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Stent-Graft Placement for the Treatment of Thoracic Aortic Diseases¹

¹ From the Departments of Radiology (E.T., G.S., M.F.G., P.P., L.B., V.L.O.) and Surgery (J.F.B., N.B.), Centre Hospitalier de l’Université de Montréal (CHUM)-Hôtel-Dieu, 3840 St-Urbain St, Montreal, Quebec, Canada H2W 1T8; and the Department of Radiology, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada (A.B.). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received March 17, 2004; revision requested April 16 and received May 26; accepted June 1. All authors have no financial relationships to disclose. Address correspondence to E.T. (e-mail: eric.therasse.chum@ssss.gouv.qc.ca).

View larger version (94K): [in a new window]   Figure 1a.  Thoracic aortic stent-grafts. (a) Photograph shows the Talent stent-graft (Medtronic Vascular, Santa Rosa, Calif), which has an internal nitinol skeleton, a polyester membrane, and a proximal uncovered stent without barbs (arrowheads). (b, c) Photographs show the Zenith stent-graft (Cook, Bloomington, Ind), which has a steel skeleton, a membrane that is outside the metallic cage at the extremities of the stent-graft for better sealing, and no proximal uncovered stent (to prevent vascular erosion at proximal aortic curvatures). The stent-graft also has anchoring barbs at its extremities (arrowheads in c).

View larger version (99K): [in a new window]   Figure 1b.  Thoracic aortic stent-grafts. (a) Photograph shows the Talent stent-graft (Medtronic Vascular, Santa Rosa, Calif), which has an internal nitinol skeleton, a polyester membrane, and a proximal uncovered stent without barbs (arrowheads). (b, c) Photographs show the Zenith stent-graft (Cook, Bloomington, Ind), which has a steel skeleton, a membrane that is outside the metallic cage at the extremities of the stent-graft for better sealing, and no proximal uncovered stent (to prevent vascular erosion at proximal aortic curvatures). The stent-graft also has anchoring barbs at its extremities (arrowheads in c).

View larger version (134K): [in a new window]   Figure 1c.  Thoracic aortic stent-grafts. (a) Photograph shows the Talent stent-graft (Medtronic Vascular, Santa Rosa, Calif), which has an internal nitinol skeleton, a polyester membrane, and a proximal uncovered stent without barbs (arrowheads). (b, c) Photographs show the Zenith stent-graft (Cook, Bloomington, Ind), which has a steel skeleton, a membrane that is outside the metallic cage at the extremities of the stent-graft for better sealing, and no proximal uncovered stent (to prevent vascular erosion at proximal aortic curvatures). The stent-graft also has anchoring barbs at its extremities (arrowheads in c).

View larger version (107K): [in a new window]   Figure 2a.  Stent-graft deployment. Photographs show the Zenith delivery system, whose sheath may be straight or curved (a), depending on the anatomy at the lesion site. Most stent-grafts are deployed by holding the inner catheter (arrow in b) stationary while the outer sheath (arrowhead in b) is withdrawn.

View larger version (61K): [in a new window]   Figure 2b.  Stent-graft deployment. Photographs show the Zenith delivery system, whose sheath may be straight or curved (a), depending on the anatomy at the lesion site. Most stent-grafts are deployed by holding the inner catheter (arrow in b) stationary while the outer sheath (arrowhead in b) is withdrawn.

View larger version (112K): [in a new window]   Figure 3a.  Multi-detector row CT evaluation of a type B dissection. (a) Curved multiplanar reformatted image allows accurate measurement of aortic and iliac artery diameters. (b) Volume-rendered image clearly displays aortic tortuosity, the extent of dissection, and the relationship of the dissection to the LSA (arrowhead). (c, d) Left (c) and right (d) anterior volume-rendered images demonstrate tortuosity of the iliac arteries.

View larger version (90K): [in a new window]   Figure 3b.  Multi-detector row CT evaluation of a type B dissection. (a) Curved multiplanar reformatted image allows accurate measurement of aortic and iliac artery diameters. (b) Volume-rendered image clearly displays aortic tortuosity, the extent of dissection, and the relationship of the dissection to the LSA (arrowhead). (c, d) Left (c) and right (d) anterior volume-rendered images demonstrate tortuosity of the iliac arteries.

View larger version (118K): [in a new window]   Figure 3c.  Multi-detector row CT evaluation of a type B dissection. (a) Curved multiplanar reformatted image allows accurate measurement of aortic and iliac artery diameters. (b) Volume-rendered image clearly displays aortic tortuosity, the extent of dissection, and the relationship of the dissection to the LSA (arrowhead). (c, d) Left (c) and right (d) anterior volume-rendered images demonstrate tortuosity of the iliac arteries.

View larger version (118K): [in a new window]   Figure 3d.  Multi-detector row CT evaluation of a type B dissection. (a) Curved multiplanar reformatted image allows accurate measurement of aortic and iliac artery diameters. (b) Volume-rendered image clearly displays aortic tortuosity, the extent of dissection, and the relationship of the dissection to the LSA (arrowhead). (c, d) Left (c) and right (d) anterior volume-rendered images demonstrate tortuosity of the iliac arteries.

View larger version (145K): [in a new window]   Figure 4a.  Carotid-subclavian artery bypass created prior to stent-graft placement. (a) Digital subtraction angiogram shows a descending thoracic artery aneurysm less than 15 mm from the LSA. (b) Drawing illustrates a bypass (arrow) that was created between the left common carotid artery and the LSA. (c) Digital subtraction angiogram shows a stent-graft that has been positioned over the origin of the LSA. (d) Digital subtraction angiogram obtained after stent-graft deployment demonstrates complete exclusion of the aneurysm.

View larger version (103K): [in a new window]   Figure 4b.  Carotid-subclavian artery bypass created prior to stent-graft placement. (a) Digital subtraction angiogram shows a descending thoracic artery aneurysm less than 15 mm from the LSA. (b) Drawing illustrates a bypass (arrow) that was created between the left common carotid artery and the LSA. (c) Digital subtraction angiogram shows a stent-graft that has been positioned over the origin of the LSA. (d) Digital subtraction angiogram obtained after stent-graft deployment demonstrates complete exclusion of the aneurysm.

View larger version (156K): [in a new window]   Figure 4c.  Carotid-subclavian artery bypass created prior to stent-graft placement. (a) Digital subtraction angiogram shows a descending thoracic artery aneurysm less than 15 mm from the LSA. (b) Drawing illustrates a bypass (arrow) that was created between the left common carotid artery and the LSA. (c) Digital subtraction angiogram shows a stent-graft that has been positioned over the origin of the LSA. (d) Digital subtraction angiogram obtained after stent-graft deployment demonstrates complete exclusion of the aneurysm.

View larger version (152K): [in a new window]   Figure 4d.  Carotid-subclavian artery bypass created prior to stent-graft placement. (a) Digital subtraction angiogram shows a descending thoracic artery aneurysm less than 15 mm from the LSA. (b) Drawing illustrates a bypass (arrow) that was created between the left common carotid artery and the LSA. (c) Digital subtraction angiogram shows a stent-graft that has been positioned over the origin of the LSA. (d) Digital subtraction angiogram obtained after stent-graft deployment demonstrates complete exclusion of the aneurysm.

View larger version (83K): [in a new window]   Figure 5a.  Elongation of an arteriosclerotic aneurysm. Drawing in a depicts a long aneurysm of the descending thoracic aorta distal to the LSA. The aneurysm is treated with two stent-grafts with minimal overlapping (arrowheads in b), but, over time, vector forces (arrows in b) induce migration and disconnection of the stent-grafts (c).

View larger version (84K): [in a new window]   Figure 5b.  Elongation of an arteriosclerotic aneurysm. Drawing in a depicts a long aneurysm of the descending thoracic aorta distal to the LSA. The aneurysm is treated with two stent-grafts with minimal overlapping (arrowheads in b), but, over time, vector forces (arrows in b) induce migration and disconnection of the stent-grafts (c).

View larger version (85K): [in a new window]   Figure 5c.  Elongation of an arteriosclerotic aneurysm. Drawing in a depicts a long aneurysm of the descending thoracic aorta distal to the LSA. The aneurysm is treated with two stent-grafts with minimal overlapping (arrowheads in b), but, over time, vector forces (arrows in b) induce migration and disconnection of the stent-grafts (c).

View larger version (144K): [in a new window]   Figure 6a.  Traumatic rupture of the descending thoracic aorta. (a) Digital subtraction angiogram shows a posttraumatic false aneurysm (arrow) very close to the LSA. (b) Photograph shows a Talent stent-graft that was notched (arrowheads) to prevent covering the LSA. (c) Follow-up image shows complete exclusion of the false aneurysm and a patent LSA.

View larger version (71K): [in a new window]   Figure 6b.  Traumatic rupture of the descending thoracic aorta. (a) Digital subtraction angiogram shows a posttraumatic false aneurysm (arrow) very close to the LSA. (b) Photograph shows a Talent stent-graft that was notched (arrowheads) to prevent covering the LSA. (c) Follow-up image shows complete exclusion of the false aneurysm and a patent LSA.

View larger version (113K): [in a new window]   Figure 6c.  Traumatic rupture of the descending thoracic aorta. (a) Digital subtraction angiogram shows a posttraumatic false aneurysm (arrow) very close to the LSA. (b) Photograph shows a Talent stent-graft that was notched (arrowheads) to prevent covering the LSA. (c) Follow-up image shows complete exclusion of the false aneurysm and a patent LSA.

View larger version (130K): [in a new window]   Figure 7a.  Aortic aneurysm with bronchial compression treated with stent-graft placement. (a) CT scan shows left bronchial compression (arrowhead) by a chronic posttraumatic aortic false aneurysm (arrows). (b) CT scan obtained 4 years after stent-graft placement shows a markedly shrunken aneurysm (arrow) and no bronchial compression.

View larger version (86K): [in a new window]   Figure 7b.  Aortic aneurysm with bronchial compression treated with stent-graft placement. (a) CT scan shows left bronchial compression (arrowhead) by a chronic posttraumatic aortic false aneurysm (arrows). (b) CT scan obtained 4 years after stent-graft placement shows a markedly shrunken aneurysm (arrow) and no bronchial compression.

View larger version (156K): [in a new window]   Figure 8a.  Aortoesophageal fistula treated with stent-graft placement in a patient with hematemesis. (a) Sagittal reconstructed image from multi-detector row CT data shows an atherosclerotic aneurysm (arrows) of the descending thoracic aorta. (b) Multi-detector row CT scan shows compression of the esophagus (arrowheads) by the aneurysm (arrow). (c) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the aneurysm. The patient no longer experienced hematemesis.

View larger version (144K): [in a new window]   Figure 8b.  Aortoesophageal fistula treated with stent-graft placement in a patient with hematemesis. (a) Sagittal reconstructed image from multi-detector row CT data shows an atherosclerotic aneurysm (arrows) of the descending thoracic aorta. (b) Multi-detector row CT scan shows compression of the esophagus (arrowheads) by the aneurysm (arrow). (c) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the aneurysm. The patient no longer experienced hematemesis.

View larger version (92K): [in a new window]   Figure 8c.  Aortoesophageal fistula treated with stent-graft placement in a patient with hematemesis. (a) Sagittal reconstructed image from multi-detector row CT data shows an atherosclerotic aneurysm (arrows) of the descending thoracic aorta. (b) Multi-detector row CT scan shows compression of the esophagus (arrowheads) by the aneurysm (arrow). (c) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the aneurysm. The patient no longer experienced hematemesis.

View larger version (152K): [in a new window]   Figure 9a.  Iatrogenic aneurysm at the insertion site of an extracorporeal circulation cannula. (a) Coronal oblique reconstructed image from multi-detector row CT data obtained 1 year after thoracoabdominal aortic aneurysm repair shows a large false aneurysm (arrowheads) with a fistula (arrow) at the insertion site of an extracorporeal circulation cannula. (b) Multi-detector row CT scan obtained 9 months after stent-graft placement helps confirm resolution of the fistula.

View larger version (147K): [in a new window]   Figure 9b.  Iatrogenic aneurysm at the insertion site of an extracorporeal circulation cannula. (a) Coronal oblique reconstructed image from multi-detector row CT data obtained 1 year after thoracoabdominal aortic aneurysm repair shows a large false aneurysm (arrowheads) with a fistula (arrow) at the insertion site of an extracorporeal circulation cannula. (b) Multi-detector row CT scan obtained 9 months after stent-graft placement helps confirm resolution of the fistula.

View larger version (135K): [in a new window]   Figure 10a.  Late false aneurysm at the site of patch angioplasty sutures in a patient with hemoptysis. (a) Digital subtraction angiogram obtained 3 decades after surgical repair of a thoracic coarctation reveals a false aneurysm (arrow). (b) Coronal oblique reconstructed image from multi-detector row CT data obtained 6 years after stent-graft insertion shows complete resolution of the aneurysm.

View larger version (170K): [in a new window]   Figure 10b.  Late false aneurysm at the site of patch angioplasty sutures in a patient with hemoptysis. (a) Digital subtraction angiogram obtained 3 decades after surgical repair of a thoracic coarctation reveals a false aneurysm (arrow). (b) Coronal oblique reconstructed image from multi-detector row CT data obtained 6 years after stent-graft insertion shows complete resolution of the aneurysm.

View larger version (135K): [in a new window]   Figure 11a.  Mycotic aneurysm treated with stent-graft placement in a patient with Salmonella septicemia. (a) Digital subtraction angiogram shows a thoracoabdominal false aneurysm (arrowheads). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates exclusion of the aneurysm. (c) Coronal reconstructed image from multi-detector row CT data obtained 1 year later shows complete resolution of the aneurysm with no sign of infection.

View larger version (78K): [in a new window]   Figure 11b.  Mycotic aneurysm treated with stent-graft placement in a patient with Salmonella septicemia. (a) Digital subtraction angiogram shows a thoracoabdominal false aneurysm (arrowheads). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates exclusion of the aneurysm. (c) Coronal reconstructed image from multi-detector row CT data obtained 1 year later shows complete resolution of the aneurysm with no sign of infection.

View larger version (128K): [in a new window]   Figure 11c.  Mycotic aneurysm treated with stent-graft placement in a patient with Salmonella septicemia. (a) Digital subtraction angiogram shows a thoracoabdominal false aneurysm (arrowheads). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates exclusion of the aneurysm. (c) Coronal reconstructed image from multi-detector row CT data obtained 1 year later shows complete resolution of the aneurysm with no sign of infection.

View larger version (71K): [in a new window]   Figure 12.  Drawing of the abdominal aorta (lateral view [A = anterior, P = posterior]) illustrates the two main types of vascular compromise associated with aortic dissection. Static vascular obstruction is not related to flow distribution between the true and false lumina and may result when the dissection flap extends directly into an aortic branch (arrow). Dynamic vascular obstruction is related to flow dynamics between the true and false lumina and may result when the flap prolapses over the origin of the branch vessel (arrowheads) or collapses the true aortic lumen from above.

View larger version (113K): [in a new window]   Figure 13a.  False lumen aneurysm of the descending aorta treated with stent-graft placement. (a) Digital subtraction angiogram shows a Stanford B dissection with a false lumen aneurysm (arrow). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the false lumen. (c, d) CT scans obtained before (c) and 12 months after (d) stent-graft placement reveal shrinkage of the false lumen and expansion of the true lumen.

View larger version (108K): [in a new window]   Figure 13b.  False lumen aneurysm of the descending aorta treated with stent-graft placement. (a) Digital subtraction angiogram shows a Stanford B dissection with a false lumen aneurysm (arrow). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the false lumen. (c, d) CT scans obtained before (c) and 12 months after (d) stent-graft placement reveal shrinkage of the false lumen and expansion of the true lumen.

View larger version (106K): [in a new window]   Figure 13c.  False lumen aneurysm of the descending aorta treated with stent-graft placement. (a) Digital subtraction angiogram shows a Stanford B dissection with a false lumen aneurysm (arrow). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the false lumen. (c, d) CT scans obtained before (c) and 12 months after (d) stent-graft placement reveal shrinkage of the false lumen and expansion of the true lumen.

View larger version (102K): [in a new window]   Figure 13d.  False lumen aneurysm of the descending aorta treated with stent-graft placement. (a) Digital subtraction angiogram shows a Stanford B dissection with a false lumen aneurysm (arrow). (b) Digital subtraction angiogram obtained after stent-graft placement demonstrates complete exclusion of the false lumen. (c, d) CT scans obtained before (c) and 12 months after (d) stent-graft placement reveal shrinkage of the false lumen and expansion of the true lumen.

View larger version (96K): [in a new window]   Figure 14a.  Endoleak treated with placement of a longer stent-graft. (a) Digital subtraction angiogram shows a large penetrating ulcer of the descending thoracic aorta (arrow). (b) Digital subtraction angiogram obtained following placement of a short stent-graft demonstrates complete exclusion of the ulcer. (c) Digital subtraction angiogram obtained 4 years later reveals a type 1 endoleak, enlargement of the aneurysm, and stent-graft migration into the aneurysm (arrow). (d) Digital subtraction angiogram obtained after insertion of a longer stent-graft depicts complete exclusion of the aneurysm.

View larger version (97K): [in a new window]   Figure 14b.  Endoleak treated with placement of a longer stent-graft. (a) Digital subtraction angiogram shows a large penetrating ulcer of the descending thoracic aorta (arrow). (b) Digital subtraction angiogram obtained following placement of a short stent-graft demonstrates complete exclusion of the ulcer. (c) Digital subtraction angiogram obtained 4 years later reveals a type 1 endoleak, enlargement of the aneurysm, and stent-graft migration into the aneurysm (arrow). (d) Digital subtraction angiogram obtained after insertion of a longer stent-graft depicts complete exclusion of the aneurysm.

View larger version (83K): [in a new window]   Figure 14c.  Endoleak treated with placement of a longer stent-graft. (a) Digital subtraction angiogram shows a large penetrating ulcer of the descending thoracic aorta (arrow). (b) Digital subtraction angiogram obtained following placement of a short stent-graft demonstrates complete exclusion of the ulcer. (c) Digital subtraction angiogram obtained 4 years later reveals a type 1 endoleak, enlargement of the aneurysm, and stent-graft migration into the aneurysm (arrow). (d) Digital subtraction angiogram obtained after insertion of a longer stent-graft depicts complete exclusion of the aneurysm.

View larger version (82K): [in a new window]   Figure 14d.  Endoleak treated with placement of a longer stent-graft. (a) Digital subtraction angiogram shows a large penetrating ulcer of the descending thoracic aorta (arrow). (b) Digital subtraction angiogram obtained following placement of a short stent-graft demonstrates complete exclusion of the ulcer. (c) Digital subtraction angiogram obtained 4 years later reveals a type 1 endoleak, enlargement of the aneurysm, and stent-graft migration into the aneurysm (arrow). (d) Digital subtraction angiogram obtained after insertion of a longer stent-graft depicts complete exclusion of the aneurysm.

View larger version (121K): [in a new window]   Figure 15a.  Aortic arch erosion caused by the uncovered stent of a stent-graft. (a) Digital subtraction angiogram obtained before stent-graft placement demonstrates a chronic posttraumatic false aneurysm of the descending aorta. (b) Digital subtraction angiogram obtained after placement of a stent-graft despite the absence of specific symptoms shows proximal bare stent struts (arrow) protruding through the aortic wall.

View larger version (122K): [in a new window]   Figure 15b.  Aortic arch erosion caused by the uncovered stent of a stent-graft. (a) Digital subtraction angiogram obtained before stent-graft placement demonstrates a chronic posttraumatic false aneurysm of the descending aorta. (b) Digital subtraction angiogram obtained after placement of a stent-graft despite the absence of specific symptoms shows proximal bare stent struts (arrow) protruding through the aortic wall.

View larger version (120K): [in a new window]   Figure 16a.  Iliac artery trauma caused by attempts at stent-graft placement. (a) CT scan shows a large aneurysm of the descending thoracic aorta. (b) CT scan reveals circumferential calcifications of the left iliac artery (arrowheads). (c) Digital subtraction angiogram obtained during stent-graft placement shows a left iliac artery stenosis (arrow). (d) Digital subtraction angiogram obtained after a failed attempt at stent-graft placement demonstrates extensive dissection of the left iliac artery (arrowheads). (e) Digital subtraction angiogram obtained after stent-graft placement in the left iliac artery helps confirm resolution of the dissection.

View larger version (141K): [in a new window]   Figure 16b.  Iliac artery trauma caused by attempts at stent-graft placement. (a) CT scan shows a large aneurysm of the descending thoracic aorta. (b) CT scan reveals circumferential calcifications of the left iliac artery (arrowheads). (c) Digital subtraction angiogram obtained during stent-graft placement shows a left iliac artery stenosis (arrow). (d) Digital subtraction angiogram obtained after a failed attempt at stent-graft placement demonstrates extensive dissection of the left iliac artery (arrowheads). (e) Digital subtraction angiogram obtained after stent-graft placement in the left iliac artery helps confirm resolution of the dissection.

View larger version (99K): [in a new window]   Figure 16c.  Iliac artery trauma caused by attempts at stent-graft placement. (a) CT scan shows a large aneurysm of the descending thoracic aorta. (b) CT scan reveals circumferential calcifications of the left iliac artery (arrowheads). (c) Digital subtraction angiogram obtained during stent-graft placement shows a left iliac artery stenosis (arrow). (d) Digital subtraction angiogram obtained after a failed attempt at stent-graft placement demonstrates extensive dissection of the left iliac artery (arrowheads). (e) Digital subtraction angiogram obtained after stent-graft placement in the left iliac artery helps confirm resolution of the dissection.

View larger version (83K): [in a new window]   Figure 16d.  Iliac artery trauma caused by attempts at stent-graft placement. (a) CT scan shows a large aneurysm of the descending thoracic aorta. (b) CT scan reveals circumferential calcifications of the left iliac artery (arrowheads). (c) Digital subtraction angiogram obtained during stent-graft placement shows a left iliac artery stenosis (arrow). (d) Digital subtraction angiogram obtained after a failed attempt at stent-graft placement demonstrates extensive dissection of the left iliac artery (arrowheads). (e) Digital subtraction angiogram obtained after stent-graft placement in the left iliac artery helps confirm resolution of the dissection.

View larger version (82K): [in a new window]   Figure 16e.  Iliac artery trauma caused by attempts at stent-graft placement. (a) CT scan shows a large aneurysm of the descending thoracic aorta. (b) CT scan reveals circumferential calcifications of the left iliac artery (arrowheads). (c) Digital subtraction angiogram obtained during stent-graft placement shows a left iliac artery stenosis (arrow). (d) Digital subtraction angiogram obtained after a failed attempt at stent-graft placement demonstrates extensive dissection of the left iliac artery (arrowheads). (e) Digital subtraction angiogram obtained after stent-graft placement in the left iliac artery helps confirm resolution of the dissection.

View larger version (164K): [in a new window]   Figure 17a.  Treatment of accidental stent-graft coverage of the LSA. (a) On a digital subtraction angiogram, a stent-graft that was placed to treat a chronic posttraumatic aneurysm partially covers the LSA (arrowhead). (b) Digital subtraction angiogram shows good patency of the LSA after stent placement into the LSA ostium (arrow).

View larger version (195K): [in a new window]   Figure 17b.  Treatment of accidental stent-graft coverage of the LSA. (a) On a digital subtraction angiogram, a stent-graft that was placed to treat a chronic posttraumatic aneurysm partially covers the LSA (arrowhead). (b) Digital subtraction angiogram shows good patency of the LSA after stent placement into the LSA ostium (arrow).