to 1,283 m (p=0.001). Spinal ische-mia resolved completely or partially insix of eight patients. Adjunctive sur-gical measures were necessary in sixpatients. Overall 30-day mortality inthe 45 patients was 6.7%; all threedeaths were in patients with acutedissections (mortality in this subgroup16.7%). Ischemia complicating aorticdissection can be effectively treated bypercutaneous interventions resultingin good early and mid-term outcomes.

Keywords Ischemia . Aorticdissection . Balloon fenestration .Stent . Percutaneous intervention

Introduction

Aortic dissection may be complicated by thoraco-abdominalmalperfusion in about 10–30% of the patients [1, 2]. Suchmalperfusion complicating type A dissections is generallyrelieved following surgical replacement of the proximal aorta[1–4]. Open surgical treatment of distal ischemia persisting

after proximal repair of the type A dissections or complicat-ing type B dissectionsmay be associatedwith highmorbidityand mortality [1–5]. Reported mortality rates range between25 and 51%, with mortality being higher in the presence ofrenal or mesenteric ischemia [1–3, 6, 7]. We report ourexperience in 45 such patients treated primarily usingpercutaneous techniques.

A. Chavan (*) . L. LutheDepartment of Diagnosticand Interventional Radiology,Klinikum Oldenburg,Rahel Straus Str. 10,26133 Oldenburg, Germanye-mail: chavan.ajay@klinikum-oldenburg.deTel.: +49-441-4032521Fax: +49-441-4032515

H. Rosenthal . S. Pfingsten .M. GalanskiDepartment of Radiology,Hannover Medical School,Carl Neuberg Str. 1,30625 Hannover, Germany

I. Kutschka . A. HaverichDepartment of Cardio-thoracic Surgery,Hannover Medical School,Carl Neuberg Str. 1,30625 Hannover, Germany

J. Easo . O. DapuntDepartment of Cardio-thoracic Surgery,Klinikum Oldenburg,Rahel Straus Str. 10,26133 Oldenburg, Germany

S. PiepenbrockDepartment of Anaesthesia,Hannover Medical School,Carl Neuberg Str. 1,30625 Hannover, Germany

Patients and methods

Forty-five consecutive patients (37 male, 8 female, meanage 58.9±11.3 years) presenting with ischemic complica-tions of aortic dissection were treated primarily withpercutaneous interventions. These interventions includedpercutaneous balloon fenestration of the intimal flap, truelumen stenting, balloon angioplasty, and thrombolysis.

Excepting for six patients already intubated at admis-sion, informed consent was obtained from all patients; inthese patients, the interventions were carried out underlocal anaesthesia. Sedation was administered whenevernecessary.

Depending on the duration of the period from onset ofsymptoms to treatment, the dissections were classified asacute (≤14 days), sub-acute (between 15 days and2 months), or chronic (more than 2 months).

Five ischemic syndromes corresponding to the affectedvascular territories or nature of ischemia were identified:mesenterohepatic, renal, critical lower extremity, chroniclower extremity, and spinal. An acute abdomen, absentbowel sounds, bloody diarrhoea, persistent serum lactatevalues above 2.4 mmol/L, and a more than threefold,persistent rise in the serum transaminase values denotedacute mesenterohepatic ischemia; abdominal angina withpostprandial pain denoted chronic ischemia. Pain in therenal area, hematuria, oliguria, or anuria, therapy refractoryhypertension, and persistently raised serum creatininevalues above 100 μmol/L signified renal ischemia. Criticallower extremity ischemia was characterized by painful,cold pulseless extremities, whereas claudication aboveFontaine stage IIa was considered a sign of chronicischemia. Acute spinal ischemia manifesting as paraparesisor paraplegia was divided into six grades (grade 0 = nomuscle activity, grade 1 = visible contractions withoutmovement, grade 2 = movement only under gravity, grade3 = movement against gravity, grade 4 = movement againstresistance, and grade 5 = normal movement).

A decision to intervene was taken only in the presence ofpositive clinical features associated with correspondingfindings at computed tomography (CT) or on the angio-gram. The severity of compression of the true lumen,the orientation of the intimal flap at various levels, and thepresence or absence of thrombus in one or both of thelumina were assessed on the pre-procedural CT scans. CT,in addition, offered information as to which vesselsoriginated from which lumen.

Assessment of clinical symptomatology and laboratoryparameters (serum creatinine, transaminase, and lactatevalues), as well as spiral CT examinations were performedbefore and after the intervention as well as at the end offollow-up. The median duration of follow-up was37 months (range 1–83 months).

For assistance during fenestration of the intimal flap, a6.2-F, 12.5-MHz intravascular ultrasound (IVUS) catheterwas used (Boston Scientific Corporation, Watertown,

USA), which was positioned in the aorta at the desiredlevel of the fenestration. It was immaterial whether theIVUS catheter was in the true or in the false lumen. UsingIVUS guidance, the curved tip of a 9-F guiding catheterwith a coaxial stiffening cannula introduced via the truelumen was positioned against the center of the intimal flap.Via the cannula, a 5-F catheter carrying a protrudingflexible stylet (Rösch-Uchida trans-jugular liver access set,William Cook Europe, Bjaeverskov, Denmark) wasadvanced through the intimal flap from the true into thefalse lumen. The passage of the catheter carrying the stylet,across the intimal flap, from the true into the false lumen wasconfirmed by moving the IVUS catheter up and down theaorta. The stylet was then replaced by a stiff guide wire(Amplatz Super Stiff, Boston Scientific Corporation, Water-town, USA) over which a balloon catheter was positionedacross the intimal flap and inflated to create the fenestration.Balloon diameters ranged between 15 and 20 mm. Only onepatient with paraplegia complicating ascending aorticreplacement underwent a fenestration in the thoracic aorta.In the rest of the patients, the fenestrations were in theabdominal aorta between the levels of the 12th thoracicvertebra and the aortic bifurcation.

True lumen stenting of the aorta, renal, superiormesenteric (SMA), or iliac vessels was performed usingthe Palmaz (Johnson & Johnson, Warren, New Jersey,USA) or the Wall stents (Schneider, Europe GmbH,Bülach, Switzerland). True lumen stenting was carriedout in cases with static obstruction caused by the dissectionextending into the branch vessels. Furthermore, if theperfusion of the vessels arising from the true lumen did notimprove after fenestration, stenting of the true lumenbetween the fenestration and the ischemic vessels wasundertaken to widen this lumen and improve blood flow tothe ischemic vessels.

Angioplasty of the renal, superior mesenteric, or iliacvessels was performed using standard techniques; this wasnecessary in six patients.

If significant thrombus which compromised blood flowin the compressed true lumen was seen, 5,000 IU of heparinand 4–10 mg bolus of recombinant tissue plasminogenactivator (rTPA, Actilyse®, Boehringer Ingelheim PharmaKG, Ingelheim, Germany) were injected directly into thethrombus to effect thrombolysis.

In addition to comparing clinical symptomatologybefore and after therapy, the serum transaminase andlactate values before and after intervention were comparedin patients with mesenterohepatic ischemia; blood pressureand serum creatinine values were compared in patients withrenal ischemia and claudication distances in patients withchronic lower limb ischemia. The Student’s paired t testand the Wilcoxon signed ranks test were used to calculatethe p value for the null hypothesis (Windows SPSS, 13.0).Quantitative data are presented as mean with standarddeviation (SD). A p value less than 0.05 denotes statisticalsignificance.

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Results

Thirty seven of the 45 patients were male, eight werefemale, with a mean age of 58.9±11.3 years. Of the 13patients with type A dissections, 3 were acute, 1 was sub-acute, and 9 were chronic; 11 of these had undergone priorascending aortic replacement. Thirty-two patients had atype B dissection of which 15 were acute, 8 sub acute, and9 chronic dissections. Altogether 88 vascular territorieswere involved of which 33 were lower extremity vessels,25 renal arteries, 22 mesenterohepatic vessels, and 8 spinalvessels (Fig. 1).

Three patients were treated purely using true lumenstenting. In the remaining 42 patients balloon fenestrationwas carried out either alone or in combination with theother interventions mentioned above (Fig. 2). The distri-bution of the various interventions is shown in Fig. 3.Following intervention, blood flow could be restored to thecompromised vessels in 84 of the 88 vascular territories(95%) (Fig. 4).

Six patients required additional surgical measures afterthe interventional therapy; these are elaborated upon in thefollowing section.

Complications, accessory surgical procedures,mortality

Minor complications were noted in four patients. In twopatients a change in orientation of the dissected flapfollowing fenestration resulted in compromise of bloodflow to the iliac vessels; both could be managed by stentingof these vessels during the same procedure. In one patient,the adventitial aortic wall of the false lumen wasaccidentally perforated by the needle while attempting toperforate the intimal flap, however, without any clinicalsequelae.

Persistent ischemia of the sole functioning left kidneypost-intervention necessitated an operative embolectomy

of the crumpled intimal sleeve in this vessel; in a furtherpatient, unresolved ischemia of the left-sided iliac vesselswas treated by a femoro-femoral bypass.

Two patients underwent explorative laparotomies afterintervention; no bowel necrosis was detected in one patient,whereas a gangrenous ascending colon was resected in theother; both made an uneventful recovery.

In one patient, critical renal and mesenteric ischemiaresolved after two fenestrations and stenting of one renalartery; however, persistent lower limb ischemia necessi-tated an operative bifurcated ‘Y graft’. Surgery wascomplicated by post-operative ileus and peritonitis result-ing ultimately in death 16 days following intervention.

One patient with acute bowel ischemia older than 12 h,suffered an acute circulatory collapse immediately aftersuccessful fenestration. The possible cause was theflushing out of endotoxins from the reperfused ischemicgut. Despite resection of necrotic bowel loops followingfenestration, the patient died of multi-organ failure 30 hafter the interventions.

In one patient acute renal and bowel ischemia dis-appeared following intervention; the patient however diedof aortic rupture 12 days later.

Thus, with three deaths, the 30-day mortality in theentire patient cohort amounts to 6.7%. All deaths were inpatients with acute dissections; calculated only for this sub-group, the mortality rate was 16.7%. In the sub-acute andthe chronic sub-groups the 30-day mortality was 0%.

Mesenterohepatic ischemia

Altogether 18 patients suffered from mesenterohepaticischemia. Following intervention, signs and symptoms ofmesenteric or hepatic ischaemia disappeared completely in16 patients (Fig. 4); as mentioned above, two patients died,one of acute circulatory collapse and the other of post-operative ileus and peritonitis following a surgicalbifurcated Y graft.

The mean serum lactate values fell from 2.89(±5.10) mmol/L pre-intervention to 1.23 (±1.07) mmol/Lafter the intervention (p=0.006). The SGOT values also fellsignificantly from 165.9 (±309.2) U/L before intervention to59.7 (±145.1) U/L following therapy (p=0.034). The drop inthe SGPT values from 227.9 (±429.7) U/L to 56.8(±128.1) U/L was not statistically significant (p=0.111).

At the end of follow-up, symptoms of mesenterohepaticischemia did not recur in any of the 16 patients.

Renal ischemia

Of the 25 patients with renal ischemia, seven were ondialysis at admission on account of acute renal failure.Within 3 days following intervention, renal functionreturned and dialysis was no longer necessary in five of

Fig. 1 Distribution of the 88 ischemic vascular territories in 45patients

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these patients. The other two patients could be taken offdialysis 3 weeks and 3 months after treatment, respectively.

Between admission and discharge, the mean serumcreatinine values fell significantly from 360.1(±328.9) μmol/L to 196.3 (±160.8) μmol/L (p=0.007).These values remained stable at the end of follow-up(193.5±141.1 μmol/L).

The mean systolic and diastolic blood pressures beforetreatment were 156.2 (±16.2) and 85.2 (±10.9) mmHg,respectively. These fell significantly to 145.0 (±18.7) (p=0.016) and 74.8 (±11.2) (p=0.001) mmHg, respectively,immediately after treatment. At follow-up, the meansystolic blood pressure remained stable (136.1±13.4 mmHg), whereas the mean diastolic blood pressurerose to 80.0 (±12.1) (p=0.052) mmHg.

Lower extremity ischemia

Altogether 33 iliac vessels were involved in 25 patientswith lower extremity ischemia.

Four of them presented acutely with inability to walkand cold pulseless extremities. One of the four died despiteintervention and an operative Y graft (as mentioned inComplications). In the remaining three, the walkingdistance improved significantly to 1,046 (±918) (p=0.009) m after treatment. At the end of follow-up, themean walking distance showed further marginal improve-ment to 1,201 (±956) m (p=0.408).

In the remaining 21 patients with claudication, the meanwalking distance was 272 (±493.4) m before treatment and1,283 (±815.8) m after intervention (p=0.001). At follow-up a further improvement in the walking distance to 1,800(±528) m (p=0.095) was noted.

Spinal ischemia

Of the eight patients with acute spinal ischemia, spontaneousremission occurred in one patient, whereas symptomspersisted in seven patients who consequently underwentintervention. Immediately following intervention, tinglingparasthesia disappeared completely in one patient and fourfurther patients responded partially with grade I to grade IVimprovement of muscle power in the lower extremities. Twopatients with dense post-operative paraplegia noticed afterextubation more than 20 h following ascending aorticreplacement showed no improvement after intervention.

Fig. 2 Contrast-enhanced CT sections of a patient with a sub-acutetype B dissection presenting with a walking distance of only 20 m(a, b). The right renal artery arises from the true lumen, the left fromthe false lumen (a). The blind sac of the infrarenal aortic false lumenbelow the renal arteries is completely thrombosed causing severecompression of the opacified true lumen (b); the thrombus in thefalse lumen extends proximally to the level of the renal arteries (a).

True lumen angiogram of the abdominal aorta confirms the CTfindings with severe narrowing of the infra-renal aortic true lumen(c). Fenestration of the intimal flap just above the level of the renalarteries to preserve blood flow to the left renal artery and to provideaccess to the vessel in case of embolic complications; stenting of theinfra-renal true lumen to treat the claudication (d)

Fig. 3 Different combinations of interventional techniques used inthe 45 patients

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Discussion

Over the past 15 years, interventional treatment hasemerged as a viable alternative to surgery for the manage-ment of ischemic complications of aortic dissection [8–28].In our present study, percutaneous therapy alone provedadequate in more than 85% (39 of 45 patients) of thepatients, with ischemia resolving in 95% (84 of 88) of thevascular territories. The corresponding figures from aseries containing 24 patients reported by Williams et al.[12] are 87.5% and 92%, respectively. Slonim et al.reported a 93% success rate in a series of 40 patients [20].Beregi and colleagues reporting a multi-center experience,could restore patency to 96% of the malperfused vessels in46 patients [24]. Vedantam et al. report restoration of bloodflow in 91% of 23 vascular territories in 11 patients [27].Despite the limitation of our study as a retrospectiveanalysis of an uncontrolled patient cohort, interventionaltreatment appears to be effective in treating ischemiccomplications, especially when viewed in the light of theexperience reported by other authors.

The less invasive nature of percutaneous therapy(compared with open surgical treatment) makes it particu-larly attractive in patients with aortic dissection. Surgicalmortality rates range between 25 and 51%, with mortalitybeing higher (up to 87%) in dissections complicated bymesenteric or renal ischemia [1–3, 6, 7]. A direct comparisonwith these figures could be misleading, given the higherproportion of type A lesions in the surgical series [1, 29, 30].Nonetheless it was encouraging to note that 42 of our 45patients (93%) survived; mortality was 0% in the sub-acuteand chronic dissections and 16.7% in the patients with acutedissections. A 25% mortality rate was reported by bothWilliams et al. [12] and Slonim’s group [20]. It is importantto emphasize that all 40 patients reported by Slonim andcolleagues [20] had acute dissections and the proportion ofacute dissections in Williams’ study [12] was higher than inour set of patients. In all three series, death occurred only in

the sub-group with acute dissection, the prognosis beingdirectly related to the severity of the ischemic injurysustained prior to intervention and to the occurrence ofrupture despite relief of ischemia. In 11 patients with acutetype B dissections treated similarly by Vedantam andcolleagues, there was no in-hospital mortality [27].

To enhance the results of percutaneous treatment,adjunctive surgery is necessary in some patients [12, 20,24, 27, 28], the primary indications being bowel necrosisand persistent branch vessel ischemia. In the reports byWilliams et al. [12] and Slonim et al. [20], 8.3% and 12.5%of patients, respectively, required subsequent surgicalintervention. Three of our patients underwent exploratorylaparotomies after intervention, of whom necrotic bowelsegments were resected in two. Three further patientsunderwent surgical revascularization procedures for un-relieved branch vessel ischemia; one of them with renalischemia and two with persistent lower extremity ischemia.In retrospect, the necessity of surgery in the latter twopatients may have been avoided, had we been more liberalwith stenting of the iliac vessels after fenestration.

Proximal entry site closure with endovascular stentgrafting of the true lumen has been reported in recentstudies [31–35]; potentially, it can relieve distal ischemia,especially if it results from thoraco-abdominal true lumencollapse [36]. However, of the 11 patients with symptom-atic branch vessel obstruction in one series [32], ischemiaresolved in only six patients (55%) following stent graftingalone. In the remaining patients, further interventionsdownstream were necessary to achieve satisfactory bloodflow in the affected vessels. Similarly, of the ten acute typeB patients reported by Duebner et al. [34], four had branchvessel obstruction. Two died of persistent branch vesselischemia despite stent grafting. Obviously, stent graftingalone may not relieve branch vessel ischemia in allpatients; additional true lumen stenting or fenestrationfurther distally for restoring blood flow to compromisedvessels may prove to be valuable adjuncts which may help

Fig. 4 True (a) and false (b) lumen angiograms of a patient withcritical bowel ischemia, caused by the dissection extending into thesuperior mesenteric artery (SMA). Occlusion of the true lumen a fewcentimeters distal to the origin of the vessel (a), caused by the blind

sac of the dilated false lumen (b). Angiogram after implanting a self-expanding stent in the true lumen shows a significantly improvedperfusion of the peripheral vessels (c)

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optimize the results of stent grafting in the acute type Bdissections. The same holds true for persistent thoraco-abdominal ischemia following proximal aortic replacementin patients with type A dissections.

Acute paraplegia resulting from abruption of the spinalvessels from the true lumen which are subsequentlyperfused via the false lumen, may respond better tofenestration of the intimal flap than to stent grafting. Staticobstruction caused by a thrombosed blind sac of the falselumen compressing the true lumen would respond best totrue lumen stenting (Figs. 2 and 4). Furthermore, given thenegligible complication and mortality rates associated withballoon fenestration and true lumen stenting in patientswith chronic dissections, these interventions may well bethe treatment of choice in such patients.

In summary, percutaneous interventions are effective inrelieving branch vessel ischemia complicating aorticdissections. They are most suited for chronic dissectionsand for post-operative type A dissections with persistentdistal ischemia. Balloon fenestration may possibly be thebest option in acute paraplegia resulting from abruption ofspinal vessels from the true lumen which are subsequentlyperfused via the false lumen. Furthermore they may bevaluable adjuncts to stent grafting for optimizing the finaloutcome. A differential approach with judicious use of thevarious options consisting of open surgery, stent grafting,balloon fenestration, and true lumen stenting may be thebest way of optimally treating this select cohort of complexpatients.

References

1. Cambria RP, Brewster DC, Gertler J etal (1988) Vascular complications asso-ciated with spontaneous aortic dissec-tion. J Vasc Surg 7:199–209

2. Fann JI, Sarris GE, Mitchell RS et al(1990) Treatment of patients with aorticdissection presenting with peripheralvascular complications. Ann Surg212:705–713

3. Borst HG, Heinemann MK, Stone CD(eds) (1996) Surgical treatment of aor-tic dissection. Churchill Livingstone,New York, pp 249–271

4. Miller DC (1988) Vascular complica-tions associated with spontaneous aor-tic dissection (discussion). J Vasc Surg7:208–209

5. Elefteriades JA, Hammond GL,Gusberg RJ et al (1990) Fenestrationrevisited. A safe and effectiveprocedure for descending aorticdissection. Arch Surg 125:786–790

6. Laas J, Heinemann M, Schaefers HJ etal (1991) Management of thoracoab-dominal malperfusion in aortic dissec-tion. Circulation 84(suppl III):III-20–III-24

7. Miller DC, Mitchell RS, Oyer PE et al(1984) Independent determinants ofoperative mortality for patients withaortic dissections. Circulation 70(supplI):I–153

8. Williams DM, Brothers TE, MessinaLM (1990) Relief of mesenteric isch-emia in type III aortic dissection withpercutaneous fenestration of the aorticseptum. Radiology 174:450–452

9. Slonim SM, Nyman U, Semba CP et al(1996) Aortic dissection: percutaneousmanagement of ischaemic complica-tions with endovascular stents andballoon fenestration. J Vasc Surg23:241–253

10. Slonim SM, Nyman U, Semba CP et al(1996) True lumen obliteration incomplicated aortic dissection: endo-vascular treatment. Radiology201:161–166

11. Chavan A, Hausmann D, Dresler C etal (1997) Intravascular ultrasound-guided percutaneous fenestration of theintimal flap in the dissected aorta.Circulation 96:2124–2127

12. Williams DM, Lee DY, Hamilton BH etal (1997) The dissected aorta: percuta-neous treatment of ischemic complica-tions - principles and results. JVIR8:605–625

13. Lacombe P, Mulot R, Labedan F et al(1992) Percutaneous recanalization of arenal artery in aortic dissection. Radi-ology 185:829–831

14. Williams DM, Andrews JC, Marx V etal (1993) Creation of reentry tears inaortic dissection by means of percuta-neous balloon fenestration: gross ana-tomic and histologic considerations.JVIR 4:75–83

15. Walker PJ, Dake MD, Mitchell RS et al(1993) The use of endovascular tech-niques for the treatment of complica-tions of aortic dissection. J Vasc Surg18:1042–1051

16. Schild HH, Düber C, Grebe P et al(1994) Transvaskuläre Fensterung einesdisseziierenden Aortenaneurysmas.Fortschr Röntgenstr 161,2:164–167

17. Trerotola SO (1996) Use of a stonebasket as a target during fenestration ofaortic dissection. JVIR 7:687–690

18. Park JH, Chung JW, Cho YK et al(1997) Percutaneous fenestration ofaortic dissection: salvage of an isch-aemic solitary left kidney. CardiovascIntervent Radiol 20:146–148

19. Yamakado K, Takeda K, Nomura Y etal (1998) Relief of mesenteric ischemiaby Z-stent placement into the superiormesenteric artery compressed by thefalse lumen of an aortic dissection.Cardiovasc Intervent Radiol 21:66–68

20. Slonim SM, Miller DC, Mitchell RS etal (1999) Percutaneous balloon fenes-tration and stenting for life-threateningischaemic complications in patientswith acute aortic dissection. J ThoracCardiovasc Surg 117:1118–1127

21. Manke C, Strotzer M, Seitz J et al(1999) Ischämische Komplikationenbei Aortendissektion - Perkutane Be-handlung mit Ballonfensterung undStentimplantation. Fortschr Röntgenstr198–204

22. Nyman U, Ivancev K, Gottsäter Anderset al (1999) Chronic aortic dissection:stenting of aortic true lumen oblitera-tion with late dynamic variations ofboth lumens. Cardiovasc Intervent Ra-diol 22:135–149

23. Beregi JP, Prat A, Gaxotte V et al(2000) Endovascular treatment for dis-section of the descending aorta. Lancet356:482–483

24. Beregi J-P, Haulon S, Otal P et al(2003) Endovascular treatment of acutecomplications associated with aorticdissection: midterm results from amulticenter study. J Endovasc Ther10:486–493

25. Hartnell GG, Gates J (2005) Aorticfenestration: a why, when and how-toguide. RadioGraphics 25:175–189

493

26. Husmann MJ, Kickuth R, Ludwig K etal (2006) Intravascular ultrasound-guided creation of re-entry sites toimprove intermittent claudication inpatients with aortic dissection. JEndovasc Ther 13:424–428

27. Vedantham S, Picus D, Sanchez LA etal (2003) Percutaneous management ofischemic complications in patients withtype-B aortic dissection. J Vasc IntervRadiol 14:181–193

28. Chavan A, Kutschka I, Rosenthal H etal (1999) Percutaneous management ofischemic complications of aortic dis-section. Radiology 213(Suppl.):S 477

29. Fann JI, Smith JA, Miller CD et al(1995) Surgical management of aorticdissection during a 30-year period.Circulation 92(suppl II):II–13–II-121

30. Panneton JM, Teh SH, Cherry KJ et al(2000) Aortic fenestration for acute orchronic aortic dissection: an uncommonbut effective procedure. J Vasc Surg32:711–721

31. Kato M, Matsuda T, Kaneko M et al(1998) Outcomes of stent-graft treat-ment of false lumen in aortic dissection.Circulation 98:II–305–II-312

32. Dake MD, Kato N, Mitchell RS et al(1999) Endovascular stent-graft place-ment for the treatment of acute aorticdissection. N Engl J Med 340:1546–1552

33. Nienaber CA, Fattori R, Lund G et al(1999) Nonsurgical reconstruction ofthoracic aortic dissection by stent-graftplacement. N Engl J Med 340:1539–1545

34. Duebener LF, Lorenzen P, Richardt Get al (2004) Emergency endovascularstent-grafting for life-threatening acutetype B aortic dissections. Ann ThoracSurg 78:1261–1267

35. Fattori R, Lovato L, Buttazzi K et al(2005) Extension of dissection in stent-graft treatment of type B aortic dissec-tion: lessons learned from endovascularexperience. J Endovasc Ther 12:306–311

36. Chung JW, Elkins C, Sakai T et al(2000) True-lumen collapse in aorticdissection. Part II. Evaluation of treat-ment methods in phantoms with pulsa-tile flow. Radiology 214:99–106

494