Aortic Remodeling After Extended PETTICOAT Technique in Acute Aortic Dissection Type III B

Technical Pitfalls for Fenestrated-Branched Endovascular Aortic Repair Following PETTICOAT

PURPOSE

The Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) uses a bare-metal stent to scaffold the true lumen in patients with acute or subacute aortic dissections. While it is designed to facilitate remodeling, some patients with chronic post-dissection thoracoabdominal aortic aneurysms (TAAAs) require repair. This study describes the technical pitfalls of fenestrated-branched endovascular aortic repair (FB-EVAR) in patients who underwent prior PETTICOAT repair.

TECHNIQUE

We report 3 patients with extent II TAAAs who had prior bare-metal dissection stents treated by FB-EVAR. Two patients required maneuvers to reroute the aortic guidewire, which was initially placed in-between stent struts. This was recognized before the deployment of the fenestrated-branched device. A third patient had difficult advancement of the celiac bridging stent due to a conflict of the tip of the stent delivery system into one of the stent struts, requiring to redo catheterization and pre-stenting with a balloon-expandable stent. There were no mortalities and target-related events after a follow-up of 12 to 27 months.

CONCLUSION

FB-EVAR following the PETTICOAT is infrequent, but technical difficulties should be recognized to prevent complications from the inadvertent deployment of the fenestrated-branched stent-graft component in-between stent struts.

CLINICAL IMPACT

The present study highlights a few maneuvers to prevent or overcome possible complications during endovascular repair of chronic post-dissection thoracoabdominal aortic aneurysm following PETTICOAT. The main problem to be recognized is the placement of the aortic wire beyond one of the struts of the existing bare-metal stent. Moreover, encroachment of catheters or the bridging stent delivery system into the stent struts may potentially cause difficulties.

Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection

OBJECTIVE

Endovascular stent therapy (EST) for spontaneous isolated superior mesenteric artery dissection (SISMAD) is gaining popularity, yet the treatment strategy - BMT or EST - remains debatable.

METHODS

A meta-analysis examined all randomized trials and observational studies exploring the relative merits and potential risks of EST vs. BMT in treating SISMAD patients. Key outcomes included early and long-term adverse effects, with odds ratios (ORs) and 95% confidence intervals (CI) calculated. A random- or fixed-effects model was selected according to a 50% heterogeneity threshold.

RESULTS

9 observational studies involving a total of 672 SISMAD patients (303 EST), met our selection criteria. We discovered no noteworthy distinctions between the EST group and the BMT group in terms of early symptoms' alleviation, reinterventions, or all-cause mortality. However, patients receiving EST management will be hospitalized longer than those receiving BMT (EST: 13.2 ± 5.1 months vs. BMT: 7.0 ± 2.2 months, P < 0.01). In the long run, EST was found to significantly contribute to a higher rate of complete remodeling (OR: 4.53, CI: 3.01 ~ 6.81, P < 0.01; heterogeneity, I2 = 50%) and a lower incidence of aneurysm formation (OR: 0.19, CI: 0.06 ~ 0.6, P < 0.01; heterogeneity, I2 = 0%) than BMT. However, there are no significant differences between ESTand BMTin terms of all-cause mortality, recurrent syndrome, reintervention, and SMA stenosis or occlusion.

CONCLUSION

EST can effectively prevent the formation of aneurysmal dissection and improve SISMAD remodeling. Both EST and BMT are similar in reducing long-term mortality, recurrent symptoms, severe SMA stenosis or occlusion, and the need for reintervention in patients with SISMAD.

Discussing on the Aortic Coverage in Type B Aortic Dissection Treatment: A Comprehensive Scoping Review

OBJECTIVE

The objective of this study is to investigate and address the question surrounding the determination of the optimal endograft length of coverage during TEVAR for type B aortic dissection (TBAD), with a particular emphasis on the distal landing zone (DLZ).

DATA SOURCES

MEDLINE, Scopus, and Web of Science databases were used.

METHODS

The PRISMA-ScR statement was followed.

RESULTS

Several variables can contribute to the length of coverage during TEVAR in TBAD patient. Baseline patient's characteristics, TBAD-related features, the type of endoprosthesis, and postoperative graft behaviour may contribute to the choice of coverage.

CONCLUSIONS

No robust data have been published regarding the optimal length of TEVAR. Therefore, reporting the percentage of covered aorta and improving computational studies should be valorised to improve postoperative outcomes.

Aortic Visceral Segment Instability is evident following Thoracic Endovascular Aortic Repair for Acute and Subacute Type B Aortic Dissection

BACKGROUND

Anatomic remodeling within the thoracic aorta following thoracic endovascular aortic repair (TEVAR) for type B aortic dissections (TBAD) has been well documented, but less is known about the response of the untreated visceral aorta. This study aims to investigate visceral aortic behavior following TEVAR for acute or subacute TBAD and identify associations with clinical outcomes.

METHODS

A multi-center retrospective review was performed of all imaging for all patients treated with TEVAR for acute (0-14 days) and subacute (14-90 days) non-traumatic TBAD between 2006-2020. Cohort was inclusive of uncomplicated, high-risk, and complicated (defined per SVS reporting guidelines) dissections. Centerline aortic measurements of the true and false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone (zones defined by SVS reporting guidelines). Diameter changes over time were evaluated using repeated measures mixed effects linear growth modeling. Visceral segment instability (VSI) was defined as any growth in TAD ≥ 5mm within aortic zones 5 through 9.

RESULTS

A total of 82 patients were identified. Median length of imaging follow-up was 2.1 years (IQR 3.9 years), with 15% of the cohort having follow-up longer than 5 years. VSI was present in 55% of the cohort, with an average maximal increase in TAD of 10.4±6.3 mm over a median follow-up of 2.1 years (IQR 3.9 years). Roughly a third of the cohort experienced rapid VSI (growth ≥5mm in first year), and 4.8% of the cohort developed a large para-visceral aneurysm aortic (TAD≥5cm) secondary to VSI. Linear growth modeling identified significant predictable growth in TAD across all visceral zones. Zones 7 had the highest rate of TAD dilation, with a fixed effect estimated rate of 1.3 mm per year (95%-CI 0.23-2.1, p=0.022). The preoperative factor most strongly associated with VSI was ≥6 cumulative number of zones dissected (OR 6.4, 95% OR 1.07-8.6, p=0.041). Odds for aortic reintervention were significantly increased in cases where VSI led to development of a para-visceral aortic aneurysm ≥5cm development (OR 3.7, 95%-CI 1.1-13, p=0.038).

CONCLUSION

VSI was identified in the majority of patients treated with TEVAR for management of acute and subacute TBAD. Preoperative anatomic features such as extent of dissection, rather than procedural details of graft coverage, may play a more significant role in VSI occurrence. Importantly, significant TAD growth occurred in all visceral segments. These results highlight the importance of lifelong surveillance following TEVAR, and identify a subset of patients that may be at increased risk for re-intervention.

Short Term Outcomes of Distal Extended EndoVascular Aortic Repair (DEEVAR) Petticoat in Acute and Subacute Complicated Type B Aortic Dissection

OBJECTIVE

The aim of this study was to evaluate the peri-operative and short term results of institutional experience with the Distal Extended EndoVascular Aortic Repair PETTICOAT (DEEVAR PETTICOAT) procedure.

METHODS

This was a single centre, observational study. From January 2015 to December 2019, 53 patients were admitted to the institution for treatment of acute and subacute complicated type B aortic dissection. Among them, data on 16 patients deemed suitable for a PETTICOAT procedure extended at infrarenal and iliac level by means of a bifurcated endograft were prospectively collected. Patients with persistent pain, visceral or lower limb malperfusion, true lumen collapse, and distal extension with computed tomography angiography (CTA) evidence of entry tears in the infrarenal or iliac zone were included. A CTA scan was performed in all patients at the baseline, before hospital discharge and then at six and 12 months post-operatively to assess aortic remodelling. Complete aortic remodelling was defined as stable aortic size (maximum enlargement < 5 mm) with complete true lumen re-expansion and complete false lumen exclusion or disappearance.

RESULTS

Technical success was obtained in all patients. One patient (7%) had intra-operative infrarenal aortic rupture during balloon dilation of the distal end of the bare stent, successfully treated by deployment of a bifurcated endograft. Additional covered stenting of the visceral arteries was necessary in nine patients (56%) and malperfusion resolved immediately in all cases. There were no spinal cord ischaemia or other peri-procedural complications, and no post-operative death, stroke, paraplegia/paraparesis, or acute renal failure was observed. Follow up ranged from one month to 24 months (median 7.5 months). One patient (7%) with a history of drug abuse died from sepsis. At the last CTA check, all patients showed complete remodelling of the thoraco-abdominal aorta and iliac arteries without vessel enlargement.

CONCLUSION

The present findings suggest that the DEEVAR PETTICOAT procedure provides effective sealing of all distal tears without increased risk of major peri-procedural complications. Further studies with larger number of patients and longer follow up are needed to confirm the safety and durability of this technique.

Chronic abdominal aortic dissection, endovascular treatment using a new Stent-graft for in situ Fenestration

Background

Although endovascular treatment of the thoracic aorta (TEVAR) has become an elective procedure for treatment of complicated type B aortic dissection, its role in treating post dissection thoraco-abdominal aortic aneurysm (TAAA), is still limited. This is a case of aortic vascular disease, which reports the use of a new endovascular device.

Case presentation

: We present the case of a 62 year old male patient with a history of hypertension, active smoker, who presented penetrating descending thoracic aortic ulcer in the setting of a chronic abdominal aortic dissection. The patient was treated using a new stent graft capable of in situ fenestration that allowed crossing the stent-graft membrane, implanting a covered stent to exclude the re-entry at the level of the left renal artery and redirecting the blood flow through the true lumen.

Conclusions

This case report demonstrates the feasibility of a novel stent-graft concept. Larger studies with longer follow-up are essential to fully evaluate the safety and effectiveness of this new design.

The provisional extension to induce complete attachment technique is associated with abdominal aortic remodeling and reduces aorta-related adverse events after aortic dissection

OBJECTIVE

This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique.

METHODS

In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively.

RESULTS

Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64).

CONCLUSIONS

This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.