Relationship of intimal flap position to endovascular treatment of malperfusion syndromes in aortic dissection

Purpose: To propose a classification system based on the position and extension of the intimal flap to assist in the endovascular repair of aortic dissection complicated by a malperfusion syndrome. Methods: Forty-one patients (34 men; mean age 58 years, range 22-78) with 19 type A and 22 type B dissections complicated by a malperfusion syndrome were treated with stenting, fenestration, or both for the peripheral ischemia. A retrospective review of the preprocedural imaging studies (computed tomographic angiography and arteriography) was performed to determine and categorize the position of the aortic intimal flap. In type 1, the flap was either parallel to or perpendicular to the origin of the malperfused collateral artery; type 2 referred to extension of the dissection into the collateral vessel, while type 3 represented the presence or absence of an avulsed branch ostium. Results: Patients treated with stenting (n=19) alone had type 2 or type 3 arterial dissections, whereas the 12 patients who were treated with fenestration alone had type 1 lesions. Ten patients treated with stenting and fenestration had arterial lesions in which a type 1 dissection was associated with types 2 or 3. Conclusions: This appearance-based imaging approach combined with the symptoms of malperfusion syndromes during aortic dissection can help guide the endovascular treatment strategy.