Endovascular management of thoracic dissections.

The first surgical management of aortic dissection was reported in 1935 by Gurin et al,1 who created a distal reentry point in the iliac artery to decompress the false lumen. In 1949, Abbott2 reported the repair of a chronic dissection by wrapping cellophane around the descending aorta to reinforce it. Despite the efforts of these early pioneers and other investigators, it was not until 1955 that a major therapeutic advance was made; this was the year that DeBakey, Cooley, and Creech introduced a revolutionary surgical treatment that involved excision of the intimal tear, obliteration of the false lumen, and either direct reanastomosis or insertion of a prosthetic graft.3 The next great milestone in therapy was introduced by Wheat et al4 in 1965, when they described medical therapy directed toward lowering blood pressure and dP/dt. Since then, investigators have made significant advances in the detection, characterization, and treatment of aortic dissection; however, the morbidity and mortality of this debilitating disease remain alarmingly high, with an overall in-hospital mortality of 27.4% reported by the International Registry of Aortic Dissection (IRAD).5 The latest additions to the armamentarium to treat dissection have been based on percutaneous interventional techniques. The minimally invasive nature of these techniques makes them an attractive alternative to open surgical intervention; however, the exact role and long-term durability of these procedures remain to be proven. The earliest endovascular therapies were directed toward the complications of aortic dissections and included angioplasty of an obstructed aorta, stenting of obstructed branch vessels, and fenestration of the dissection flap to relieve mesenteric ischemia.6–8 More recently, the advent of the stent graft has led to a novel endovascular approach aimed at treating the inciting lesion of aortic dissection by obliterating the primary intimal tear.9,10 Since the first reports in 1999, which involved treatment of acute and chronic aortic dissections, investigators have extended the application of stent grafts to treat a variety of related pathologies, such as intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and traumatic dissection.11,12 In this report, we begin by reviewing key features of aortic dissection pertinent to endovascular management. We also review the natural history of aortic dissection and conventional medical and surgical management. Then, we introduce the principles and techniques of endovascular management and review the current literature. Specifically, we will discuss the use of stent grafts, fenestration, and branch-vessel stenting in the treatment of aortic dissection and related pathologies.