Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair: The STABILISE concept

Early results of transcatheter electrosurgical aortic septotomy for endovascular repair of chronic dissecting aortoiliac aneurysms

Objective

Endovascular repair of chronic dissecting aortoiliac aneurysms is challenging given the rigid septum, compressed true lumen (TL), and target vessels frequently originating in the false lumen. We have used transcatheter electrosurgical aortic septotomy (TEAS) before stent graft implantation under intravascular ultrasound (IVUS) and fusion guidance. The purpose of this study is to assess the outcomes of TEAS during complex endovascular repair of dissecting aneurysms.

Methods

From 2021 to 2023, 17 patients underwent TEAS. The primary end point was technical success, with secondary end points of proximal and distal seals, target vessel instability, aortic and iliac TL and cross-sectional area (CSA) expansion, and aortic-related death. During the procedure, the aortic septum is crossed through a pre-existing entry or via electrocautery-activated 0.018-in. Astato XS20 wire (Asahi-Intecc) under IVUS and fusion guidance. The penetrated wire is then snared in the false lumen and pulled through the ipsilateral femoral access. A 1-cm length of the middle of the Astato wire coating is kinked in a three-sided polygonal configuration, denuded the inner surface of the wire using a no. 15 blade, and positioned at the apex of the septum. Both ends of the Astato wire are insulated with 0.018-in. microcatheters, and the back end of the wire is denuded and connected to cautery. Gentle traction is applied to the wire, and short bursts of electrocautery cutting are applied at 60 to 80 W.

Results

The technical success of the septotomy was 100%. No incidence of visceral or lower extremity malperfusion, vascular injury, or distal embolization occurred. Of the 17 patients, 4 underwent thoracic endovascular aneurysm repair, 2 underwent endovascular aortic repair, and 11 underwent fenestrated/branched endovascular aneurysm repair after septotomy. All target vessels were successfully stented. A distal landing zone seal with exclusion of the false lumen was achieved in 16 of the 17 patients (94.1%). One patient required embolization of the false lumen of the celiac artery after septotomy. The TL mean diameter and CSA of the descending thoracic aorta after septotomy was expanded by 7.01 ± 1.9 mm (relative mean diameter expansion, 42.3%; P < .0001) and 2.71 ± 0.4 cm2 (relative mean CSA expansion, 57.3%, P<.0001). For patients who required septotomy through the common iliac arteries, the mean TL was expanded by 8.1 ± 3.7 mm (relative mean diameter expansion, 76%; P < .0001) and 1.76 ± 0.91 cm2 (relative mean CSA expansion, 209%; P < .0001). The 1-year freedom from target vessel instability was 91%.

Conclusions

The use of IVUS and fusion-guided TEAS offers a promising technique to facilitate TL expansion and false lumen exclusion in chronic dissecting aortic aneurysms before repair. The durability and long-term outcomes of this technique in a larger cohort remain to be elucidated.

Volumetric analysis in primary and residual type B aortic dissection treated with stented-assisted balloon-induced intimal disruption and relamination technique can predict aortic reintervention

OBJECTIVE

The aim of this study was to investigate the mid-term results of stented-assisted balloon-induced intimal disruption and relamination (STABILISE) in patients with aortic dissection with the implementation of volumetric analysis.

METHODS

This was a single-center retrospective analysis of prospectively collected data. From May 2017 to September 2022, 42 patients underwent STABILISE for acute complicated or subacute high-risk aortic dissection. STABILISE was completed with distal extended endovascular aortic repair in 24 patients. A computed tomography scan was performed at baseline, before hospital discharge, and at 1, 3, and 5 years. Perfused total aortic, true lumen, and false lumen volumes were assessed for thoracic, visceral, and aorto-iliac segment. The ratio between false lumen and total volume was named perfusion dissection index (PDI). Complete remodeling was defined as PDI = 0, and positive remodeling as PDI ≤0.1.

RESULTS

Technical success was 97.6%. No 30-day deaths, spinal cord injuries, or retrograde dissections were observed. Mean follow-up was 44 ± 19.4 months. Thoracic diameter was lower at last available computed tomography scan (36.7 vs 33.0 mm; P = .01). Aortic growth >5 mm was observed in 9.5% of the patients. Thoracic and visceral aortic complete remodeling were 92.8% and 83.3%, respectively, with no difference between acute and subacute group. Distal extended endovascular aortic repair significantly increased complete remodeling in the aorto-iliac segment, compared with STABILISE alone (69.6% vs 21.4%; P < .001). Freedom from vascular reinterventions at 3 years was 83.1% (95% confidence interval, 71.5%-96.6%). Total PDI ≤0.1 at first postoperative control was a predictor of vascular reinterventions (P < .0001).

CONCLUSIONS

STABILISE is a safe and feasible technique associated with high mid-term rates of complete remodeling in the thoracic and visceral aorta. Volumetric analysis allows the quantification of aortic remodeling and represents a predictor of aortic reinterventions.

Staging reinterventions for remodeling of residual aortic dissection: a single-center retrospective study

Objective

Inadequate remodeling of residual aortic dissection (RAD) following repair of Stanford A or B aortic dissections has been identified as a significant predictor of patient mortality. This study evaluates the short- to mid-term outcomes of staged reinterventions for RAD at a single center with prospective follow-up.

Methods

Data were retrospectively collected from patients with RAD who underwent staged reinterventions or received none-surgery treatment in the Cardiovascular Surgery Department of our hospital between July 2019 and December 2021. The cohort included 54 patients with residual distal aortic dissection post-primary surgery, comprising 28 who underwent open surgery and 26 who received thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups: those who underwent staged stent interventions for distal dissection [staged reintervention (SR) group] and those who did not undergo surgery (non-surgery group). For the SR group, second or third staged stent interventions were performed. The study assessed distal remodeling of aortic dissection between the groups, focusing on endpoints such as mortality (both general and aortic-specific), occurrences of visceral branch occlusion, necessity for further interventions, and significant adverse events. Morphological changes were analyzed to determine the therapeutic impact.

Results

The study encompassed 54 participants, with 33 in the SR group and 21 in the non-surgical control group. Baseline demographics and clinical characteristics were statistically comparable across both groups. During an average follow-up of 31.5 ± 7.0 months, aortic-related mortality was 0% in both groups; all-cause mortality was 3% (one case) and 5% (one case) in the SR and control groups, respectively, with no statistically significant difference noted. In the SR group, a single patient experienced complications, including renal artery thrombosis, leading to diminished blood flow. An increased true lumen (TL) area and a decreased false lumen area at various aortic planes were observed in the SR group compared to the control group.

Conclusion

The staged reintervention strategy for treating RAD is safe and provides promising early results.

Efficacy of intentional undersized thoracic endovascular repair for Stanford type B aortic dissection

OBJECTIVE

Thoracic endovascular aneurysm repair (TEVAR) is widely used for the treatment of aortic dissection. Endograft oversizing is a risk factor for stent graft-induced new entry tears and retrograde type A aortic dissection. However, there is no clear consensus on the optimal graft size selection for Stanford type B acute or subacute aortic dissection (TBAD). Herein, we examined the safety and efficacy of TEVAR using an intentionally undersized endograft to treat TBAD.

METHODS

This retrospective chart review study included 82 patients who underwent TEVAR for acute or subacute Stanford TBAD between 2015 and 2022. We measured the true lumen diameter just distal to the subclavian artery and opted for a stent graft of the same diameter. In instances where deformation resulting from false lumen pressure displacement was pronounced, we measured the diameter at the site just proximal to the subclavian artery. Patients' characteristics, procedural, in-hospital, and follow-up data, and aortic remodeling were analyzed. The aortic diameter was analyzed using one-way analysis of variance followed by Dunnett's test. Survival and freedom from reintervention were estimated using Kaplan-Meier curves.

RESULTS

The follow-up rate was 98.4%. The mean age was 58.3 ± 12.3 years, and 76 were men (92.7%). The mean diameters of the stent graft and native proximal landing zone were 30.9 ± 3.2 mm and 30.8 ± 3.0 mm, respectively. The oversize rate of the stent graft in relation to the native proximal aortic diameter was 0.3% ± 4.7%. In-hospital mortality was observed in one patient, retrograde type A aortic dissection in one patient, distal stent graft-induced new entry tear in zero patients, and type 1a endoleak in 22 patients (26.8%). Type 1a endoleaks, characterized by antegrade false lumen blood flow originating from the primary entry, in 12 patients spontaneously disappeared within 1 year of follow-up. According to aortic remodeling, 59 patients (86.8%) achieved complete aortic remodeling at the aortic arch level and 51 (75.0%) at the eighth thoracic vertebral level. The diameters of the aortic arch and descending aorta were significantly reduced compared with the postoperative measurements (P <.001). Survival rates were 97.5% and 93.6% at 1 and 3 years, respectively. Freedom from reintervention was 84.7% and 84.7% at 1 and 3 years, respectively.

CONCLUSIONS

Intentionally undersized TEVAR was safe and achieved acceptable aortic remodeling despite a high rate of type 1a endoleaks. A type 1a endoleak was acceptable as it primarily diminished during the mid-term follow-up.

Current perspectives in acute type B aortic dissections: a literature review

In this new millennial, endovascular strategies have revolutionized the treatment of acute type B aortic dissection (aTBAD). With reduced in-hospital mortality and good long-term outcomes TEVAR has become the gold standard for the treatment of complicated dissection and is gaining increasing support for its preventive applicability in some uncomplicated dissections. With this new paradigm came a shift of the treatment goal where just covering the entry tear is not enough and instead achieving long-term positive thoracoabdominal remodeling is needed. More extensive approaches with composite device designs (covered stent graft and bare metal stent) emerged to answer this aortic conundrum. At 5-year of follow-up, "Provisional ExTension To Induce COmplete Attachment technique" (PETTICOAT) and its evolution "Stent assisted balloon induced intimal disruption and relamination in aortic dissection repair" (STABILISE) seem to be safe techniques that can allow, when anatomically feasible, excellent aortic remodeling and, in some cases, even the healing of the dissection. Nevertheless, STABILISE results, although promising, are mostly based on small series and therefore need to be validated by analyzing medium-long-term results from the international registry. Given the plethora of new data and the disparity of expert opinions on the best treatment to adopt, in this review we aim to summarize the current knowledge on the results of these different strategies for acute TBAD.

Repeated endovascular approaches achieve successful complete remodelling for type IIIb acute aortic dissection

Thoracic endovascular repair for type IIIb aortic dissection results in the disappearance of false lumen perfusion in the abdominal aorta in only about 20% of cases, with concern for expansion in the long term. Staged endovascular therapy with intervention on all re-entries can lead to complete false lumen thrombosis and remodelling of the entire aorta. This approach could be an option in cases in which long-term expansion is anticipated.

Dissection flap fenestration can reduce re-apposition force of the false lumen in type-B aortic dissection: a computational and bench study

Thoracic endovascular aortic repair (TEVAR) has been widely adopted as a standard for treating complicated acute and high-risk uncomplicated Stanford Type-B aortic dissections. The treatment redirects the blood flow towards the true lumen by covering the proximal dissection tear which promotes sealing of the false lumen. Despite advances in TEVAR, over 30% of Type-B dissection patients require additional interventions. This is primarily due to the presence of a persistent patent false lumen post-TEVAR that could potentially enlarge over time. We propose a novel technique, called slit fenestration pattern creation, which reduces the forces for re-apposition of the dissection flap (i.e., increase the compliance of the flap). We compute the optimal slit fenestration design using a virtual design of experiment (DOE) and demonstrate its effectiveness in reducing the re-apposition forces through computational simulations and benchtop experiments using porcine aortas. The findings suggest this potential therapy can drastically reduce the radial loading required to re-appose a dissected flap against the aortic wall to ensure reconstitution of the aortic wall (remodeling).

Risk Factors for Incomplete Aortic Remodeling With Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair for Complicated Aortic Dissection: Results of a Multicenter Study

PURPOSE

The STABILISE technique has extended the treatment of aortic dissection to the thoracoabdominal aorta to achieve complete aortic remodeling. The aim of this multicenter study was to analyze the short- and midterm anatomical results of the STABILISE technique.

MATERIALS AND METHODS

We retrospectively analyzed patients treated with the STABILISE technique for complicated aortic dissection at 3 French academic centers. The aortic diameter at different levels was measured preoperatively, postoperatively, and at 1 year.

RESULTS

Between 2018 and 2020, 58 patients, including 47 men (average patient age: 60±11 years), were treated for type B aortic dissection in 34 cases and residual aortic dissection after type A repair in 24 cases. Three (5.2%) patients died postoperatively. Complete aortic remodeling (false lumen thrombosis and complete reapposition of the intimal flap) was achieved in 45/55 patients (81.8%), and false lumen thrombosis in the thoracic aorta was achieved in 52/55 patients (94.5%). At 1 year, with a computed tomographic (CT) scan available for 98.2% (54/55) of patients, we observed a significant decrease in the maximal thoracic aortic diameter and a significant increase in the aortic diameter at the bare-stent level compared with the preoperative CT scan. Severe aortic angulation (p=0.024) was a risk factor for incomplete aortic remodeling and significantly increased the aortic diameter (p=0.032). Chronic aortic dissection was associated with an increased risk of incomplete aortic remodeling (p=0.002).

CONCLUSIONS

STABILISE for complicated aortic dissection results in false lumen thrombosis, complete reapposition of the intimal flap, and a decrease in the maximum aortic diameter in most cases. Incomplete reapposition of the intimal flap, which is more frequent in cases of chronic aortic dissection and severe aortic angulation, is a risk factor for a significant increase in the aortic diameter at the bare-stent level, and this risk justifies close follow-up and better patient selection.

CLINICAL IMPACT

STABILISE technique for complicated aortic dissection results in false lumen thrombosis, complete aortic remodeling and a decrease in the maximum aortic diameter in most cases. At the bare-stent level, incomplete reapposition of the intimal flap, more frequent in chronic aortic dissection and severe aortic angulation, is a risk factor for an increased aortic diameter. This finding justifies close follow-up and better patient selection; thus, the STABILISE technique should be used with care in chronic aortic dissection and severe aortic angulation.

Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE): A Meta-Analysis of Early Outcomes

BACKGROUND

This meta-analysis aims to determine the early clinical outcomes and rate of complete false lumen obliteration associated with the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique in the management of aortic dissection.

METHODS

Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies reporting early outcomes of the STABILISE technique. In addition, we retrospectively analyzed all patients treated with the STABILISE technique for aortic dissection at our institution. The case series data were pooled with relevant studies to perform a meta-analysis of proportions using random-effects models.

RESULTS

One hundred and ninety two patients from 9 relevant studies were pooled with an additional 13 patients undergoing STABILISE at our institution over a 3-year period. Pooled in-hospital mortality rate was 6% [95% confidence interval (CI); 3%-10%, I2 = 0.00%] and the overall rate of intraoperative aortic rupture was 4% [95% CI; 2%-8%, I2 = 0.00%]. The rate of in-hospital reintervention was 8% [95% CI; 5%-14%, I2 = 13.37%]. Median follow-up ranged from 8 to 36 months. Pooled cumulative mortality at follow-up was 8% [95% CI; 4%-18%, I2 = 23.15%]. The overall rate of late reintervention was 11% [95% CI; 7%-17%, I2 = 0.00%]. Complete obliteration of the false lumen in the thoracic aorta was achieved in 93% of patients [95% CI; 84%-97%, I2 = 47.49%] and in the abdominal aorta in 86% of patients [95% CI; 79%-91%, I2 = 0.00%].

CONCLUSIONS

The STABILISE technique carries an acceptable operative safety profile with low in-hospital morbidity and mortality and excellent complete false lumen obliteration.

Hemodynamic Implications of STABILISE Technique for Aortic Dissection Repair

BACKGROUND

The stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique for treatment of type B dissection has shown promising clinical results at mid-term. Computational modeling is a way of noninvasively obtaining hemodynamic effects, such as pressure and wall shear stress, leading to a better understanding of potential benefits. Particular areas of interest are (1) the effect of intimal disruption and re-lamination and (2) the effect of the bare metal stent in the visceral aortic segment.

METHODS

Single-center prospective case series. Data from 5 consecutive locally performed cases of STABILISE technique were analyzed. Included cases were type B aortic dissection with or without prior de-branching. The STABILISE procedure had to be performed without 30-day major complications. Preoperative and postoperative imaging data for each patient were transferred to the biomedical engineering team. Each case was reconstructed, meshed, and simulated with computational fluid dynamics using patient-specific data (heart rate, blood pressure, height, and weight). Hemodynamic parameters were then extracted from the simulations.

RESULTS

In all cases, computational analysis showed for postoperative patients: (1) a drop in pressure difference between lumina and (2) lower wall shear stress effects, compared to their preoperative status. These observations were most pronounced in the visceral aortic segment.

CONCLUSIONS

Computational modeling shows favourable changes in the flow dynamics of type B dissection treated using the STABILISE technique. This may suggest protective effects of this technique for long-term aortic healing and cicatrization.

Aortic rupture during STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique

The STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique has shown promising results for treating type B aortic dissections, but the potential exists for fatal adverse effects. We present a case of infrarenal aortic rupture while using a compliant balloon to balloon mold the true lumen inside previously placed bare metal stents during the STABILISE technique. Caution is advised for providers who wish to perform the STABILISE technique, and we recommend using a semi-compliant balloon sized to the smallest total aortic diameter to mitigate the risk of rupture.

Comparative outcomes of physician-modified fenestrated-branched endovascular repair of post-dissection and degenerative complex abdominal or thoracoabdominal aortic aneurysms

OBJECTIVE

Fenestrated-branched endovascular repair has become a favorable treatment strategy for patients with complex abdominal aortic aneurysms (cAAAs) and thoracoabdominal aortic aneurysms (TAAAs) who are high risk for open repair. Compared with degenerative aneurysms, post-dissection aneurysms can pose additional challenges for endovascular repair. Literature on physician-modified fenestrated-branched endovascular aortic repair (PM-FBEVAR) for post-dissection aortic aneurysms is sparse. Therefore, the aim of this study is to compare the clinical outcomes of patients who underwent PM-FBEVAR for degenerative and post-dissection cAAAs or TAAAs.

METHODS

A single-center institutional database was retrospectively reviewed for patients that underwent PM-FBEVAR between 2015 and 2021. Infected aneurysms and pseudoaneurysms were excluded. Patient characteristics, intraoperative details, and clinical outcomes were compared between degenerative and post-dissection cAAAs or TAAAs. The primary outcome was 30-day mortality. The secondary outcomes included technical success, major complications, endoleak, target vessel instability, and reintervention.

RESULTS

Of the 183 patients who underwent PM-FBEVAR in the study, 32 had aortic dissections, and 151 had degenerative aneurysms. There was one 30-day death (3.1%) in the post-dissection group and eight 30-day deaths (5.3%) in the degenerative aneurysm group (P = .99). Technical success, fluoroscopy time, and contrast usage were similar between the post-dissection and degenerative groups. Reintervention during follow-up (28% vs 35%; P = .54) and major complications were not statistically significantly different between the two groups. Endoleak was the most common reason for reintervention, with the post-dissection group having a higher rate of type IC, II, and IIIA endoleaks (31% vs 3%; P < .0001; 59% vs 26%; P = .0002; and 16% vs 4%; P = .03). During the mean follow-up of 14 months, all-cause mortality was similar between the groups (12.5% vs 21.9%; P = .23).

CONCLUSIONS

PM-FBEVAR is a safe treatment for post-dissection cAAAs and TAAAs with high technical success. However, endoleaks requiring reintervention were more frequent in post-dissection patients. The impact of these reinterventions on long-term durability will be assessed with continued follow-up.

[Malperfusion after Aortic Dissection - Management and Techniques]

Malperfusion is a common complication of aortic dissection and further increases this deadly disease's mortality. An effective treatment strategy requires a timely diagnosis based on the clinical findings and the available instruments, understanding the disease's pathomechanism, recognising the therapy options recommended by the guidelines, and the diagnostic and therapeutic innovations of the area of research. The final treatment decision should be patient- and case-specific. In this work, we have considered malperfusion after aortic dissection, not only as a complication of aortic dissection but as a separate disease and summarise important information that can contribute to efficient therapy decisions in everyday clinical practice.

The fate of spinal arteries after the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair technique: a case series

Objective

We evaluated the patency of the spinal arteries (intercostal and lumbar) after the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique.

Methods

A retrospective analysis of all patients with aortic dissection treated with the STABILISE technique between April 2018 and July 2021 was performed. Imaging analysis of the spinal cord vascular supply was accomplished using multiplanar and maximum intensity projection reconstructed images of pre- and postoperative computed tomography angiograms at 1 month, 12 months, and annually thereafter.

Results

Twelve patients were treated for complicated aortic dissection. Primary technical success was 100% and mid-term clinical success, at a mean follow-up of 27 ± 12 months, was 90%. No cases of spinal cord ischemia were identified. One patient died after 1 year (non-aortic related), and one patient was lost to follow-up. A significant decrease was found in the mean number of patent spinal arteries in the stent graft area at 1 month (P < .001), 1 year (P < .001), and 2 years (P = .004). However, no significant reduction was found in the number of spinal arteries in either the bare metal stented or nonstented aorta (P > .05).

Conclusions

Use of the STABILISE technique decreased intercostal artery patency in the thoracic stent graft area, but spinal artery patency was not significantly affected by the bare metal stent nor its aggressive ballooning. These findings constitute a step toward a better understanding of the safety of this technique.

Scandinavian trial of uncomplicated aortic dissection therapy: study protocol for a randomized controlled trial

BACKGROUND

Contemporary management of uncomplicated type B aortic dissections (uTBAD) is based on the acuity and various morphological features. Medical therapy is mandatory, while the risks of early thoracic endovascular aortic repair (TEVAR) are balanced against the potential for rupture, complex surgery, and death. Improved aortic morphology following TEVAR is documented, but evidence for improved overall survival is lacking. The costs and impact on quality of life are also needed.

METHODS

The trial is a randomized, open-label, superiority clinical trial with parallel assignment of subjects at 23 clinical sites in Denmark, Norway, Sweden, Finland, and Iceland. Eligibility includes patients aged ≥ 18 with uTBAD of < 4 weeks duration. Recruited subjects will be randomized to either standard medical therapy (SMT) or SMT + TEVAR, where TEVAR must be performed between 2-12 weeks from the onset of symptoms.

DISCUSSION

This trial will evaluate the primary question of whether early TEVAR improves survival at 5 years among uTBAD patients. Moreover, the costs and the impact on quality of life should provide sorely needed data on other factors that play a role in treatment strategy decisions. The common Nordic healthcare model, with inclusion of all aortic centers, provides a favorable setting for carrying out this trial, while the robust healthcare registries ensure data validity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05215587. Registered on January 31, 2022.

Balloon Inducted Re-Lamination and False lUmen Thrombosis in Chronic Type B Aortic Dissection: Technique and Long-Term Results

BACKGROUND

To evaluate the safety, feasibility, and effectiveness of the BAlloon Inducted re-Lamination and false lUmen Thrombosis (BAILOUT) as a simple technique to address the retrograde false lumen (FL) perfusion and subsequent aneurysmatic degeneration of the thoracic aorta due to a stent-graft crimped in a small true lumen in chronic Type B dissections.

METHODS

An observational, retrospective, single-center study analyzing a nonconsecutive cohort of 8 patients affected by chronic type B aortic dissections already treated with thoracic endovascular repair and with an FL lumen backflow corrected with BAILOUT between 2006 and 2020. After a standard distal extension of the previously implanted graft, the distal end of the graft area was ballooned to completely rupture the dissection lamella to relaminate the aorta hindering the FL backflow. Computed tomography was routinely performed within the first postoperative week before discharge and then at 3 months, at 6 months, and yearly thereafter. The technical and clinical success rates were analyzed. Primary outcomes were safety and feasibility of the technique, secondary ones included FL thrombosis evaluation, and total aortic diameter analysis at the above-defined levels during the follow-up. Safety was defined if clinical success was reached. Feasibility was intended as technical success obtention.

RESULTS

The technical and clinical success achieved was 100% with the complete interruption of FL backflow stating the safety and feasibility of the BAILOUT technique. No early procedure reinterventions were recorded and during a median follow-up of 62.5 months [interquartile range 43.2-94.1], only 1 death unrelated to the procedure was recorded. Freedom from aortic-related adverse events at 1 month, 3 months, 1 year, 5, and 7 years was 87.5%, 62.5%, 62.5%, 62.5%, and 62.5%, respectively. During the follow-up, no one increment of the diameter of the thoracic aorta was documented and all the patients at 3 years of computed tomography angiography showed a complete FL thrombosis.

CONCLUSIONS

The BAILOUT technique demonstrates to be safe and feasible in this small cohort of patients as a simple and quick way to overcome the issue of FL backflow in chronic type B dissection. Small cohort and retrospective designs were limitations of the study.

Changing Management of Type B Aortic Dissections

The purpose of this manuscript is to review recent trends in the management of acute type B aortic dissection. Due to its efficacy and low morbidity, thoracic endografting has rapidly been adopted as the treatment of choice for most patients with malperfusion or rupture as a consequence of acute aortic dissection. This technology is increasingly applied to patients without rupture or malperfusion, so-called "uncomplicated" dissections, to reduce the incidence of late aneurysmal degeneration in the ungrafted segments of the thoracoabdominal aorta. A variety of techniques have been proposed, including intentional rupture of the dissection membrane to obliterate the false lumen as well as the candy-plug technique to eliminate retrograde flow in the false lumen.

Initial Single-Center Experience With the Knickerbocker Technique During Thoracic Endovascular Aortic Repair to Block Retrograde False Lumen Flow in Patients With Type B Aortic Dissection

OBJECTIVE

Effectiveness of thoracic endovascular aortic repair in type B aortic dissection is impaired by persistent retrograde false lumen flow via distal re-entry tears. Controlled, stentgraft-assisted balloon dilatation of the true lumen at its lower end, or Knickerbocker technique, may block retrograde false lumen flow and consequently improve effectiveness by inducing immediate thrombosis along the entire descending thoracic aorta.

MATERIALS AND METHODS

A single-center retrospective analysis was performed for all consecutive patients with aortic dissection treated with the Knickerbocker technique to block retrograde false lumen flow.

RESULTS

Eleven patients were included for analysis. Intraoperative control angiography showed successful occlusion of the false lumen at the level of balloon dilatation in 9 out of 11 patients (82%). There was one perioperative mortality (9%), due to stroke. There were 2 early reinterventions, due to retroperitoneal bleeding and due to chyle leakage in the neck after left subclavian artery bypass. Median clinical follow-up duration was 6 (interquartile range [IQR] 2-11] months. There were 2 deaths during follow-up, one at 2 months after TEVAR from unknown cause of death, and one after 11 months due to rupture of an ascending aortic pseudoaneurysm. The Knickerbocker technique led to positive aortic remodeling. At 3 months follow-up, 100% of patients showed complete false lumen thrombosis in the thoracic aorta proximal to the level of balloon dilatation, with decreasing false lumen diameters (100%) and stable (44%) or decreasing (56%) total aortic diameters. In most patients, the false lumen distal to the stentgraft (i.e. at visceral level) remained patent (11% false lumen thrombosis rate), leading to ≥2 mm dilatation at this level (78% of patients) and in the infrarenal abdominal aorta (56% of patients) at 3 months postoperatively. No distal stent-graft-induced new entry tears were noticed during follow-up.

CONCLUSION

The Knickerbocker technique is feasible and effective, leading to positive aortic remodeling of the aorta covered by stentgraft in all of a small cohort of patients.

CLINICAL IMPACT

Persistent, retrograde false lumen perfusion from distal re-entries following thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection, may lead to progressive, aneurysmal dilatation. Controlled, stent graft-assisted balloon dilatation of the true lumen in the distal descending aorta (i.e. Knickerbocker technique) during TEVAR effectively excludes the false lumen from persistent flow resulting in positive aortic remodeling in our small cohort of patients, and hence potentially eliminates the risk of late post-dissection aneurysm formation in the descending thoracic aorta.

Endovascular interventions in main renal artery pathologies: an overview and update

Renal arteries are involved in a wide spectrum of pathologies including atherosclerosis, fibromuscular dysplasia, Takayasu arteritis, aneurysms, and aortic type B dissections extending into main renal arteries. They manifest as renovascular hypertension, renal ischemia, and cardiovascular dysfunction. The location of the renal arteries in relation to the abdominal aortic aneurysm is a critical determinant of interventional options and long-term prognosis. This article provides a comprehensive review of the role of interventional radiologists in transcatheter interventions in various pathologies involving the main renal arteries with analysis of epidemiology, pathophysiology, newer interventional techniques, and management options.

Hemodynamic Changes Before and After Endovascular Treatment of Type B Aortic Dissection by 4D Flow MRI

Objective:

The standard treatment for complicated Stanford type B aortic dissection (TBAD) is thoracic endovascular aortic repair (TEVAR). Functional parameters, specifically blood flow, are not measured in the clinical assessment of TEVAR, yet they are of outmost importance in patient outcome. Consequently, we investigated the impact of TEVAR on the flows in the aorta and its branches in TBAD using 4D Phase-Contrast Magnetic Resonance Imaging (4D Flow MRI).

Methods

Seven patients with TBAD scheduled for TEVAR underwent pre and post-operative 4D Flow MRI. An experienced reader assessed the presence of helical flow in the false lumen (FL) using streamlines and measured net flow at specific locations. In addition, forward and reverse flows, stasis, helicity, and absolute helicity were computed automatically along the aorta centerline. Average values were then computed in the segmented vessels. Impact of TEVAR on these parameters was assessed with a Wilcoxon signed rank test. Impact of the metallic stent on the velocity quantification was assessed using intra-class correlation coefficient (ICC) between velocities measured intra-stent and in adjacent stent-free regions.

Results

FL helical flow was observed proximally in 6 cases and distally in 2 cases pre-operatively. Helical flow disappeared post-TEVAR proximally, but developed distally for 2 patients. Intra-stent measures were similar to stent-free with a median difference of 0.1 L/min and an ICC equal to 0.967 (p &lt; 0.01). Forward flow increased from 59.9 to 81.6% in the TL and significantly decreased in the FL from 15.9 to 3.3%. Similarly, reverse flow increased in the TL from 4.36 to 10.8% and decreased in the FL from 10.3 to 4.6%. No significant changes were observed in net flow for aortic branches (p &gt; 0.05). A significant increase in FL stasis was observed (p = 0.04).

Discussion

TEVAR significantly increased forward flow in the TL and significantly decreased both forward and reverse flows in the FL. Interestingly, reverse flow in the TL increased post-TEVAR, which could be due to increased rigidity of the wall, due to the metallic stent. User independent helicity quantification enabled detection of elevated helicity at the level of secondary entry tears which had been missed by streamline visualization.

Initial Study of the Extended STABILISE Technique for Complete Remodeling in Aortic Dissection

OBJECTIVES

Thoracic endovascular aortic repair (TEVAR) is the standard treatment for acute complicated type B aortic dissection (TBAD). However, long-term results reveal that TEVAR does not achieve a complete aortic remodeling and poses a risk of aneurysmal aortic degeneration. Distal reentry treatment at the abdominal level seems to be necessary to obtain a complete remodeling in TBAD. Moreover, it is necessary to treat the aortoiliac bifurcation in patients with persistent true lumen collapse or limb ischemia.

METHODS

Between January 2018 and October 2019, 11 patients with acute or sub-acute complicated TBAD or non-A non-B aortic dissection were treated in our institution in an endovascular fashion. We performed the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABLISE) technique in all cases, but two cases required complementary treatment of the aortoiliac bifurcation with a bifurcated AFX endograft system for limb ischemia due to true lumen collapse.

RESULTS

Technical success was obtained in all patients. No procedural complications occurred. No postoperative deaths, stroke, paraplegia, mesenteric, or renal ischemia were observed, and no secondary intervention was necessary. Satisfactory aortic remodeling was obtained after the follow-up periods with a 57.5% mean true lumen expansion.

CONCLUSION

Our initial experience using the extended STABILISE (e-STABILISE) technique using a bifurcated AFX endograft did not result in any postoperative mortality or complications. Without additional data, this technique should be reserved for specific patients who require revascularization of the aortoiliac bifurcation.

The STABILISE technique to address malperfusion on acute-subacute type B aortic dissections

Endovascular treatment is the current standard of care for complicated acute and subacute type B aortic dissection. Closure of the primary entry tear with thoracic endovascular aneurysm repair (TEVAR) is often insufficient to induce complete false lumen thrombosis and a positive aortic remodeling. Moreover, TEVAR does not solve all the cases of malperfusion. The Provisional ExTension to Induce COmplete ATtachment (PETTICOAT) technique (deploying self-expandable bare metal stents in the true lumen in addition to TEVAR) can re-expand the true lumen, stabilize the lamella and promote aortic remodeling, but it does not recreate a single-lumen aorta and long-term aneurysmal degeneration of the aorta is frequent. Endovascular treatment by means of TEVAR + PETTICOAT does not recreate a single-lumen aorta so long-term aneurysmal degeneration of the aorta is frequent. The stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) technique may help to this purpose disrupting the intimal lamella and creating a relaminated uni-luminal aorta.

STABILISE; treatment of aortic dissection, a single Centre experience

Purpose

To outline the process of the STABILISE technique and its use; reporting patient outcomes and midterm follow up for complicated aortic dissection.

Materials and methods

Single centre retrospective analysis from January 2011 to January 2021 using the STABILISE technique which utilises balloon assistance to facilitate intimal disruption and promote aortic relamination.

Results

Sixteen patients underwent endovascular aortic repair with the STABILISE technique for aortic dissection over the study period. Fourteen patients (14/16; 88%) had acute dissection. Two of 16 (12%) were chronic. The median age of the patient cohort was 61 years (range 32–80 years) and consisted of a male majority (n = 11; 69%). The median time from diagnosis to intervention was 5 days (1–115 days; IQR 1–17.3). More than half (56%) had surgical repair of a acute type A aortic dissection prior to radiological intervention. The procedure was technically successful with no procedural mortality. Two patients were lost to follow up and two died in the post-operative period. Twelve patients had ongoing follow up with an average number of 2.9 ± 1.6 scans performed. Follow up was available in thirteen patients (81%) with a median follow up period of 1097 days (IQR 707–1657). The rate of re-intervention (n = 2/16; 13%) requiring additional stenting was in line with published re-intervention data (15%). Follow up showed a reduction in false lumen size following treatment with total luminal dimensions remaining stable over the follow-up period.

Conclusion

The STABILISE technique as a procedure for complicated aortic dissection, either acute or chronic, appears safe with stable mid-term aortic remodelling and patient outcomes.

Level of evidence

Level 3, Retrospective cohort study.

A New Era of Diagnosis and Therapy in Acute Aortic Syndromes: The Mainz-Essen Experience (Part II)-Management and Outcomes

Over the years, the cardiovascular department of Johannes Gutenberg University in Mainz-West-German Heart Centre in Essen (Germany) designed and implemented the hybrid operating room (2003) along with advanced endovascular and surgical procedures, including the frozen elephant trunk technique. For the study purpose, the Mainz-Essen experience on acute aortic syndromes was summarized by considering original articles from single-center or multicenter studies performed at West German Heart Centre, Essen, Germany, or at the cardiovascular department of Johannes Gutenberg University, Mainz, Germany. We present the 35-year-long Mainz-Essen research, education, and patient management journey in creating an integrated multidisciplinary "Aortic Center" in the heart of Europe.

“Branch-First total arch replacement”: a valuable alternative to frozen elephant trunk in acute type A aortic dissection?

The "Branch-First total arch replacement" technique has been used extensively in both elective and acute situations, including in type A aortic dissection. The focus of the Branch-First technique is to reduce the risk of neurological and end-organ dysfunction associated with arch replacement by optimising neuroprotection, distal organ perfusion and myocardial protection. The Branch-First technique is a valuable alternative to the frozen elephant trunk (FET) technique in type A aortic dissection, providing a stable landing zone for subsequent interventions on the distal aorta should they be required. Combining the Branch-First technique with FET in appropriate cases can further improve outcomes. We discuss the merits of the Branch-First technique, and contrast them to those of FET techniques for repair of type A aortic dissection.

STABILISE Technique via a Transapical Approach to Repair Residual Type A Aortic Dissection

The stent-assisted balloon-induced intimal disruption and relamination in aortic dissection or STABILISE concept is a novel endovascular strategy in Type A and Type B dissections. We report a case of Type A aortic dissection repair combining, first, an open thoracic aortic surgery with an elephant trunk procedure and, second, an endovascular treatment using the STABILISE technique via a combined transapical approach commonly used for transcatheter aortic valve implantation and a femoral pathway.

Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection

OBJECTIVE

The role of thoracic endovascular aortic repair for chronic type B aortic dissection remains controversial. Clinical outcomes of thoracic endovascular aortic repair with recently implemented aortic septotomy strategy were compared with stand-alone thoracic endovascular aortic repair.

METHODS

Between 2008 and 2020, 88 patients with chronic type B aortic dissection and degenerative aortic aneurysm underwent a thoracic endovascular aortic repair with or without adjunctive aortic septotomy, consisting of 36 (41%) with de novo chronic type B aortic dissection and 52 (59%) with residual chronic type B aortic dissection after type A aortic dissection repair.

RESULTS

Aortic septotomy was performed in 31 patients (35%) to optimize the proximal (3/31;10%) and distal (31/31;100%) landing zones. The aortic septotomy techniques comprised laser aortic septotomy in 16 patients (52%) and cheese wire septotomy in 15 patients (48%) with a 97% overall technical success rate. The median time interval between aortic dissection occurrence and thoracic endovascular aortic repair was 1.2 years. During follow-up, there were 12 (21%) sudden deaths and 17 (30%) combined aorta-related and sudden deaths in the nonaortic septotomy group, whereas there were no deaths in the septotomy group (P < .001). Patients without aortic septotomy required aortic reinterventions more frequently than those with aortic septotomy (30% vs 7%; P = .014), and 77% of these procedures were related to residual retrograde false lumen flow. Positive aortic remodeling was confirmed in 90% and 37% in the aortic septotomy and nonseptotomy groups, respectively (P < .001).

CONCLUSIONS

Stand-alone thoracic endovascular aortic repair outcomes without adjunctive procedures for chronic type B aortic dissection remain unfavorable. In contrast, landing zone optimization using aortic septotomy resulted in a remarkably higher positive aortic remodeling rate. Routine aortic septotomy strategy may positively affect long-term chronic type B aortic dissection survival and expand thoracic endovascular aortic repair candidacy.

Hybrid Surgical Approach to a Giant Post-Coarctation Aortic Aneurysm

PURPOSE

To report a rare case of giant aortic coarctation (CoA)-related descending thoracic aneurysmal degeneration, complicated by an acute aortic dissection.

CASE REPORT

A 57-year-old man referred with acute chest pain to the emergency department. A computed tomography angiography (CTA) revealed a CoA with a giant post-stenotic descending thoracic aneurysm (14 cm) and a concomitant left subclavian artery (LSA) aneurysm, complicated by an acute type B aortic dissection. A single-stage hybrid procedure was planned in an urgent setting. Initially, a left common carotid-to-left subclavian artery (LCCA-LSA) bypass was performed to gain a suitable proximal landing zone, the procedure was then completed with 3 thoracic endografts and 1 aortic dissection stent through a percutaneous femoral approach. The patient was discharged in postoperative day 8th without complications; the CTA performed at 1 month demonstrated patency of supra-aortic and visceral vessels, dilation of CoA site and exclusion of the false lumen.

CONCLUSIONS

CoA is a congenital malformation rarely found in adults that may represent a challenge for the surgeon, especially when combined with a complication like an acute aortic dissection. This case shows that a hybrid approach is a safe and feasible treatment option even in such complex anatomies.

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.

Thoracic Endovascular Aortic Repair With Additional Distal Bare Stents in Type B Aortic Dissection Does Not Prevent Long-Term Aneurysmal Degeneration

PURPOSE

TEVAR (thoracic endovascular aortic repair) + PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) technique has been selectively employed since 2005 at our institution during endovascular treatment of type B aortic dissection (TBD). The aim of this study is to evaluate the long-term (>5 years) clinical results and the evolution of aortic volume.

MATERIALS AND METHODS

All the patients receiving an endovascular treatment for TBD with the PETTICOAT technique were collected in a prospectively maintained database and follow-up computed tomography scan were retrospectively analyzed. Study endpoints included short- and long-term clinical success (absence of need for reintervention) and any major adverse event. The volumes of thoracic and abdominal aorta at long-term follow-up were also analyzed.

RESULTS

Twenty-eight patients received a TEVAR + PETTICOAT and were followed up (median follow-up 85 months). Primary 30-day clinical success rate was 82% with an adverse event rate of 31%; 4 type I endoleak and 1 retrograde dissection were recorded. Secondary mid-term clinical success was 96% while the long-term clinical success rate was 79%. Six cases (21%) received either an open repair or an endovascular repair for a significant distal aortic enlargement at follow-up. With regards to volumetric analysis, an increase of overall (thoracic and abdominal) aortic volume was observed in 8 cases mainly related to an increase (mean: +31%) of the abdominal volume that was observed in 11 cases.

CONCLUSIONS

PETTICOAT technique does not protect from long-term significant aneurysmal degeneration that may require aortic open or endovascular reinterventions. Aortic growth occurs mainly in the bare-stented aorta and thus, life-long surveillance is advisable in these patients.

False Lumen Stent-Grafts for Repair of Postdissection Aortic Aneurysms

PURPOSE

To evaluate the safety and efficacy of false lumen (FL) stent-grafts in the treatment of postdissection aortic aneurysms.

MATERIALS AND METHODS

Eleven patients who underwent endovascular repair using FL stent-grafts from January 2016 to June 2019 were included. Among them, 2 patients had a prior history of type A aortic dissection, whereas 9 had undergone a prior endovascular repair for type B aortic dissection. Computed tomography angiography was performed to evaluate the reintervention and technical success rate, aortic remodeling, and other related aortic complications.

RESULTS

The mean age of patients was 55.6 ± 10.4 years. Technical success was achieved in all patients, and neither early mortality nor paralysis occurred. In total, 8 visceral branch arteries originating from the FL were reconstructed. The true lumen areas at the celiac axis, superior mesenteric artery, renal artery, and abdominal aortic bifurcation were significantly increased from 230.1 mm² to 312.3 mm², 212.1 mm² to 277.5 mm², 209.1 mm² to 291.6 mm², and 214.4 mm² to 300.6 mm², respectively (P < .05). The total diameter of the aorta at the 4 designated levels was stable or had shrunk in all patients. At a mean follow-up of 18.9 ± 7.6 months, 1 patient received re-intervention owing to iliac stent-graft occlusion. No aortic-related mortality occurred.

CONCLUSIONS

FL stent-grafts can safely and effectively treat patients with postdissection aortic aneurysms. This strategy can be used to promote thrombosis of the FL and aortic remodeling. A larger sample and an extended follow-up period are needed to produce more conclusive results.

Early outcomes associated with use of the Zenith TX2 Dissection Endovascular Graft for the treatment of Stanford type B aortic dissection

OBJECTIVE

To evaluate short term outcomes related to the use of the Zenith TX2 Dissection Endovascular Graft (ZDEG) and the Zenith Dissection Bare stent (ZDES) for the treatment of Stanford type B aortic dissections.

METHODS

This retrospective multicenter case cohort study collated data from 10 European institutions for patients with both complicated and uncomplicated type B aortic dissection treated with ZDEG and ZDES between 2011 and 2018. The primary end point was mortality at 30 and 90 days. Secondary end points included complications related to TEVAR, such as, type Ia endoleak, stroke, paraparesis, paraplegia, and retrograde type A dissection (RTAD). Statistical analysis was carried out using the t test, or one-way analysis of variance and the χ² or Fisher exact tests.

RESULTS

We treated 120 patients (87 male; mean age, 62.7 ± 12.2years) either in the acute 76 (63.3%), subacute 16 (13.3%), or chronic 28 (23.3%) phase. Seven patients (5.8%) died within 30 days after the index procedure and two (1.7%) between 30 and 90 days. There was one instance of postoperative RTAD in a patient treated for rupture. Stroke and paraplegia occurred in three (2.5%) and five (4.2%), patients, respectively. Eight patients (6.7%) had a type Ia endoleak in the perioperative period. There were no instances of paraplegia, no permanent dialysis, and no requirement for adjunctive superior mesenteric or celiac artery stenting in the 33 patients (27.5%) who were treated by concurrent placement of ZDES distal to the ZDEG. The length and distal oversizing of ZDEG components used was less in this group.

CONCLUSIONS

The present series demonstrates a low (<1%) RTAD rate and favorable morbidity and mortality. The lower rate of paraplegia, dialysis, and visceral artery stenting in the cohort that had adjunctive use of ZDES is compelling and merits further assessment.

Technique-Based Evaluation of Clinical Outcomes and Aortic Remodelling Following TEVAR in Acute and Subacute Type B Aortic Dissection

INTRODUCTION

To evaluate the clinical outcomes and aortic remodelling rates following thoracic endovascular aortic repair (TEVAR) for acute or subacute type B aortic dissection (TBAD) based on technique.

MATERIAL AND METHODS

All TEVARs for acute/subacute TBAD between 01/01/2008 and 01/06/2020 were included. TEVARS were grouped by technique (TEVAR only, PETTICOAT and STABILISE). Aortic remodelling was assessed at three aortic levels on follow-up CT. Thirty-day technical/clinical success rates, re-intervention rates and complications were recorded.

RESULTS

A total of 29 patients were included. The median age was 55 years (31-82). The median duration from initial presentation to TEVAR was 7 days (0-84). Intra-procedural complications included one aortic rupture from balloon moulding in a STABILISE case. Thirty-day mortality, stroke, spinal cord ischaemia and visceral ischaemia were 3% (n = 1), 3% (n = 1), 3% (n = 1) and 3% (n = 1), respectively. (All occurred in acute TBAD.) Overall survival was 50.5 months (18-115). Median follow-up was 31 months (1-115). Six patients (21%) required re-intervention, with a median time of 5 months (5-46) from first TEVAR. Overall complete aortic remodelling rates were: 89% at the proximal descending thoracic aorta, 78% at the distal thoracic aorta and 50% at the infra-renal abdominal aorta. At the infra-renal aorta, the STABILISE group (n = 11) had a higher complete aortic remodelling rate (82%) compared to TEVAR alone (n = 12) (20%).

CONCLUSION

Endovascular intervention for acute and subacute TBAD is safe with a high rate of technical success. STABILISE results in higher aortic remodelling at the infra-renal aorta (82%) compared to TEVAR alone (20%) but risks aortic rupture from balloon moulding.

Endovascular strategies for post-dissection aortic aneurysm (PDAA)

Residual patent false lumen (FL) after type B aortic dissection (TBAD) repair is independently associated with poor long-term survival. Open surgery and endovascular repair result in good clinical outcomes in patients with AD. However, both treatments focus on proximal dissection but not distal dissection. About 13.4–62.5% of these patients present with different degrees of distal aneurysmal dilatation after primary repair. Although open surgery is the first-choice treatment for post-dissection aortic aneurysm (PDAA), there is a need for high technical demand since open surgery is associated with high mortality and morbidity. As a treatment strategy with minimal invasion, endovascular repair shows early benefits and low morbidity. For PDAA, the narrow true lumen (TL), rigid initial flap and branch arteries originating from FL have increased difficulties in operation. The aim of endovascular treatment is to promote FL thrombosis and aortic remodeling. Endovascular repair includes intervention from FL and TL sides. TL intervention techniques (parallel stent-graft, branched and fenestrated stent-graft among others) have been proven to be safe and effective in PDAA. Other FL intervention techniques that have been used in selected patients include FL embolization and candy-plug techniques. This article introduces available endovascular techniques and their outcomes for the treatment of PDAA.

Trends and controversies in type A aortic surgery in the 21st century: Branch first aortic arch replacement

BACKGROUND

Acute type A dissection (ATAAD) remains a morbid condition with reported surgical mortality as high as 26%.

AIMS

We describe our surgical approach to ATAAD using a "branch first" total arch replacement technique which avoids a traditional approach of ascending aorta and "hemi-arch" replacement utilising deep hypothermic circulatory arrest (DHCA) and an open distal anastomosis. We also discuss the indications for adjunct techniques such as the frozen elephant trunk or complete aortic repair with endovascular methods.

MATERIALS & METHODS

Thirty-nine patients underwent a "branch first" total aortic arch replacement for ATAAD.

RESULTS

We had an overall 5(12.8%) hospital mortalities and 2 (5.1%) strokes. There were no deaths or strokes in patients without pre-operative organ malperfusion or shock.

DISCUSSION

Arch replacement using the "branch-first technique" allows for complete proximal aortic replacement and sets up for straightforward future distal aortic intervention.

CONCLUSION

The use of a branch first aortic arch replacement technique in ATAAD results in improved outcomes and is an approach applicable to all cardiac surgeons not only the aortic sub specialist.

The Number of Preoperative Abdominal False Lumen-perfused Small Branches Is Related to Abdominal Aortic Remodeling after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

BACKGROUND

Abdominal aortic enlargement (AAE) is a commonly seen complication after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). This study assessed the relationship between preoperative abdominal false lumen-perfused small branches (pre-AFLSBs) and risk of AAE after TEVAR for TBAD extending through the abdominal aorta.

METHODS

One hundred and eighty-four patients with TBAD who had been treated by TEVAR at 4 hospitals in China were stratified in accordance with median pre-AFLSBs: ≤8 (group A) and >8 (group B). AAE was defined as ≥20% increase in abdominal total aortic volume, measured using imaging software featuring centerline analysis, on most recent postoperative computed tomography angiography relative to preoperative examination. Multivariable Cox proportional hazard regression was used to evaluate the relationship between the number of pre-AFLSBs and the risk of AAE after TEVAR.

RESULTS

At median 12.4 months imaging follow-up, AAE was present in 65 patients at higher cumulative rate (log-rank test P < 0.001) in group B, which had more frequent partially thrombosed or patent abdominal false lumen than group A at 6-12 months (P < 0.01) and 12-24 months (P = 0.03) of follow-up. In a multivariable Cox proportional hazard regression model, the number of pre-AFLSBs was independently associated with risk of AAE after TEVAR (hazard ratio [for one increase], 1.10; 95% confidence interval, 1.00-1.21; P = 0.04) after adjustment for age, gender, dissection chronicity, Society for Vascular Surgery risk score, preoperative maximum descending aortic diameter, false lumen status of the abdominal aorta, numbers of false lumen-perfused visceral arteries, abdominal intimal larger tears, and preoperative abdominal intimal small tears, and dissection length and descending aortic length ratio.

CONCLUSIONS

The number of pre-AFLSBs was positively associated with the risk of AAE after TEVAR for TBAD extending through the abdominal aorta.

STABILISE Technique for a Non-A Non-B Acute Aortic Dissection in Marfan Syndrome

A 35-year-old man, with a deep pectus excavatum due to a Marfan syndrome treated 9 years before for an acute type A dissection involving only the aortic arch, by a Bentall surgery, was admitted for acute chest pain. Computed tomography (CT) scan showed an acute type non-A non-B dissection extending to the iliac. After 5 days with strict arterial blood pressure management, the patient had recurrent refractory chest pain and a hybrid technique associating full supra-aortic vessels debranching and STABILISE technique during the same procedure was performed. The patient had an uneventful recovery with CT scan showing complete aortic arch aneurysm exclusion.

One-Year Single-Center Results of the Multilayer Flow Modulator Stents for the Treatment of Type B Aortic Dissection

Purpose

To report a single-center series of patients with type B aortic dissection treated with the Multilayer Flow Modulator (MFM).

Materials and Methods

Over a 36-month period, 23 patients (median age 53 years; 20 men) with complicated type B aortic dissections (2 acute, 5 subacute, and 16 chronic) were treated with the MFM. Primary endpoints of rupture or dissection-related death, overall mortality, and reintervention were evaluated using the Kaplan-Meier method; estimates for freedom from the endpoints are reported with the 95% confidence interval (CI). Secondary outcomes included technical success, adverse events, and aortic remodeling. Clinical and imaging data were collected preoperatively, directly postoperatively, and annually to 36 months for analysis using computational fluid dynamics (CFD).

Results

Initial technical success was 91.3%. The estimates of the endpoints at 12 months were 100% for freedom from rupture or aortic-related death, 95.7% for freedom from overall mortality, and 91.3% for freedom from reintervention. No device-related neurological or systemic complications occurred, and no additional reinterventions were needed during follow-up. A total of 144 branches overstented by the MFM remained patent. Morphologic analysis of the aortic dissection showed progressive true lumen volume increase (75.9%, p<0.001) with concomitant false lumen volume decrease (42.8%, p<0.001); the CFD analyses showed increased laminar flow.

Conclusion

In the current series, the MFM provided a safe and feasible treatment option for complicated acute, subacute, and chronic type B aortic dissections, with high technical success, low mortality, and active aortic remodeling. Further studies should elucidate the long-term safety of the MFM and its effectiveness in a larger patient cohort.

Laser aortic septotomy during thoracic endovascular aortic repair for chronic type B aortic dissection

OBJECTIVE

Persistent false lumen perfusion due to the presence of a thick aortic septum is a significant obstacle to successful thoracic endovascular aortic repair for chronic type B aortic dissection (cTBAD). We describe our new approach of laser aortic septotomy to optimize the landing zone.

METHODS

Between 2019 and 2020, 11 patients with cTBAD with degenerative aneurysm underwent laser aortic septotomy during thoracic endovascular aortic repair. A prospectively maintained database was retrospectively reviewed.

RESULTS

The median age was 70.0 years, and 10 (91%) were men. Six (55%) were de novo type B aortic dissection and 5 (45%) were residual type B aortic dissection. The age of aortic dissection was 2.9 years (interquartile range, 1.1-12.1). Technical success was achieved in 91% (10/11). In 1 case (9%), laser aortic septotomy was not feasible due to extremely tortuous aorta. Among successful cases, the median extents of proximal and distal laser fenestrations were Th7.5 and Th11.0, respectively and distal landing zones included zone 4 (40%) and zone 5 (60%). Two (18%) underwent a continuous longitudinal laser fenestration, and 8 (73%) had longitudinal spot laser fenestrations with immediate balloon dilatations. Apposition of the stent-graft to the outer aortic wall of the newly created common aortic lumen with elimination of retrograde false lumen flow was achieved in all cases.

CONCLUSIONS

This is the first description using the laser technology to optimize the distal landing zone for cTBAD. This new technique is safe and reproducible, with excellent controllability to achieve aortic septotomy at the desired target aorta segment.