It is not too surprising, given the lower prevalence of thoracic aortic aneurysms (TAA) as compared with abdominal aortic aneurysms (AAA), that development of endovascular devices for thoracic disease has lagged behind progress in the infrarenal area. Recently, published reports of decreased mortality associated with endovascular device implantation for ruptured AAAs have highlighted its potential advantage in emergent situations. The first reported use of an endovascular stent graft to treat a ruptured TAA was reported by Semba et al in 1997. Although the use of endovascular therapy to treat ruptured AAAs is gaining wider acceptance, its use in thoracic pathologies has been slow to develop in the United States, even though 20% of TAAs and nearly 50% of thoracic dissections present with rupture in the EUROSTAR registry. This may be a factor of relatively limited dissemination of technology. Examination of clinical trial enrollment shows that 10 sites in the United States account for approximately 50% of the cumulative implantations

Farber, Mark A.

Elsevier - Publisher Connector 

Chapter 7
Emergent stent-graft treatment
for rupture
Mark A. Farber, MD, Chapel Hill, NCIt is not too surprising, given the lower prevalence of
thoracic aortic aneurysms (TAA) as compared with ab-
dominal aortic aneurysms (AAA), that development of
endovascular devices for thoracic disease has lagged behind
progress in the infrarenal area. Recently, published reports
of decreased mortality associated with endovascular device
implantation for ruptured AAAs have highlighted its poten-
tial advantage in emergent situations.1-3 The first reported
use of an endovascular stent graft to treat a ruptured TAA
was reported by Semba et al4 in 1997. Although the use of
endovascular therapy to treat ruptured AAAs is gaining
wider acceptance, its use in thoracic pathologies has been
slow to develop in the United States, even though 20% of
TAAs and nearly 50% of thoracic dissections present with
rupture in the EUROSTAR registry.5 This may be a factor
of relatively limited dissemination of technology. Examina-
tion of clinical trial enrollment shows that 10 sites in the
United States account for approximately 50% of the cumu-
lative implantations.
Endoluminal repair provides several advantages over
traditional surgical repair, including the avoidance of aortic
cross-clamping and thoracotomy, limited blood loss, short
procedural time, and single-lung ventilation. Published
reports indicate that less than 50% of patients with ruptured
thoracic aortas reach a medical facility and only 24% are
alive more than 24 hours after the onset of symptoms
without intervention.6 Mortality rates for open repair for
ruptured TAAs have been as high as 67%, and associated
paraplegia is present in 20% of individuals.7,8 Surgical mor-
tality for perforated type B dissections may be as high as
60%, and paraplegia is present in one fifth of patients.9
Ruptured thoracic aortic pathologies can be catego-
rized into two types: traumatic and nontraumatic. Each is
associated with significant morbidity and mortality. In gen-
eral, trauma patients are younger and succumb to the
injuries sustained from the trauma, whereas nontrauma
patients are older and usually die from complications asso-
From the University of North Carolina.
Competition of interest: Dr Farber has been paid a consulting fee or was on
the speaker’s bureau for Medtronic, Cook, and W.L. Gore.
Reprint requests: Mark A. Farber, MD, University of North Carolina,
210 Burnett-Womack, Campus Box 72, Chapel Hill, NC 27599-7212
(e-mail: farberm@med.unc.edu).
0741-5214/$32.00
Copyright © 2006 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2005.11.001
44Aciated with pre-existing medical conditions. This chapter
focuses on themanagement of nontraumatic thoracic aortic
ruptures, whereas the endovascular management of tho-
racic transection is discussed in Chapter 5.
DIAGNOSIS AND TREATMENT PLANNING
Ruptured TAAs and dissections are generally diagnosed
when a chest computed tomography (CT) scan is obtained
to evaluate chest pain in a patient without evidence of
myocardial pathology. It is of critical importance that both
noncontrasted and contrasted scans be scrutinized. In some
circumstances, intramural hematomas can be indistinguish-
able from a dissection unless the noncontrasted scan is
evaluated for aortic wall attenuation (Fig 1).10 This identi-
fying feature can help tremendously in the treatment plan
and management of the patient who presents acutely. Even
though a CT scan shows blood outside the adventitia, many
times it is difficult to determine the exact location of the
original injury (Fig 2), and this must be factored into the
overall evaluation of the patient. Adjuvant techniques such
as transesophageal echocardiography or intravascular ultra-
sonography may also be used to aid in more precise local-
ization of the rupture.
The CT scan is crucial for preprocedural planning and
device sizing. In situations of renal insufficiency, magnetic
resonance angiographymay be substituted. During prepro-
cedural assessment, appropriate landing zones should be
chosen to ensure re-establishment of aortic integrity. Oc-
casionally in emergent situations the radiographic evalua-
tion may not include the aortoiliac segment. In these cases,
angiographic evaluation should be performed before device
insertion to determine whether femoral access is adequate.
When the access vessels are smaller than 8 mm or contain
significant calcification or tortuosity, one should anticipate
placement of an aortic or iliac conduit. According to pub-
lished reports, elective procedures require conduit place-
ment in approximately 15% to 20% of cases, generally more
often in women.11,12
As popularized by Veith and Ohki, hypotensive hemo-
stasis is preferable in all patients.13,14 This is more easily
accomplished with thoracic ruptures than with infrarenal
ruptured aneurysms because the left thorax is a defined
space that, once filled with blood, should tamponade.Most
patients will require intubation for respiratory decompen-
sation. Decompression of the left chest should not be
JOURNAL OF VASCULAR SURGERY
Volume 43, Number A Farber 45Aperformed until after exclusion of the rupture is completed.
Only at that time should chest tube drainage be instituted.
Decompensation may require several interventions if a
complicated hemothorax or loculation develops.
As with infrarenal ruptures, treatment of ruptured tho-
racic pathology requires dedicated hospital resources and a
skilled management team. Most infrarenal aneurysms can
be treated with a small rupture kit consisting of a subset of
devices and limb configurations to obtain complete exclu-
sion. Thoracic aortic diameters are more variable than
infrarenal aortic measurements and therefore may require
more device sizes to treat. Additionally, intravascular ultra-
sonography (IVUS) and experience with ultrasonography-
guided access of the brachial artery are needed to provide
appropriate care.
PROCEDURE
The implantation of a thoracic stent graft for emergent
conditions is not that different from the elective scenario.
For ruptured aneurysms, adequate proximal and distal
landing zones should be chosen, and the device oversizing
should be based on its instructions for use. Often ruptured
plaques or penetrating ulcers are associated with an intra-
mural hematoma (Fig 3), and the “original” diameter is
Fig 1. Attenuation of aortic wall visualized with a noncontrasted
computed tomographic scan suggesting acute intramural hema-
toma.
Fig 2. Computed tomographic scan showing blood outside of
the aortic wall without an identifiable source.hard to determine. In these cases, one should be extremelycareful about seal zones and device oversizing. If possible,
the seal site should be in normal, nontortuous regions of
the aorta. Often such regions do not exist, thus necessitat-
ing placement of the sealing zones in suboptimal locations.
Additionally, one must be careful not to oversize aggres-
sively. The aortic wall is more friable in these acute situa-
tions, and retrograde dissections and additional perfora-
tions have been reported.15-18 One should err on the side
of additional seal length rather than increased oversizing if
in doubt.
Endograft sizing for dissections is most problematic,
because ruptured dissections are often associated with acute
dilatation of the aorta. The proximal attachment site is
typically targeted in the distal transverse arch just distal to
the left common carotid artery. This helps reduce the effect
of aortic arch angulation and places the device in the least
angulated area. Estimates of the original diameter at the left
subclavian artery and celiac should also be made. Because
the “true” lumen is typically smaller, there is increased
surface-area contact between the device and the aortic wall,
which decreases the potential for migration.Most commer-
cial devices should be oversized no more than 10% for the
treatment of dissections. Additionally, the length of tho-
racic aortic coverage should be altered to exclude the signifi-
cant communications between the true and false lumens.
The goal of the procedure is threefold: to obliterate the
perforation site and the major communications between
the false and true lumens, to completely thrombose the
false lumen, and to re-expand the true lumen. This gener-
ally requires devices to be 15 to 20 cm long and leaves the
distal thoracic aorta untreated, so that persistent flow is
maintained in both lumens throughout the visceral section
to avoid branched vessel compromise. Some experts advo-
cate near-complete coverage of the thoracic aorta to in-
crease the chances of false lumen thrombosis.16 However,
this is generally applied to treating dissections for malper-
fusion complications, not aortic rupture.
Three additional technical aspects should also be re-
membered. First, IVUS should always be used to document
that the primary deployment wire has not traversed into the
false lumen before device insertion. Second, reverse deploy-
ment should be avoided in acute dissection treatment.
Fig 3. Intramural hematoma from a penetrating ulcer.When the distal fenestrations are covered before the pri-
JOURNAL OF VASCULAR SURGERY
February Supplement 200646A Farbermary entry site, the false lumen pressure may become
increased, thereby increasing the risk for the development
of a type A dissection. Finally, completion aortography for
dissection patients should also include critical evaluation of
the visceral section for branched occlusions and type A
dissection.
RESULTS
Published reports concerning outcomes for ruptured
dissections and aneurysms are extremely varied, because
many reports include aortic transactions, which generally
have an excellent outcome, in their analysis.5,19-22 Further-
more, urgent and emergent procedures are grouped to-
gether, thus complicating the analysis. Most reports are
from single-institution series and comprise detailed initial
outcomes accompanied by short-term follow-up data.
Technical success, defined as the ability to implant the
device and re-establish aortic integrity, approaches 100% in
most reported series. In 21 patients treated by Scheinert
et al,23 the operative mortality was 14.3%, and 28.6% experi-
enced major complications (renal failure, n  4; stroke,
n  2), but none developed paraplegia. These are promising
results when compared with traditional surgical outcomes.
Morishita et al24 examined a cohort of 29 patients treated
with either handmade stent grafts or surgical means for rup-
ture (endovascular, n 18; surgery, n 11). The mortality
rate for the two groups was 9% and 17%, respectively, with
63% of the patients in the entire combined cohort surviving
2 years. There were 2 late conversions to open repair, and
there was 1 patient who required a secondary endovascular
procedure. Analysis of the EUROSTAR registry showed
that the mortality rate increased from 5.3% to 28% when
treatment of aneurysms was elective rather than emergent.5
However, no additional information is available concerning
differences in morbidity or long-term follow-up.
These reports are tempered by other published series.
Doss et al25 reported their experience of 60 patients treated
by either surgical or endovascular means. Approximately
30% of their patients had traumatic injuries. The mean
follow-up was 36.4 months, and there was a higher second-
ary intervention and late complication rate in the endovas-
cular group, even though they demonstrated superior
short-term results with reduced 30-day mortality rates of
3.1% vs 17.8%. We have reported our results with 22
patients treated with endovascular techniques for ruptured
thoracic aneurysms or ruptured dissections.26 Although
results were promising compared with open surgery, the
in-hospital mortality was higher than reported by others, at
45.5% (aneurysms, 27.3%; dissections, 63.6%), mainly be-
cause of the large percentage of patient presenting with
hemorrhagic shock and multisystem organ failure (35%).
Additionally our analysis excluded those patients undergo-
ing treatment for aortic transactions, which are associated
with a better outcome. Not unexpectedly, the left subcla-
vian artery required coverage in a higher proportion of the
ruptured thoracic dissections, but this did not result in a
notable incidence of arm ischemia or paraplegia. The meanfollow-up in this cohort was 11.1 months, and life-table
survival was 46.5% at 6 months.
CONCLUSION
Emergent stent-graft repair of nontraumatic rup-
tured thoracic aortic pathologies is technically feasible in
a large percentage of cases and imparts an early advan-
tage with respect to morbidity and mortality. Hospital
resources and available expertise should encompass all
aspects of interventional therapy, including guidewire
skills, ultrasonography, and IVUS proficiency. These
encouraging results should be tempered, however, until
longer follow-up is obtained.
REFERENCES
1. Veith FJ, Ohki T, Lipsitz EC, Suggs WD, Cynamon J. Endovascular
grafts and other catheter-directed techniques in the management
of ruptured abdominal aortic aneurysms. Semin Vasc Surg 2003;16:
326-31.
2. Scharrer-Pamler R, Kotsis T, Kapfer X, Gorich J, Sunder-Plassmann L.
Endovascular stent-graft repair of ruptured aortic aneurysms. J Endo-
vasc Ther 2003;10:447-52.
3. Reichart M, Geelkerken RH, Huisman AB, van Det RJ, de Smit P,
Volker EP. Ruptured abdominal aortic aneurysm: endovascular re-
pair is feasible in 40% of patients. Eur J Vasc Endovasc Surg 2003;
26:479-86.
4. Semba CP, Kato N, Kee ST, Lee GK, Mitchell RS, Miller DC, et al.
Acute rupture of the descending thoracic aorta: repair with use of
endovascular stent-grafts. J Vasc Interv Radiol 1997;8:337-42.
5. Leurs LJ, Bell R, Degrieck Y, Thomas S, Hobo R, Lundbom J. Endo-
vascular treatment of thoracic aortic diseases: combined experience
from the EUROSTAR and United Kingdom Thoracic Endograft reg-
istries. J Vasc Surg 2004;40:670-79; discussion 79-80.
6. Johansson G, Markstrom U, Swedenborg J. Ruptured thoracic aortic
aneurysms: a study of incidence and mortality rates. J Vasc Surg 1995;
21:985-88.
7. Mastroroberto P, Chello M. Emergency thoracoabdominal aortic an-
eurysm repair: clinical outcome. J Thorac Cardiovasc Surg 1999;118:
477-81; discussion 81-2.
8. DossM, Balzer J, Martens S,Wood JP,Wimmer-Greinecker G, Fieguth
HG, et al. Surgical versus endovascular treatment of acute thoracic
aortic rupture: a single-center experience. Ann Thorac Surg 2003;76:
1465-69; discussion 9-70.
9. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodo-
litsch Y, et al. Nonsurgical reconstruction of thoracic aortic dissection by
stent-graft placement. N Engl J Med 1999;340:1539-45.
10. Castaner E, Andreu M, Gallardo X, Mata JM, Cabezuelo MA, Pallardo
Y. CT in nontraumatic acute thoracic aortic disease: typical and atypical
features and complications. Radiographics 2003;23(Spec No.):S93-
110.
11. Makaroun MS, Dillavou ED, Kee ST, Sicard G, Chaikof E, Bavaria J, et
al. Endovascular treatment of thoracic aortic aneurysms: results of the
phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J
Vasc Surg 2005;41:1-9.
12. Riesenman PJ, FarberMA,Mendes RR,MarstonWA, Fulton JJ,Mauro
M, et al. Endovascular repair of lesions involving the descending tho-
racic aorta. J Vasc Surg. In press.
13. Veith FJ, Ohki T. Endovascular approaches to ruptured infrarenal
aorto-iliac aneurysms. J Cardiovasc Surg (Torino) 2002;43:369-78.
14. Ohki T, Veith FJ. Endovascular grafts and other image-guided catheter-
based adjuncts to improve the treatment of ruptured aortoiliac aneu-
rysms. Ann Surg 2000;232:466-79.
15. Kato N, Hirano T, Kawaguchi T, Ishida M, Shimono T, Yada I, et al.
Aneurysmal degeneration of the aorta after stent-graft repair of acute
aortic dissection. J Vasc Surg 2001;34:513-8.
JOURNAL OF VASCULAR SURGERY
Volume 43, Number A Farber 47A16. Criado FJ, Abul-Khoudoud O. Endograft repair of acute aortic dissec-
tion. Promises and challenges. J Cardiovasc Surg (Torino) 2005;46:
107-12.
17. Malina M, Brunkwall J, Ivancev K, Lindblad B, Malina J, Nyman U, et
al. Late aortic arch perforation by graft-anchoring stent: complication of
endovascular thoracic aneurysm exclusion. J Endovasc Surg 1998;5:
274-7.
18. Toyama M, Usui A, Yoshikawa M, Ueda Y. Thoracic aneurysm rupture
due to graft perforation after endovascular stent-grafting via median
sternotomy. Eur J Cardiothorac Surg 2005;27:162-4.
19. Doss M, Balzer J, Martens S, Fieguth HG, Vogl T, Moritz A, et al.
Emergent endovascular interventions for contained rupture of thoracic
aortic aneurysms. Heart Surg Forum 2003;6:E133-7.
20. Orford VP, Atkinson NR, Thomson K, Milne PY, Campbell WA,
Roberts A, et al. Blunt traumatic aortic transection: the endovascular
experience. Ann Thorac Surg 2003;75:106-11; discussion 11-2.
21. Orend KH, Pamler R, Kapfer X, Liewald F, Gorich J, Sunder-Plassmann
L. Endovascular repair of traumatic descending aortic transection. J
Endovasc Ther 2002;9:573-8.22. Bell RE, Taylor PR, AukettM, Sabharwal T, Reidy JF. Results of urgent
and emergency thoracic procedures treated by endoluminal repair. Eur
J Vasc Endovasc Surg 2003;25:527-31.
23. Scheinert D, Krankenberg H, Schmidt A, Gummert JF, Nitzsche S,
Scheinert S, et al. Endoluminal stent-graft placement for acute rupture
of the descending thoracic aorta. Eur Heart J 2004;25:694-700.
24. Morishita K, Kurimoto Y, Kawaharada N, Fukada J, Hachiro Y, Fuji-
sawa Y, et al. Descending thoracic aortic rupture: role of endovascular
stent-grafting. Ann Thorac Surg 2004;78:1630-4.
25. Doss M, Wood JP, Balzer J, Martens S, Deschka H, Moritz A. Emer-
gency endovascular interventions for acute thoracic aortic rupture:
four-year follow-up. J Thorac Cardiovasc Surg 2005;129:645-51.
26. Farber MA, Criado FJ. Endovascular repair of nontraumatic ruptured
thoracic aortic pathologies. Ann Vasc Surg 2005;19:167-71.Submitted Oct 23, 2005; accepted Nov 2, 2005.


Emergent stent-graft treatment for rupture 

Carolina Digital Repository

Chapter 7Emergent stent-graft treatmentfor ruptureMark A. Farber, MD, Chapel Hill, NCIt is not too surprising, given the lower prevalence ofthoracic aortic aneurysms (TAA) as compared with ab-dominal aortic aneurysms (AAA), that development ofendovascular devices for thoracic disease has lagged behindprogress in the infrarenal area. Recently, published reportsof decreased mortality associated with endovascular deviceimplantation for ruptured AAAs have highlighted its poten-tial advantage in emergent situations.1-3 The first reporteduse of an endovascular stent graft to treat a ruptured TAAwas reported by Semba et al4 in 1997. Although the use ofendovascular therapy to treat ruptured AAAs is gainingwider acceptance, its use in thoracic pathologies has beenslow to develop in the United States, even though 20% ofTAAs and nearly 50% of thoracic dissections present withrupture in the EUROSTAR registry.5 This may be a factorof relatively limited dissemination of technology. Examina-tion of clinical trial enrollment shows that 10 sites in theUnited States account for approximately 50% of the cumu-lative implantations.Endoluminal repair provides several advantages overtraditional surgical repair, including the avoidance of aorticcross-clamping and thoracotomy, limited blood loss, shortprocedural time, and single-lung ventilation. Publishedreports indicate that less than 50% of patients with rupturedthoracic aortas reach a medical facility and only 24% arealive more than 24 hours after the onset of symptomswithout intervention.6 Mortality rates for open repair forruptured TAAs have been as high as 67%, and associatedparaplegia is present in 20% of individuals.7,8 Surgical mor-tality for perforated type B dissections may be as high as60%, and paraplegia is present in one fifth of patients.9Ruptured thoracic aortic pathologies can be catego-rized into two types: traumatic and nontraumatic. Each isassociated with significant morbidity and mortality. In gen-eral, trauma patients are younger and succumb to theinjuries sustained from the trauma, whereas nontraumapatients are older and usually die from complications asso-From the University of North Carolina.Competition of interest: Dr Farber has been paid a consulting fee or was onthe speaker’s bureau for Medtronic, Cook, and W.L. Gore.Reprint requests: Mark A. Farber, MD, University of North Carolina,210 Burnett-Womack, Campus Box 72, Chapel Hill, NC 27599-7212(e-mail: farberm@med.unc.edu).0741-5214/$32.00Copyright © 2006 by The Society for Vascular Surgery.doi:10.1016/j.jvs.2005.11.00144Aciated with pre-existing medical conditions. This chapterfocuses on the management of nontraumatic thoracic aorticruptures, whereas the endovascular management of tho-racic transection is discussed in Chapter 5.DIAGNOSIS AND TREATMENT PLANNINGRuptured TAAs and dissections are generally diagnosedwhen a chest computed tomography (CT) scan is obtainedto evaluate chest pain in a patient without evidence ofmyocardial pathology. It is of critical importance that bothnoncontrasted and contrasted scans be scrutinized. In somecircumstances, intramural hematomas can be indistinguish-able from a dissection unless the noncontrasted scan isevaluated for aortic wall attenuation (Fig 1).10 This identi-fying feature can help tremendously in the treatment planand management of the patient who presents acutely. Eventhough a CT scan shows blood outside the adventitia, manytimes it is difficult to determine the exact location of theoriginal injury (Fig 2), and this must be factored into theoverall evaluation of the patient. Adjuvant techniques suchas transesophageal echocardiography or intravascular ultra-sonography may also be used to aid in more precise local-ization of the rupture.The CT scan is crucial for preprocedural planning anddevice sizing. In situations of renal insufficiency, magneticresonance angiography may be substituted. During prepro-cedural assessment, appropriate landing zones should bechosen to ensure re-establishment of aortic integrity. Oc-casionally in emergent situations the radiographic evalua-tion may not include the aortoiliac segment. In these cases,angiographic evaluation should be performed before deviceinsertion to determine whether femoral access is adequate.When the access vessels are smaller than 8 mm or containsignificant calcification or tortuosity, one should anticipateplacement of an aortic or iliac conduit. According to pub-lished reports, elective procedures require conduit place-ment in approximately 15% to 20% of cases, generally moreoften in women.11,12As popularized by Veith and Ohki, hypotensive hemo-stasis is preferable in all patients.13,14 This is more easilyaccomplished with thoracic ruptures than with infrarenalruptured aneurysms because the left thorax is a definedspace that, once filled with blood, should tamponade. Mostpatients will require intubation for respiratory decompen-sation. Decompression of the left chest should not beJOURNAL OF VASCULAR SURGERYVolume 43, Number A Farber 45Aperformed until after exclusion of the rupture is completed.Only at that time should chest tube drainage be instituted.Decompensation may require several interventions if acomplicated hemothorax or loculation develops.As with infrarenal ruptures, treatment of ruptured tho-racic pathology requires dedicated hospital resources and askilled management team. Most infrarenal aneurysms canbe treated with a small rupture kit consisting of a subset ofdevices and limb configurations to obtain complete exclu-sion. Thoracic aortic diameters are more variable thaninfrarenal aortic measurements and therefore may requiremore device sizes to treat. Additionally, intravascular ultra-sonography (IVUS) and experience with ultrasonography-guided access of the brachial artery are needed to provideappropriate care.PROCEDUREThe implantation of a thoracic stent graft for emergentconditions is not that different from the elective scenario.For ruptured aneurysms, adequate proximal and distallanding zones should be chosen, and the device oversizingshould be based on its instructions for use. Often rupturedplaques or penetrating ulcers are associated with an intra-mural hematoma (Fig 3), and the “original” diameter isFig 1. Attenuation of aortic wall visualized with a noncontrastedcomputed tomographic scan suggesting acute intramural hema-toma.Fig 2. Computed tomographic scan showing blood outside ofthe aortic wall without an identifiable source.hard to determine. In these cases, one should be extremelycareful about seal zones and device oversizing. If possible,the seal site should be in normal, nontortuous regions ofthe aorta. Often such regions do not exist, thus necessitat-ing placement of the sealing zones in suboptimal locations.Additionally, one must be careful not to oversize aggres-sively. The aortic wall is more friable in these acute situa-tions, and retrograde dissections and additional perfora-tions have been reported.15-18 One should err on the sideof additional seal length rather than increased oversizing ifin doubt.Endograft sizing for dissections is most problematic,because ruptured dissections are often associated with acutedilatation of the aorta. The proximal attachment site istypically targeted in the distal transverse arch just distal tothe left common carotid artery. This helps reduce the effectof aortic arch angulation and places the device in the leastangulated area. Estimates of the original diameter at the leftsubclavian artery and celiac should also be made. Becausethe “true” lumen is typically smaller, there is increasedsurface-area contact between the device and the aortic wall,which decreases the potential for migration. Most commer-cial devices should be oversized no more than 10% for thetreatment of dissections. Additionally, the length of tho-racic aortic coverage should be altered to exclude the signifi-cant communications between the true and false lumens.The goal of the procedure is threefold: to obliterate theperforation site and the major communications betweenthe false and true lumens, to completely thrombose thefalse lumen, and to re-expand the true lumen. This gener-ally requires devices to be 15 to 20 cm long and leaves thedistal thoracic aorta untreated, so that persistent flow ismaintained in both lumens throughout the visceral sectionto avoid branched vessel compromise. Some experts advo-cate near-complete coverage of the thoracic aorta to in-crease the chances of false lumen thrombosis.16 However,this is generally applied to treating dissections for malper-fusion complications, not aortic rupture.Three additional technical aspects should also be re-membered. First, IVUS should always be used to documentthat the primary deployment wire has not traversed into thefalse lumen before device insertion. Second, reverse deploy-ment should be avoided in acute dissection treatment.Fig 3. Intramural hematoma from a penetrating ulcer.When the distal fenestrations are covered before the pri-JOURNAL OF VASCULAR SURGERYFebruary Supplement 200646A Farbermary entry site, the false lumen pressure may becomeincreased, thereby increasing the risk for the developmentof a type A dissection. Finally, completion aortography fordissection patients should also include critical evaluation ofthe visceral section for branched occlusions and type Adissection.RESULTSPublished reports concerning outcomes for ruptureddissections and aneurysms are extremely varied, becausemany reports include aortic transactions, which generallyhave an excellent outcome, in their analysis.5,19-22 Further-more, urgent and emergent procedures are grouped to-gether, thus complicating the analysis. Most reports arefrom single-institution series and comprise detailed initialoutcomes accompanied by short-term follow-up data.Technical success, defined as the ability to implant thedevice and re-establish aortic integrity, approaches 100% inmost reported series. In 21 patients treated by Scheinertet al,23 the operative mortality was 14.3%, and 28.6% experi-enced major complications (renal failure, n  4; stroke,n  2), but none developed paraplegia. These are promisingresults when compared with traditional surgical outcomes.Morishita et al24 examined a cohort of 29 patients treatedwith either handmade stent grafts or surgical means for rup-ture (endovascular, n  18; surgery, n  11). The mortalityrate for the two groups was 9% and 17%, respectively, with63% of the patients in the entire combined cohort surviving2 years. There were 2 late conversions to open repair, andthere was 1 patient who required a secondary endovascularprocedure. Analysis of the EUROSTAR registry showedthat the mortality rate increased from 5.3% to 28% whentreatment of aneurysms was elective rather than emergent.5However, no additional information is available concerningdifferences in morbidity or long-term follow-up.These reports are tempered by other published series.Doss et al25 reported their experience of 60 patients treatedby either surgical or endovascular means. Approximately30% of their patients had traumatic injuries. The meanfollow-up was 36.4 months, and there was a higher second-ary intervention and late complication rate in the endovas-cular group, even though they demonstrated superiorshort-term results with reduced 30-day mortality rates of3.1% vs 17.8%. We have reported our results with 22patients treated with endovascular techniques for rupturedthoracic aneurysms or ruptured dissections.26 Althoughresults were promising compared with open surgery, thein-hospital mortality was higher than reported by others, at45.5% (aneurysms, 27.3%; dissections, 63.6%), mainly be-cause of the large percentage of patient presenting withhemorrhagic shock and multisystem organ failure (35%).Additionally our analysis excluded those patients undergo-ing treatment for aortic transactions, which are associatedwith a better outcome. Not unexpectedly, the left subcla-vian artery required coverage in a higher proportion of theruptured thoracic dissections, but this did not result in anotable incidence of arm ischemia or paraplegia. The meanfollow-up in this cohort was 11.1 months, and life-tablesurvival was 46.5% at 6 months.CONCLUSIONEmergent stent-graft repair of nontraumatic rup-tured thoracic aortic pathologies is technically feasible ina large percentage of cases and imparts an early advan-tage with respect to morbidity and mortality. Hospitalresources and available expertise should encompass allaspects of interventional therapy, including guidewireskills, ultrasonography, and IVUS proficiency. Theseencouraging results should be tempered, however, untillonger follow-up is obtained.REFERENCES1. Veith FJ, Ohki T, Lipsitz EC, Suggs WD, Cynamon J. Endovasculargrafts and other catheter-directed techniques in the managementof ruptured abdominal aortic aneurysms. Semin Vasc Surg 2003;16:326-31.2. Scharrer-Pamler R, Kotsis T, Kapfer X, Gorich J, Sunder-Plassmann L.Endovascular stent-graft repair of ruptured aortic aneurysms. J Endo-vasc Ther 2003;10:447-52.3. 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