Endovascular management of chronic symptomatic aortic dissection with the Streamliner Multilayer Flow Modulator: Twelve-month outcomes from the global registry

Multilayer Stent for Emergency Treatment of Acute Type B Aortic Dissection: A Case Report

PURPOSE

We report the case of an acute type B dissection with high-risk features treated with multilayer stent.

CASE REPORT

A 50-year-old female patient presented to the emergency department with an acute type B aortic dissection. Conservative medical treatment did control blood pressure but did not alleviate her dissection symptoms. She was treated endovascularly with multilayer stents extensively covering the whole dissected area. HThe aortic arch side branches, visceral arteries and renal arteries remained patent after treatment. The recovery was uneventful, and she was discharged the day after the intervention. At 6- and 12-month follow-up, the patient remained asymptomatic, the true lumen volume increased and all side branches remained patent.

CONCLUSION

We present a case of the use of a multilayer stent for acute type B aortic dissection. This technique allows to treat the whole dissection with low risk of paraplegia or side branch occlusion. Long-term results of ongoing clinical studies should confirm the place of the multilayer stent as a treatment option for type B aortic dissection.

Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review

Background

Thoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.

Methods

This is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.

Results

There were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.

Conclusion

Acute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.

TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome

This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.

The contemporary design of endovascular aneurysm stent-graft materials: PTFE versus polyester

Endovascular aneurysm repair of the abdominal aorta (EVAR) and of the thoracic aorta (TEVAR) have revolutionised therapeutic strategies in the management of aortic pathology, and endovascular repair is now an established and attractive alternative to open surgical repair (OSR) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost-effectiveness, which is reflected in the controversial NICE guidelines on abdominal aortic aneurysm (AAA) repair published in 2018, which advised against EVAR for elective aortic repair due to high secondary intervention rates and resultant associated costs. There is no doubt that OSR continues to have a valuable role to play in aortic repair, but it is not universally applicable, especially in older and sicker patients. Therefore, we should not dismiss EVAR and TEVAR without examining the reasons for long-term failure, and the most obvious starting point is stent graft material properties. Polytetrafluoroethylene (PTFE) and polyester are the two most common stent-graft materials; however, there has been no objective comparison of PTFE and polyester stent-graft post-procedural outcomes in EVAR and TEVAR, or even OSR. This lack of definitive data on different stent-graft materials and their configuration necessitates a comprehensive review to elucidate the post-procedural outcome in terms of endograft failure, cardiovascular events, and aortic-related mortality and morbidity.

Unibody design for aortic disease with a narrow aortic bifurcation: tips and tricks for success

Background

Surgical management of patients with abdominal aortic diseases associated with distal narrowing is a challenging situation.

Objectives

To evaluate outcomes of unibody bifurcated endovascular stent graft repair.

Methods

This is a retrospective, observational, multi-institutional database study of a cohort of consecutive cases, approved by the local Ethics Committee. Records were reviewed of patients diagnosed from 2010 to 2020 with “shaggy” aorta, saccular aneurysm, penetrating aortic ulcer, and isolated aortic dissection located in the infrarenal abdominal aorta. All patients were treated with a unibody bifurcated stent graft. Main outcomes were technical success, procedure complications, long-term patency, and mortality in the follow-up period up to 5 years. Data on demographics, comorbidities, surgical management, and outcomes were analyzed.

Results

Twenty-three patients were treated with unibody bifurcated stent graft repair, including 7 cases of “shaggy” aorta, 3 isolated dissections of the abdominal aorta, 4 penetrating aortic ulcers, and 9 saccular aneurysms. Immediate technical success was achieved in 100% of cases. At follow-up, all stent grafts remained patent and there were no limb occlusions. The patients were symptom-free and reported no complications related to the procedure. There were 5 deaths during the follow-up period (median= 4 years), but none were related to the procedure and there were no aorta-related deaths.

Conclusions

The present study shows that unibody bifurcated stent grafting is safe and effective in this group of patients with narrow distal abdominal aorta and complex aortic pathology. The results were similar for both infrarenal aortic aneurysms and aorto-iliac atherosclerotic disease.

Endovascular therapies for Type B Aortic Dissection

Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.

Staged hybrid single lumen reconstruction (TIGER) with bilateral subclavian transposition coupled with thoracic endovascular aneurysm repair in the management of acute symptomatic complex type B aortic dissection in a patient with arteria lusoria

We present a 54-year-old Caucasian woman, who presented with acute symptomatic type B aortic dissection with deteriorating renal function. She was a known smoker with a 2-year history of dysphagia. CT angiography documented the artery of lusoria arising from the mid-thoracic aorta, aneurysmal dilation of her descending aorta, and kinetic and static flaps around her visceral ostia. The patient was managed by staged hybrid single lumen reconstruction and bilateral subclavian to carotid transpositions. During follow-up, there was no aortic rupture or retrograde type A dissection. There were no renal, visceral, cardiac, pulmonary or spinal complications. The patient went off her antihypertensive medication with a normal estimated glomerular filtration rate and accelerated aortic modulation.

Multilayer stents affect the final diameter of aortic aneurysms and maintain renal artery patency for a short time in a swine experimental model

OBJECTIVES

We sought to analyze the hemodynamic effects of the multilayer flow-modulated stent (MFMS) in Thoracoabdominal aortic aneurysms (TAAAs).

METHODS

The hemodynamic effects of MFMS were analyzed in aortic thoracoabdominal aneurysms in experimental swine models. We randomly assigned 18 pigs to the stent or control groups and underwent the creation of an artificial bovine pericardium transrenal aneurysm. In the stent group, an MFMS (Cardiatis, Isnes, Belgium) was immediately implanted. After 4 weeks, we evaluated aneurysm sac thrombosis and renal branch patency by angiography, duplex scan, and morphological analysis.

RESULTS

All the renal arteries remained patent after re-evaluation in both groups. Aneurysmal sac thrombosis was absent in the control group, whereas in the stent group it was present in 66.7% of aneurysmal sacs (p=0.061).The mean final aneurysm sac diameter was significantly lower in the stent group (mean estimated reduction, 6.90 mm; p=0.021). The proximal neck diameter decreased significantly in the stent group (mean difference, 2.51 mm; p=0.022) and grew significantly in the control group (mean difference, 3.02 mm; p=0.007). The distal neck diameter increased significantly in the control group (mean difference, 3.24 mm; p=0.017). There were no significant findings regarding distal neck measurements in the stent group.

CONCLUSION

The MFMSs remained patent and did not obstruct the renal arteries within 4 weeks. In the stent group, the device was also associated with a significant decrease in aneurysmal sac diameter and a large proportion (albeit non-significant) of aneurysmal sac thrombosis.

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.

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.

Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection

In recent guidelines of international societies, the most frequent indication for treatment after chronic type B aortic dissection (cTBAD) is aneurysmal dilatation. Endovascular repair is recommended in patients with moderate to high surgical risk or with contraindications to open repair. During the last decade, many advances have been made in the field of endovascular techniques and devices. The aim of this article is to address the current status of endoluminal techniques for the management of cTBAD including standard thoracic endovascular repair, new devices, fenestrated and branched abdominal aortic devices and false lumen occlusion techniques.

Results of a three-year follow-up after endovascular therapy with multilayer flow modulator in complex thoracoabdominal aortic aneurysm: A case report

OBJECTIVES

Studies on the short-, medium and long-term effects of flow guiding stents are still limited. In this case report, we present three-year follow-up of the multilayer flow modulator stent in a 55-year-old patient with Crawford Type 2 thoracoabdominal aortic aneurysm.

METHODS

A 55-year-old male patient with Crawford Type 2 thoracoabdominal aortic aneurysm had applied to our medical center. The aneurysm involved coeliac truncus and superior mesenteric artery and extended to the renal artery ostia. Multilayer flow modulator stent was successfully placed, and follow-up CT (Computed tomography) angiographic examination images recorded intermittently (36 months).

RESULTS

After three years, it was observed that the left renal artery was thrombosed and the left kidney went to atrophy. Other major vascular branches were observed to be open. During this time, the aneurysm was completely closed with thrombus, but the diameter of the aneurysm continued to increase.

CONCLUSIONS

Multilayer flow modulator stents are safe in complex aortic aneurysms. The device increases the thrombus load in the aortic aneurysm and maintains the flow of the main vascular branches. But re-interventions, dilatation of the aneurysm sac and visceral branch obstructions are still challenging for multilayer flow modulator stents.

Geometric Analysis of Type B Aortic Dissections Shows Aortic Remodeling After Intervention Using Multilayer Stents

Recently, multilayer stents for type B aortic dissections (TBAD) have been proposed to decrease false lumen flow, increase and streamline true lumen flow, and retain branch vessel patency. We aimed to provide a protocol with standardized techniques to investigate aortic remodeling of TBAD by multilayer flow modulators (MFM) in static geometric and hemodynamic analyses. Combining existing literature and new insights, a standardized protocol was designed. Using pre- and postoperative CT scans, geometric models were constructed, lumen dimensions were calculated, computational fluid dynamics (CFD) models were composed, and velocity and pressures were calculated. Sixteen TBAD cases treated with MFM were included for analysis. For each case, aortic remodeling was analyzed using post-processing medical imaging software. After 3D models were created, geometrical anatomical measurements were performed, and meshes for finite element analysis were generated. MFM cases were compared pre- and postoperatively; true lumen volumes increased (p < 0.001), false lumen volumes decreased (p = 0.001), true lumen diameter at the plane of maximum compression (PMC) increased (p < 0.001), and false lumen index decreased (p = 0.008). True lumen flow was streamlined, and the overall fluid velocity and pressures decreased (p < 0.001 and p = 0.006, respectively). This protocol provided a standardized method to evaluate the effects of MFM treatments in TBAD on geometric analyses, PMC, and CFD outcomes.

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.

Hemodynamic Effects of Multiple Overlapping Uncovered Stents on Aortic Dissection: Surgical Strategies and Implications for False Lumen Thrombosis

PURPOSE

Multiple overlapping uncovered stents (MOUS) are employed to promote false lumen thrombosis in the aortic dissections (AD), when the tears are in close vicinity to the branch vessels. However, the overall rate of false lumen thrombosis remains unsatisfactory. This study was performed to investigate the hemodynamic influence of MOUS on aortic dissection to shed some light on the mechanism of post-stenting false lumen thrombosis.

METHODS

An anatomically accurate computational fluid dynamics model was developed to investigate the hemodynamics of AD. A parametric study was carried out to demonstrate the hemodynamic influence of MOUS in various post-surgery scenarios featuring the representative surgical strategies involving MOUS.

RESULTS

The use of reduced-porosity MOUS slowed the blood flow in the false lumen and decreased the wall shear stress. MOUS depressed the false lumen and enlarged the true lumen, without significantly altering the blood outflow distribution among the branch vessels. Compared with MOUS-alone and stent graft-alone scenarios, the combination of MOUS and stent graft generated a substantially large region of stagnant flow. The active flow was confined to an area in close vicinity to the tears covered by the MOUS, which perfuse the right renal artery in the false lumen.

CONCLUSIONS

MOUS helps to generate a favored hemodynamic environment for thrombus formation in the false lumen. Application of MOUS along with covered stent grafts may represent a more effective treatment for AD than utilizing MOUS or stent graft alone.

Kinetic Elephant Trunk Technique: Early Results in Chronic Symptomatic Aortic Dissection Management

BACKGROUND

The aim was to expand our understanding of the dynamic evolution of the aorta throughout the dissection time course. We investigated how the disease process can be modulated to equalize lumen pressure, enhance perfusion, and stabilize the aorta along its entire length using the kinetic elephant trunk (kET) technique.

METHODS

We performed the kET on 9 patients with chronic symptomatic aortic dissection (CSAD) as a primary or secondary intervention, regardless of the chronicity of the dissection. Endovascular scissoring of the intraluminal septum is performed in the infradiaphragmatic dissected aorta to equalize pressure between true and false lumens and allow all branched vessels to be supplied from one lumen. The Streamliner Multilayer Flow Modulator (SMFM), an uncovered cobalt-alloy aortic device, is deployed from the aortic sinus, covering the supra-aortic branches, distally into the distal aorta (primary intervention). In the case of a previous ascending aorta Dacron graft, the SMFM is deployed (secondary intervention) at the level of the Dacron graft so that it is overlapped with the graft and landed in the distal aorta.

RESULTS

In the initial study period, all-cause and aortic-related survival were 100%, respectively; all great vessels and visceral branches were patent; and freedom of stroke, end-organ ischemia, paraplegia, and renal failure were 100%.

CONCLUSIONS

The kET is a treatment process for managing CSAD. Its simplicity, consistency, and reproducibility in high-risk patients with low morbidity and mortality add to the armamentarium of the cardiovascular specialist. Further assessment of the medium- and long-term outcomes is needed to fully establish the benefits of kET.

Aortic Remodeling After Total Endovascular Aortic Repair With Multilayer Stents: Computational Fluid Dynamics Analysis of Aortic Remodeling Over 3 Years of Follow-up

PURPOSE

To report Multilayer Flow Modulator (MFM) implantation from the sinotubular junction to the distal infrarenal aorta in the treatment of type B aortic dissection (TBAD) and demonstrate aortic remodeling using computational fluid dynamics (CFD) analysis over the course of 3-year follow-up.

CASE REPORT

A hypertensive patient with complicated TBAD required thoracic endovascular aortic repair due to severe thoracic pain associated with rapid progression of the false lumen aneurysm toward the distal aortic arch. Under general anesthesia, 2 aortic multilayer stents were placed over a 0.035-inch stiff guidewire in the compressed true lumen. The aorta was covered with 2 MFM stents between the sinotubular junction and the distal infrarenal aorta. Serial computed tomography scans showed progressive remodeling of the entire dissected aortic wall, with an excellent result at 24 months. Morphological and CFD vascular analysis confirmed the aortic remodeling, with a false lumen index drop from a preoperative 4.04 to 0.01 at 36 months.

CONCLUSION

Endovascular aortic repair with multilayer stents is a promising treatment for complicated TBAD due to the unique ability of these devices to stabilize the entire aortic wall without compromising the flow in the major aortic side branches.

Multilayer flow modulator enhances vital organ perfusion in patients with type B aortic dissection

Management of aortic dissections (AD) is still challenging, with no universally approved guideline among possible surgical, endovascular, or medical therapies. Approximately 25% of patients with AD suffer postintervention malperfusion syndrome or hemodynamic instability, with the risk of sudden death if left untreated. Part of the issue is that vascular implants may themselves induce flow disturbances that critically impact vital organs. A multilayer mesh construct might obviate the induced flow disturbances, and it is this concept we investigated. We used preintervention and post-multilayer flow modulator implantation (PM) geometries from clinical cases of type B AD. In-house semiautomatic segmentation routines were applied to computed tomography images to reconstruct the lumen. The device was numerically reconstructed and adapted to the PM geometry concentrically fit to the true lumen centerline. We also numerically designed a pseudohealthy case, where the geometry of the aorta was extracted interpolating geometric features of preintervention, postimplantation, and published representative healthy volunteers. Computational fluid dynamics methods were used to study the time-dependent flow patterns, shear stress metrics, and perfusion to vital organs. A three-element Windkessel lumped parameter module was coupled to a finite-volume solver to assign dynamic outlet boundary conditions. Multilayer flow modulator not only significantly reduced false lumen blood flow, eliminated local flow disturbances, and globally regulated wall shear stress distribution but also maintained physiological perfusion to peripheral vital organs. We propose further investigation to focus the management of AD on both modulation of blood flow and restoration of physiologic end-organ perfusion rather than mere restoration of vascular lamina morphology. NEW & NOTEWORTHY The majority of aortic dissection modeling efforts have focused on the maintenance of physiological flow using minimally invasive placed grafts. The multilayer flow modulator is a complex mesh construct of wires, designed to eliminate flow disruptions in the lumen, regulate the physiological wall stresses, and enhance endothelial function and offering the promise of improved perfusion of vital organs. This has never been fully proved or modeled, and these issues we confirmed using a dynamic framework of time-varying arterial waveforms.

A clinical review of early outcomes from contemporary flow modulation versus open, fenestrated and branch technologies in the management of thoracoabdominal aortic aneurysm

Traditional therapeutic options for complex thoracoabdominal aneurysm include open repair, hybrid repair or endovascular repair (involving fenestrated or branched endografts). The Streamliner Multilayer Flow Modulator has been available for treatment of thoracoabdominal aneurysms since 2010. Its design permits blood flow to perfuse through the mesh in a modus that preserves collateral branch patency, while modulating turbulent to laminar flow within the device. The flow then stagnates over time within the surrounding aneurysm sac. Significant complications, including paraplegia, renal failure and cerebrovascular accident, are much lower with Streamliner Multilayer Flow Modulator treatment. Application of the Streamliner Multilayer Flow Modulator to complex aortic pathologies presents a novel solution to an, as of yet, unmet clinical need, and has resulted in promising clinical outcomes when compared to existing solutions. The Streamliner Multilayer Flow Modulator offers potential for treatment of thoracoabdominal aortic pathologies in patients and is not just confined to those with complexity that dictates no other management options. While current literature illustrates that there is a decreased risk of mortality and associated complications when this new disruptive technology is utilised, there is still a need for prospective, long-term clinical trials, as well as comparative trials to accurately assess outcomes of Streamliner Multilayer Flow Modulator treatment that are both precise and reproducible. This article is a review of current clinical literature regarding contemporary flow modulating technology compared with open, branched and fenestrated managements, presenting early outcomes.