Thoracic endovascular aortic repair versus open surgery for type-B chronic dissection

Radiomics-Based Risk Assessment Correlates With Outcomes in Patients With Acute Type B Aortic Dissection Undergoing Thoracic Endovascular Repair

OBJECTIVES

Our study aimed to investigate the correlations between radiomics-based assessment and outcomes, including positive aortic remodeling (PAR), reintervention for dissection at 1 year, and overall survival, in patients with Type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair (TEVAR).

METHODS

This was a single-center, retrospective, cohort study. The cohort comprised 104 patients who had undergone TEVAR of TBAD in our institution between January 2010 and October 2022. We segmented preoperative computed tomography (CT) images of the patients' descending aorta regions, then extracted a comprehensive set of radiomic features, including first-order features, shape features (2D and 3D), gray-level co-occurrence matrix (GLCM), gray-level size zone matrix, gray-level run length matrix, gray-level dependence matrix, neighborhood gray-tone difference matrix, from the regions of interest. Next, we selected radiomics features associated with total descending aorta positive aortic remodeling (TDA-PAR) and reintervention by least absolute shrinkage and selection operator (LASSO) regression and features associated with survival by LASSO-Cox regression. This enabled us to calculate radiomics-based risk scores for each patient. We then allocated the patients to high and low radiomics-based risk groups, the cutoff being the median score. We used 3 different models to validate the radiomics-based risk scores.

RESULTS

The patients' baseline characteristics did not differ between those who achieved TDA-PAR and those who did not. The radiomics-based risk scores were significantly and independently associated with all 3 outcomes. As to the impact of specific radiomics features, we found that GLSZM_SmallAreaLowGrayLevelEmphasis and shape_Maximum2DDiameterColumn had positive impacts on both reintervention and survival outcomes, whereas GLCM_Idmn positively affected survival but negatively affected reintervention. We found that radiomics-based risk for TDA-PAR correlated most significantly with zone 6 PAR.

CONCLUSIONS

Radiomics-based risk scores were significantly associated with the outcomes of TDA-PAR, reintervention, and overall survival. Radiomics has the potential to make significant contributions to prediction of outcomes in patients with TBAD undergoing TEVAR.

CLINICAL IMPACT

In this study of 104 patients with Type B aortic dissection, we demonstrated associations between radiomics-based risk and postoperative outcomes, including total descending aorta positive aortic remodeling, reintervention and survival. These findings highlight radiomics' potential as a tool for risk stratification and prognostication in acute Type B aortic dissection management.

Mid- and long-term results of open repair for chronic type B aortic dissection in endovascular era

Medical management is the standard treatment of chronic type B aortic dissection (CTBAD). However, the roles of open surgical repair (OSR) and thoracic endovascular repair (TEVAR) in patients with CTBAD remain controversial. Thus, this study aimed to assess and compare the mid- and long-term clinical outcomes of OSR via left thoracotomy with that of TEVAR for CTBAD. The data of 85 consecutive patients who underwent surgery for CTBAD from April 2007 to May 2021 were retrospectively reviewed. The patients were divided into two groups: Group G, which included patients who underwent OSR, and Group E, which included patients who underwent TEVAR. Groups G and E comprised 33 and 52 patients, respectively. Preoperative and postoperative computed tomography (CT) studies were retrospectively analyzed for the maximum diameter. The mean duration of the follow-up period was 5.8 years. Operative mortality did not occur. There was no difference in complications, such as stroke (G: 2 vs. E: 0, p = 0.30), paraplegia (G: 1 vs. E: 1, p = 0.66), and respiratory failure (G: 2, vs. E: 0, p = 0.30). The difference in preoperative factors was observed, including the intervals between onset and operation (G; 4.9 years vs. E; 1.9 years, p < 0.01), maximum diameter in preoperative CT (G; 59.0 mm vs. E; 50.5 mm, p < 0.001), and maximum false lumen diameter (G; 35.5 mm vs. E; 29.0 mm, p < 0.01). There was no significant difference in the mid- and long-term survival rates (p = 0.49), aorta-related deaths (p = 0.33), and thoracic re-intervention rates (p = 0.34). Postoperative adverse events occurred in Group E: four cases of retrospective type A aortic dissection, two cases of aorto-bronchial fistula, and one case of aorto-esophagus fistula. Aorta-related death and re-intervention rates crossed over in both groups after seven years postoperatively. Although endovascular repair of CTBAD is less invasive, the rate of freedom from re-intervention was unsatisfactory. Some fatal complications were observed in the endovascular group, and the mid- and long-term outcomes were reversed compared with those in the OSR group. Although OSR is an invasive procedure, it could be performed safely without perioperative complications. OSR has more feasible mid- and long-term outcomes.

Effect of False Lumen Occlusion Treatment With AFX VELATM, Candy-Plug Technique for Chronic Aortic Dissection

INTRODUCTION

We sought to examine midterm results and remodeling effect of false-lumen occlusion treatment using AFX VELA in case of chronic dissection repair.

MATERIAL AND METHODS

From June 2019 to May 2022, we performed false lumen occlusion treatment using a modified Candy-Plug technique with AFX VELA on 8 chronic aortic dissection patients with a patent false lumen. We collected operative data, short-term clinical outcomes, mid-term clinical outcomes and imaging test results. We conducted follow-up examinations at postoperative, 6-month and 1-, 2- and 3-year intervals, including contrast-enhanced computed tomography to evaluate the diameter, false lumen thrombosis and any events.

RESULTS

The average time from the symptom onset to the thoracic endovascular repair was 81.5 (35-155) months. The aorta showed aneurysmal dilation with an average maximum short-axis diameter of 58.9 (41-91) mm. Two cases needed emergency surgery due to rupture and impending rupture. There were no postoperative deaths. Complete thrombosis within the false lumen was achieved in 6 cases (75%), but 2 cases had incomplete thrombosis, requiring additional treatment. The mean maximum diameter showed a significant decrease at 6 months, 1 year and 2 years postoperatively compared to preoperative measurements (P < .05).

CONCLUSION

We showed the results of false lumen occlusion treatment using the AFX VELA cuff. We observed favorable clinical outcomes and remodeling effects. While the long-term durability and efficacy of this technique in aortic remodeling will need to be monitored with further observation, the use of this cuff is considered a reliable approach to false lumen occlusion treatment.

Surgical treatment in the chronic phase for uncomplicated Stanford type B aortic dissection

BACKGROUND

The most appropriate surgical method for patients with uncomplicated type B aortic dissection (UTBAD) in the chronic phase remains controversial. This study evaluated the outcomes of patients with UTBAD who needed aortic treatment as well as the impact of the treatment method or indication criteria on their prognosis.

METHODS

This retrospective review of 106 consecutive patients with aortic events in the chronic phase who underwent initial treatment for UTBAD between 2004 and 2021 comprised three groups: 19 patients who underwent endovascular repair (TEVAR), 38 who underwent open aortic repair and the medication group that included 49 patients. Aortic events were defined as a late operation or indication for operation for dissected aorta, aortic diameter (AD) ≥ 55 mm, rapid aortic enlargement (≥5 mm/6 months), and saccular aneurysmal change. The endpoint was all-cause death. We assessed the association between treatment methods or surgical indication criteria and mortality using a Cox regression analysis.

RESULTS

The 5-year actuarial mortality rates were 27.1% in the TEVAR group, 19.6% in the open aortic repair group, and 38.4% in the medication group (p = 0.86). Moreover, the 5-year actuarial mortality rates in patients who had AD ≥ 55 mm were significantly higher than those patients with other surgical indication criteria (41.2% vs. 18.7%, p < 0.01). Multivariable analysis revealed a significant difference in AD ≥ 55 mm (hazard ratio [HR]: 2.88, 95% confidence interval [CI] 1.38-6.02, p < 0.01) and age (HR: 1.09, 95% CI 1.05-1.13, p < 0.01).

CONCLUSIONS

Under the existing surgical indication criteria, there was no difference in mortality rates among patients with UTBAD based on their surgical treatment.

Evaluation of false lumen occluders implanted in the abdominal aorta false lumen

OBJECTIVE

Management of postdissection thoracoabdominal aneurysms with a fenestrated and/or branched endograft (F/BEVAR) is associated with favorable outcomes. Treatment should include both true lumen endografting and false lumen occlusion (FLO). Favorable results have recently been reported for FLO in the false lumen of the thoracic aorta. The purpose of this study is to analyze the results of FLO of the abdominal aorta in patients treated for post dissection thoracoabdominal aneurysm.

METHODS

A multicenter retrospective analysis of prospective data of consecutive patients managed for post dissection thoracoabdominal aortic aneurysm from April 2019 to December 2022 with F/BEVAR associated with FLO in the abdominal false lumen was conducted. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) was followed. Baseline demographics, operative details, and early outcomes (mortality, length of stay) were recorded. Primary endpoints were technical and clinical success. FLO technical success was defined as complete occlusion of false lumen backflow above the FLO on completion angiogram.

RESULTS

During the 3-year study, 23 patients were treated for post dissection thoracoabdominal aneurysm with F/BEVAR and the use of abdominal FLO. Twenty-one patients (91.3%) had received prior endovascular treatment. The technical and clinical success was 95.7%. The abdominal FLO had a technical success rate of 78.3%. The median diameter of the FLO was 34 mm. No patient died during the perioperative period, and one patient had spinal cord ischemia (4.3%) with partial recovery. Six patients (26.1%) required early reintervention. The median duration of hospitalization in the intensive care unit and overall was 1 day (interquartile range, 0-3 days) and 7.5 days (interquartile range, 2-22 days), respectively. During the mean follow-up of 9.9 ± 9.0 months, no patient died. False lumen occlusion was complete or partial in nine (39.1%) and nine (39.1%) patients, respectively. No aortic rupture occurred during follow-up. Maximum aortic diameter decreased in 48% and remained stable in 39% of cases.

CONCLUSIONS

Abdominal aorta FLO during endovascular treatment of post dissection thoracic abdominal aortic aneurysm is associated with favorable outcomes. It offers an additional staging therapeutic option before extensive aorto-bi-iliac coverage, associated with low spinal cord ischemia rates. FLO also provides high rates of false lumen occlusion and false lumen remodeling during follow-up. Longer follow-up and larger cohorts are required to confirm these very promising early findings.

Type Ib endoleak repaired with a thoracic endovascular graft inside previous visceral debranching bypass in a patient with chronic type B aortic dissection

We present the case of a patient with chronic type B aortic dissection with a previous iliac to visceral debranching graft and thoracoabdominal endograft who, because of a type Ib endoleak and aortic diameter enlargement, required a complex solution involving placement of a thoracic endovascular graft inside a Dacron graft with a 180° curved shape in three-stage surgery. At 9 months of follow-up, he had no evidence of type I endoleaks, and the aortic diameter had decreased.

Distal aortic replacement followed by endovascular repair for the management of severe intra-pleural adhesions accidentally detected during open surgery for chronic type B aortic dissection: a report of two cases

BACKGROUND

Open repair is the most promising curative treatment option for patients with chronic type B aortic dissection. However, based on our experience, following the accidental detection of intra-pleural adhesions during open surgery for chronic type B aortic dissection, complete replacement of the diseased aorta cannot be accomplished. To overcome this problem, we switched the procedure to create a distal landing zone for subsequent endovascular repair by replacing the distal aorta with a vascular graft.

CASE PRESENTATION

We report two cases in which open repair was attempted; however, the proximal descending thoracic aorta could not be exposed due to the presence of severe adhesion in the pleural cavity. In these patients, we accessed the lower descending thoracic aorta or thoracoabdominal aorta and created a distal landing zone for subsequent endovascular repair by replacing the aorta with a vascular graft. Thereafter, endovascular repair was performed with good outcomes.

CONCLUSIONS

Replacement of the distal aorta, which is typically easy to access despite the presence of intra-pleural adhesions, with a vascular graft serves as a reliable distal landing zone for subsequent endovascular repair. This method may be a viable option for the management of severe adhesions accidentally detected in the pleural cavity during open repair for chronic type B aortic dissection.

Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association

All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.

Chronic thoracoabdominal aortic dissection: endovascular options to obliterate the false lumen

Background

Persistent false lumen patency in chronic thoracoabdominal aortic dissections after thoracic endovascular aortic repair (TEVAR) contributes to negative aortic remodeling. We have previously described the evolution of various endovascular techniques to treat persistent false lumen perfusion including false lumen embolization. Objectives of this study are to describe endovascular techniques to obliterate the false lumen and present updated outcomes in a recent series of patients undergoing false lumen embolization for chronic aortic dissection.

Methods

From January 2018 to May 2021, 17 patients with chronic dissection underwent false lumen embolization with coils, iliac plugs, and nitinol plugs. This was often in conjunction with or following TEVAR and balloon fracture fenestration. Mean follow-up 354±324 days.

Results

After false lumen embolization there was no mortality, stroke, spinal cord ischemia, or visceral and limb ischemia. No patients required dialysis, though 1 (5.9%) did experience acute kidney injury. There was 1 (5.9%) patient that required endovascular re-intervention on the thoracoabdominal aorta. No patients underwent subsequent open surgical repair.

Conclusions

TEVAR with adjunctive false lumen embolization and balloon fracture fenestration are techniques to obliterate retrograde flow into the false lumen of chronic thoracoabdominal aortic dissections in appropriately selected patients.

Surgical Strategy for Chronic Type B Dissecting Aortic Aneurysm to Prevent Aorta-Related Events

BACKGROUND

This study was aimed to evaluate the outcomes of performing open repair or thoracic endovascular aortic repair for chronic type B dissecting aortic aneurysm.

METHODS

From July 2004 to February 2019, 52 patients underwent surgery as open repair (n = 32) or endovascular repair (n = 20) for chronic type B dissecting aortic aneurysm. Replacement of the aorta was limited to the aneurysmal portion with or without reconstructing the visceral arteries or the segmental arteries. Stent grafts were deployed in the true lumen above the celiac artery to cover the primary entry for even DeBakey IIIb dissection.

RESULTS

Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. Operative mortality and morbidity rates, including spinal cord ischemia incidence, did not differ between the groups. In the endovascular repair group, 3 patients died due to rupture of residual false lumen in the early, and late postoperative follow-up. The 5-year rate of freedom from all-cause death, aorta-related death, and aorta-related event were 84% ± 6%, 94% ± 3% and 84% ± 6%. The endovascular repair was independently associated with all-cause death (hazard ratio [HR], 5.7; confidence interval [CI], 1.02-31.6; P = 0.04) and aorta-related event (HR, 30.9; CI 4.9-195.0; P < 0.001). In the open group, postoperative residual aortic diameter was an independent predictor of aorta-related events, and the threshold was 41 mm.

CONCLUSIONS

Open repair remains a better option than simple endovascular repair alone in DeBakey IIIb dissection, but the distal un-resected aortic portion over 41 mm was associated with late aortic events.

Changes of stent-graft orientation after frozen elephant trunk treatment in aortic dissection

OBJECTIVES

Our goal was to evaluate the extent of stent-graft (SG) elastic recoil in the descending aorta after the frozen elephant trunk procedure in acute (AAD) and chronic (CAD) aortic dissection as well as the impact of SG movement on distal stent graft-induced new entry (d-SINE).

METHODS

We retrospectively analysed 149 (105 AAD, 44 CAD) of 259 aortic dissection patients after the frozen elephant trunk procedure between January 2005 and April 2019. Inclusion criteria were at least 1-year computed tomography angiography (CTA) aortic examinations during a follow-up time of 3.8 ± 2.7 years and absence of open or endovascular reintervention. Multiplanar reconstruction of CTA scans was used to define the SG vector position and movement in a virtual Cartesian coordinate system. The angle φ of vector movement and changes of aortic areas at the distal landing zone were analysed.

RESULTS

The distal SG position changed over time in the cranial (10.06 ± 11.12 mm), dorsal (8.45 ± 11.12 mm) and lateral (4.96 ± 9.89 mm) directions (P < 0.001). The total change of φ (4.08 ± 7.03°) was greater in AAD than in CAD (P = 0.026). d-SINE was more common in CAD (P < 0.001) and was associated with the size of the aortic area, aortic area enlargement and continuous SG unfolding (P < 0.001).

CONCLUSIONS

With the frozen elephant trunk technique, movement and change of SG orientation in the descending aorta were observed over time. Elastic recoil was greater in AAD than in CAD. The incidence of d-SINE was particularly dependent on the size of the aortic lumen and SG radial expansion and less on elastic recoil.

Shrinkage of a Giant Type-B Dissecting Aneurysm Treated by Complete False Lumen Occlusion 20 Years after Presentation: A Case Report

In this study, we report the case of a 47-year-old female who presented with extensive acute type IIIb aortic dissection and cerebral infarction. At 69 years of age, dilatation of the descending aorta was noted to be more than 70 mm with compression of the left atrium. We performed endovascular repair with distal false lumen occlusion. However, further dilatation of the descending aorta with false lumen flow from the re-entry of the common carotid artery was detected. She subsequently underwent additional proximal false lumen occlusion by embolization at the aortic arch. A year later, as per her computed tomography angiography findings, appreciable shrinkage of the descending aorta without endoleakage was observed.

Effect of Aortic Valve Type on Patients Who Undergo Type A Aortic Dissection Repair

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Impact of Endovascular False Lumen Embolization on Thoracic Aortic Remodeling in Chronic Dissection

BACKGROUND

Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival.

METHODS

From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years]).

RESULTS

After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology.

CONCLUSIONS

FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion.

Staged Hybrid Single Lumen Reconstruction (TIGER) in Management of Chronic Symptomatic Complex Type B Aortic Dissection, Techniques, and Literature Review

BACKGROUND

Endovascular intervention for chronic symptomatic type B aortic dissection (CS-TBAD) induces aortic wall stress with negative hemodynamic cardiovascular consequences. CS-TBAD risks increased morbidity and mortality due to septum maturation with significant impact on false lumen modulation, and partial lumen thrombosis conveying the worst outcome. The aim of the TIGER technique is total aortic remodeling with true lumen expansion, false lumen regression and complete thrombosis, and stabilization of overall aortic diameter.

METHODS

We report 5 cases of aortic dissection with a mean follow-up of 16 months (6-28 months). All had aneurysmal dilation, with 3 having acute pan aortic dissection and 2 having CS-TBAD. All were managed by sTaged HybrId sinGle lumEn Reconstruction (TIGER). Our first approach was to create one single lumen from the supraceliac, infradiaphragmatic aorta to both common iliac arteries with open surgical patching of the visceral arteries; then, we performed a TEVAR 3 months later.

RESULTS

Three patients required a left subclavian artery chimney graft and one required bilateral subclavian to carotid artery transposition. No spinal drainage was required, and all patients had intraoperative transesophageal echo for wire guidance. We had no aortic rupture or retrograde type A dissection, and we experienced no renal, visceral, cardiac, pulmonary, or spinal complications. All patients, but one, went off their antihypertensive medication. All patients had normal estimated glomerular filtration rate postoperatively, and they all demonstrated accelerated aortic modulation.

CONCLUSIONS

TIGER was not only effective at the semiacute stage to initiate remodeling and prevent malperfusion, it also facilitated a straightforward TEVAR at stage 2, which was made easier by avoiding visceral branch stenting. Moreover, it decreased the length of aortic segment, which was stented, thereby avoiding critical shattering, branch dislodgment, and visceral compromise; spinal ischemia; and negative cardiovascular consequences.

Proposed classification of endoleaks after endovascular treatment of Stanford type-B aortic dissections

Objectives

Despite two decades of experience, no dedicated classification system exists to document and prognosticate patterns of endoleak encountered after endovascular therapy of type-B aortic dissection. This nomenclature gap has led to inconsistent management and underreporting of significant findings associated with adverse outcomes after endovascular treatment of type-B aortic dissection. Our goal was to propose a reproducible and prognostically relevant classification.

Methods

A multidisciplinary team of seven experienced open and endovascular aortic surgeons was assembled to provide consensus opinion. Extensive literature review was conducted. Deficiencies in the current classification approach of the various patterns of persistent filling of false lumen after endovascular therapy were identified.

Results

Our focus was to categorize high-risk and low-risk subgroups within endoleaks after endovascular treatment of type-B aortic dissection. In this classification, type-Ia endoleak refers to persistent filling of the false lumen in an antegrade manner. Causes include failure to cover the primary entry tear and sizing or technical related proximal seal failure. False lumen filling via distal entry tears is classified as type Ib endoleak, which is further sub-classified into b1 (major branch-related tears), and b2 (multiple small branches related tears). Retrograde ascending aortic dissection and stent graft-induced new entry were classified as type-I endoleaks (type-Ir and type-Is, respectively). Another focus was reclassification type-II endoleaks, with type-IIa endoleak referring to conventional retroleak from one or more posterior branches and type-IIx referring to retroleak from major branches (visceral or left subclavian arteries).

Conclusions

The majority of endoleaks after endovascular treatment of type-B aortic dissection are related to persistent or new filling of the false lumen. We propose a new false lumen-based classification schema for endoleaks occurring after endovascular therapy of type-B aortic dissection.

False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up

OBJECTIVE

Failure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections.

METHODS

Between June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs.

RESULTS

The technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001).

CONCLUSIONS

Embolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.

Distal Neo-Neck Formation for Chronic Type B Dissection: False Lumen Closure After TEVAR

OBJECTIVES:

Patients with chronic aortic dissection often require repeat interventions due to enlargement of the pressurized false lumen or disseminated intravascular coagulation even after additional thoracic endovascular aortic repair (TEVAR) to occlude the entry tear. Residual false lumen flow can persist even after performing the candy-plug technique or branched stent-graft placement in some cases. We have devised a new method for false lumen closure.

METHODS:

From December 2010 to May 2017, 5 patients (mean age: 57 [13] years, range: 43-77 years) with chronic dissection at the aortic arch and descending aorta, who underwent initial TEVAR, required additional treatment. Using an open surgical approach, the endograft was fixed with an outer felt under cardiopulmonary bypass after the endograft with stent was expanded by fenestration. The false lumen was closed using this procedure, and the aortotomy was repaired by direct closure in 2 cases and by graft replacement in 3 cases.

RESULTS:

No major operative complications occurred, such as respiratory failure or paraplegia. Postoperative enhanced computed tomography (CT) images showed that the false lumen flow disappeared in all cases. All patients were discharged under normal conditions. They were all followed up and their CT did not indicate any complications for a mean of 33.6 (20.3) months.

CONCLUSIONS:

Our combined procedure was effective and provided a higher success rate compared with endovascular therapy alone. This staged treatment approach, using a combination of TEVAR and false lumen closure, is less invasive compared with open surgery alone and may represent a valid treatment option for chronic type B dissection.

Operative results of the anterolateral thoracotomy with partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch

Objectives

There are various treatment strategies for chronic-type B aortic dissection involving the aortic arch. Our aim was to review our surgical experience in the anterolateral thoracotomy with the partial sternotomy approach for chronic-type B aortic dissection involving the aortic arch.

Methods

From January 2000 to October 2015, 39 patients underwent the single-stage open surgery for chronic-type B aortic dissection involving the aortic arch using the anterolateral thoracotomy with partial sternotomy approach.

Results

Among the 39 patients, 32 were men (82.1%; mean age at surgery, 61.3 ± 11.9 years), with a mean dissecting aortic aneurysm diameter of 50.21 ± 12.20 mm; 28 patients (71.8%) had patent false lumens of the descending aorta. The median interval from dissection occurrence until surgery was 34.05 ± 52.34 months. Twenty-one patients underwent descending aortic replacement plus total aortic arch replacement and 18 underwent descending aortic replacement (plus partial aortic arch replacement). Overall in-hospital mortality and postoperative stroke rates were 5.1% (2 patients) and 10.3% (4 patients), respectively. Survival rates at 1, 3 and 5 years were 94.7%, 94.7% and 90.2%, respectively. Aortic event-free rates at 1, 3 and 5 years were 90.9%, 90.9% and 80.2%, respectively.

Conclusions

The anterolateral thoracotomy with partial sternotomy approach is a useful surgical procedure with acceptable outcomes for chronic-type B aortic dissection cases involving the aortic arch, when aortic remodelling using thoracic endovascular aortic repair cannot be performed.

Uncomplicated Acute Type B Aortic Dissection: Selection Guidelines for TEVAR

Traditionally, the surgical management of acute type B aortic dissections was reserved for patients with signs of malperfusion, rapid expansion, retrograde dissection or rupture. The adjunct of endovascular techniques has brought a paradigm shift, leaning towards preventing long term dissection complications. Multiple risk factors have been proposed to identify patients at risk for long term aortic complications. The patients, who are offered a prophylactic endovascular therapy for uncomplicated aortic dissection, should be selected carefully, and offered intervention by an experienced team in a high-volume center. (This is a review article based on the invited lecture of the 57th Annual Meeting of Japanese College of Angiology.).

Original Off-Label Endovascular Solution to Occlude False Lumen Rupture in Chronic Type B Aortic Dissection

After Thoracic Endovascular Aortic Repair (TEVAR) for chronic type B aortic dissection (cTBD), the patency of the false lumen is quite common and its presence is associated with the risk of developing complications and is a predictor of death by aortic rupture. We report a case of a patient treated in emergency for the rupture of the false lumen in cTBD. He had previous TEVAR with persisting distal dissection and retrograde reperfusion of the false lumen. We performed an original endovascular treatment with graft relining and false lumen occlusion with a homemade "candy plug" obtained with 2 commercially available stent grafts.