Intraoperative Stent-Graft-Induced Aortic Intimal Intussusception During TEVAR for Type B Aortic Dissection

BACKGROUND

Aortic intimal intussusception is well described in the natural progression of type A aortic dissection. Only 3 cases of aortic intimal intussusception were reported to be related to thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection. In our study, we are reporting a rare but potentially fatal complication, the intraoperative stent-graft (SG)-induced aortic intimal intussusception (ISAII); this study reports a series of endovascular repair for ISAII cases. By presenting the ISAII definition, the diagnostic steps to rule out or to identify the condition, and the techniques to resolve it, we intended to raise the awareness of this severe complication, so that physicians can adapt to overcome the complications while performing TEVAR.

MATERIALS AND METHODS

ISAII was defined as the partial or circumferential disruption of the distal intimal flap as an intraoperative complication of endovascular treatment. From January 2014 to June 2020, 1,096 patients underwent TEVAR for Stanford type B aortic dissection at our hospital. Among them, 14 ISAII complications were witnessed. All these patients underwent endovascular repair for ISAII lesions, and their data were extracted for analysis.

RESULTS

The ISAII lesions were classified into 3 types according to their location in different aortic segments: type I, ISAII was limited within the intended SG coverage segment; type II, ISAII occurred after SG introduction or deployment, and the detached intimal flap extended beyond the intended SG coverage segment but did not affect the abdominal aortic visceral branches; type III, ISAII occurred during SG introduction or deployment, and the detached intimal flap descended to the abdominal aortic segment with visceral branches. Our results showed ISAII as a rare complication with an incidence of 1.28% (14/1096), and endovascular repair for all types of ISAII is an effective treatment. With a mean follow-up of 27.36 months (range 5-71 months), all the ISAII lesions were stable, and all the major aortic branches, SGs, and bare stents were patent.

CONCLUSIONS

The management of this potentially devastating intraoperative complication relies on accurate diagnosis and prompt management. Our results suggested that endovascular repair for ISAII is effective and durable for correcting this complication.

GRAPHICAL ABSTRACT

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Aortic Intimo-intimal Intussusception: A Pooled Analysis of Published Reports

AIM

Aortic intimo-intimal intussusception (AoII) is a rare manifestation of aortic dissection with high mortality. This study aimed to obtain a comprehensive understanding of AoII.

METHODS

Three databases (PubMed, Scopus, Embase) were searched with predefined search terms ["intimal intussusception", "aortic intussusception", "(circumferential) AND (intimal dissection)" and "(circumferential) AND (aortic dissection)"]. Demographics, clinical manifestations, imaging methods, therapies, and follow-up data were recorded and analyzed.

RESULTS

The literature search finally identified 81 papers comprising 87 patients (Mean age: 53.7 ± 14.9 years old; male: n = 63). According to morphologic criteria (orientation of AoII intimal flap), patients were divided into three groups: antegrade (n = 37), retrograde (n = 49) and bidirectional (n = 1) orientation. The most frequent symptoms in antegrade group were chest pain (62.2%), syncope (27%), and unconsciousness (21.6%), while in retrograde group, they were chest pain (71.4%), dyspnea (20.4%), and back pain (16.3%). Regarding applied imaging modalities, 67.5% of patients in antegrade group were diagnosed with≥2 methods, comparing with 87.7% in retrograde group. A total of 21 patients (24.1%) with AoII finally died, among which 13.8% (12/87) died before surgery.

CONCLUSION

AoII is a rare form of aortic dissection with high mortality. Antegrade orientation of the intima flap was more accompanied with neurological disorders and asymmetric blood pressure, while retrograde orientation mostly manifested with aortic regurgitation. Application of multiple imaging examinations may detect this rare entity in time.

Type B Aortic Dissection Complicated by Intimo-Intimal Intussusception and Extensive Intimal Denuding: Case Report with Long-term Follow-up

BACKGROUND

Acute aortic dissection rarely results in circumferential dissections of the aortic intima that may lead to intimo-intimal intussusception (IIS) with complete separation from the aortic wall. Circumferential dissection may then result in distal embolization of the involved intima and media, adding considerable complexity to the management of such cases. Despite the severity of this complication, the natural history of aortic disease following extensive intimal denuding and IIS is not well documented in the literature. Here we present a case with long-term follow-up of type B aortic dissection (TBAD) complicated by IIS and embolization of the intima into the distal aorta following thoracic endovascular aortic repair.

METHODS

Medical records and imaging studies were retrospectively reviewed with the approval of the Institutional Review Board. A single patient underwent repair of a TBAD that was complicated by IIS, with follow-up for 6 years. Aortic recovery was monitored with serial computerized tomography scans.

RESULTS

During endovascular stent deployment, the patient's dissection progressed circumferentially, leading to distal embolization of the intima and aortic occlusion. An open transabdominal aortic exploration was performed to extract the embolized intima. Despite this severe aortic structural disruption, the patient recovered well postoperatively and exhibited favorable aortic remodeling over long-term follow-up. The denuded aorta did not rupture or develop progressive worsening aneurysmal dilation and the diameter of the involved aortic segment remained stable during follow-up.

CONCLUSIONS

Acute TBADs can progress to circumferential intimal separation and IIS when managed with endovascular stenting and balloon dilation. Continued endovascular management once IIS has occurred may lead to further intimal damage, resulting in distal embolization of the intima and aortic occlusion. Thus, IIS may require conversion to open repair. However, in the event that loss of the aortic intima does occur following IIS, it is possible for the denuded aorta to recover well and remain stable with favorable remodeling over long-term follow-up.

Aortic intimal intussusception during acute type B aortic dissection endovascular repair

Aortic intimal intussusception (AoII) is rare, especially during the endovascular repair of acute uncomplicated type B aortic dissection. Here we present a case of 47-year-old man who suffered AoII during the endovascular repair of type B aortic dissection. An abdominal aortic stent was inserted to recanalize the aorta, but failed. He was immediately transferred to our department from the local hospital. Computed tomography angiography confirmed the AoII and showed thrombus in the abdominal aortic stent. Hybrid operation was performed. Final angiography showed patency of the aorta. His postoperative period was uneventful and was discharged on the postoperative 8^th day. No complications happened during the 6^th month follow-up.

Descending thoracic endovascular aortic repair does not require cardiothoracic surgery support

Objective

Descending thoracic endovascular aneurysm repair (D-TEVAR) is often performed by vascular surgeons. At many institutions, cardiothoracic surgery support is required for an elective TEVAR to take place. Oftentimes, this means a dedicated cardiopulmonary bypass team must be available. This study aims to investigate that TEVAR is a safe procedure that does not require such a resource-intensive “back-up plan.”

Methods

This is a retrospective analysis of data collected from March 2014 to January 2018 of 18 patients who underwent TEVAR at a tertiary care facility with a level I trauma center. There were 11 males and 7 females with an average age of 68.8 years old (range 19–97; SD ± 19.52). The average body mass index (BMI) was 24.7 kg/m2 (range 16.8–35; SD ±4.67). Nine were never smokers, four were former smokers, and five were currently smoking at the time of the procedure. The most common presenting symptom prior to intervention was chest pain ( n = 10), followed by cough/dyspnea ( n = 5), back pain ( n = 3), and trauma ( n = 2).

Results

The average maximum diameter of the thoracic aortic aneurysms (TAA) treated with TEVAR was 5.49 cm ( n = 7; range 4.3–6.7; SD ± 0.855). Six patients had Stanford Type B aortic dissections. Two patients with TAAs had concomitant, rapidly expanding aortic ulcers. Two patients had traumatic pseudoaneurysms, one of which ruptured prior to TEVAR. One patient had an expanding 1.9 × 1.8 cm saccular pseudoaneurysm of the aortic arch. The mean follow-up time was 69.2 weeks ( n = 17; range 3–166; SD ± 62.67), and one patient did not follow up following their initial TEVAR procedure. Of the 18 patients who received TEVAR, there were no major complications. Two patients experienced a type II endoleak. No patients required conversion to an open procedure, nor did any patients necessitate intervention by cardiothoracic surgery or cardiopulmonary bypass support.

Conclusion

These data suggest that cardiothoracic surgery support is not required for descending thoracic endovascular aneurysm repair (D-TEVAR). Further research is warranted on the risk factors associated with open conversion during these procedures.

Imaging of the Postsurgical Thoracic Aorta: A State-of-the-Art Review

Techniques for repair of the aorta currently include open and endovascular methods, hybrid approaches, minimally-invasive techniques, and aortic branch vessel reimplantation or bypass. Collaboration among radiologists and vascular and cardiothoracic surgeons is essential. An awareness of the various surgical techniques, expected postoperative appearance, and potential complications is essential for radiologists. This review will cover the postoperative appearance of the thoracic aorta with a focus on the ascending aorta. The value of three-dimensional image evaluation will also be emphasized.

Acute Aortic Dissection With Intussusception of the Partition Between the True and False Channels Leading to Near Total Aortic Occlusion (True Aortic Stenosis)

Described herein are 2 patients with fatal acute aortic dissection resulting in a circumferential intimal-medial tear causing the partition between the true and false channels to roll up and propagate forward as an intra-aortic intussusception (a receiving within).