Impact of Oversizing on the Risk of Retrograde Dissection After TEVAR for Acute and Chronic Type B Dissection

The Impact of Oversizing in Thoracic Endovascular Aortic Repair on Long-Term Outcomes in Uncomplicated Type B Aortic Dissection: A Single-Center Retrospective Study

PURPOSE

The purpose of this study was to assess the impact of oversizing in thoracic endovascular aortic repair (TEVAR) on early and long-term survival and major adverse events in patients with uncomplicated type B aortic dissection (TBAD).

METHODS

Between January 2010 and December 2018, 226 patients who were diagnosed with uncomplicated TBAD and received TEVAR were analyzed retrospectively. The patients were divided into ≤5% oversizing (n=153) and >5% oversizing (n=73) groups. Primary end points were all-cause and aortic-related mortalities. Secondary end points were procedure-related complications, including retrograde type A aortic dissection (RTAD), endoleak, distal stent-induced new entry (SINE), and late reintervention. All-cause and aortic-related mortalities were assessed using the Kaplan-Meier survival method, while procedure-related complications were evaluated using a competing risk model with all-cause death as a competing risk.

RESULTS

Mean oversizing was 2.1%±1.5% in the ≤5% oversizing group and 9.6%±4.1% in the >5% oversizing group. Differences in the 30-day mortality and adverse events between the 2 groups were statistically insignificant. The freedom from all-cause mortality was comparable between the ≤5% oversizing group and the >5% oversizing group (≤5%: 93.3% at 5 years, >5%: 92.3% at 5 years, p=0.957). No significant difference was observed between both groups in the freedom from aortic-related mortality (≤5%: 95.0% at 5 years, >5%: 96.7% at 5 years, p=0.928). However, the competing risk analyses revealed that the cumulative incidence of RTAD was statistically significantly greater in the >5% oversizing group than in the ≤5% oversizing group (≤5%: 1(0.7%) at 5 years, >5%: 6(6.9%) at 5 years, p=0.007). All RTADs occurred within a year of TEVAR. The differences in the cumulative incidences of type I endoleak, distal SINE, and late reintervention were not significant between the 2 groups.

CONCLUSION

The differences in the 5-year all-cause mortality and aortic-related mortality between patients with uncomplicated TBAD who received TEVAR with ≤5% oversizing and those who got TEVAR with >5% oversizing were insignificant. However, oversizing >5% was considerably associated with an increased risk of RTAD within a year of TEVAR, suggesting that oversizing ≤5% may be the appropriate size for TEVAR in patients with uncomplicated TBAD.

CLINICAL IMPACT

For patients with uncomplicated TBAD, choosing oversizing ≤5% in endovascular treatment is beneficial to reduce the risk of postoperative retrograde type A aortic dissection. This finding provides a basis for stent size selection in endovascular repair. In addition, one year after TEVAR is the main time period for postoperative retrograde type A aortic dissection, and attention should be paid to the management and follow-up of this period.

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

OBJECTIVE

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

DATA SOURCES

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

METHODS

The PRISMA-ScR statement was followed.

RESULTS

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

CONCLUSIONS

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

Mid-term results of a prospective study for aortic dissection with a gutter-plugging chimney stent graft

OBJECTIVES

Our goal was to access early and mid-term outcomes of a gutter-plugging chimney stent graft for treatment of Stanford type B aortic dissections in the clinical trial Prospective Study for Aortic Arch Therapy with stENt-graft for Chimney technology (PATENCY).

METHODS

Between October 2018 and March 2022, patients with Stanford type B aortic dissections were treated with the Longuette chimney stent graft in 26 vascular centres. The efficiency and the incidence of adverse events over 12 months were investigated.

RESULTS

A total of 150 patients were included. The technical success rate was 99.33% (149/150). The incidence of immediate postoperative endoleak was 5.33% (8/150, type I, n = 6; type II, n = 1; type IV, n = 1) neurologic complications (stroke or spinal cord ischaemia); the 30-day mortality was 0.67% (1/150) and 1.33% (2/150), respectively. During the follow-up period, the median follow-up time was 11.67 (5-16) months. The patent rate of the Longuette graft was 97.87%. Two patients with type I endoleak underwent reintervention. The follow-up rate of the incidence of retrograde A type aortic dissection was 0.67% (1/150). There was no paraplegia, left arm ischaemia or stent migration.

CONCLUSIONS

For revascularization of the left subclavian artery, the Longuette chimney stent graft can provide an easily manipulated, safe and effective endovascular treatment. It should be considered a more efficient technique to prevent type Ia endoleak. Longer follow-up and a larger cohort are needed to validate these results.

CLINICAL TRIAL REGISTRY NUMBER

NCT03767777.

Short-term follow-up of proximal aorta remodeling after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection

BACKGROUND

To evaluate the early remodeling of the proximal aorta in patients with acute type B aortic dissection (ATBAD) after zone 2 thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2016 to May 2022, 53 ATBAD patients underwent zone 2 TEVAR were divided into two groups, the Castor single-branched stent-graft (CSS) group (n = 26) and the common stent-graft group (n = 27). Three-dimensional imaging created by computed tomography angiography was used to measure different parameters of the aorta, such as angulation, cross-sectional area (CSA), length and tortuosity. Early remodeling of the proximal aorta was evaluated by comparing geometric parameters of the proximal aorta before and 3 months after surgery.

RESULTS

In terms of angle, the postoperative angle of aortic arch to ascending aorta, descending aorta increased in all patients compared with that before surgery (all P < 0.05), while the angle of aortic arch to left subclavian artery increased after surgery only in the CSS group (P < 0.001); As for CSA, the CSA of distal aortic arch and true lumen increased (all P < 0.05), while the CSA of false lumen decreased in both groups after operation (all P < 0.05); Only in CSS group, the CSA of the ascending aorta, proximal aortic arch and total descending thoracic aorta decreased after surgery (all P < 0.05); In terms of length, the aortic arch prolonged after operation in both groups (P = 0.018 and P = 0.004, respectively). In addition, the ascending aorta tortuosity decreased in the CSS group after surgery (P = 0.011). There was no significant difference in the alterations of other aortic parameters after operation (P > 0.05).

CONCLUSIONS

The CSS implantation provided a more relatively safe and effective treatment for acute type B aortic dissection patients with unfavorable proximal landing zone. It can promote the earlier remodeling of the proximal aorta compared with the common stent-graft implantation after zone 2 TEVAR.

Intramural hematoma in the proximal sealing zone of the thoracic endovascular aneurysm repair: frequency and safety in acute and subacute type B dissections

Introduction

To assess the outcomes after thoracic endovascular aneurysm repair (TEVAR) in the presence of intramural hematoma (IMH) in the proximal sealing zone.

Material and methods

Patient data were retrospectively extracted from the hospital records of patients treated with TEVAR for acute and chronic aortic dissection type B in one single center. The initial, preoperative, first postoperative, and last follow-up CT scans were evaluated in the aortic 3D multiplanar reformats and the centerline regarding IMH presence in the proximal sealing zone, anatomical preconditions, and the morphological TEVAR complications including migration and bird-beak. Groups with (IMH) and without IMH (no-IMH) were compared.

Results

Overall, 84 patients (IMH:42; no-IMH:42) were treated at the age of 63(55; 72) years, of whom 23/84 (27%), 34/84 (40%), and 27/84 (32%) were in the hyperacute, acute and subacute dissection phases, respectively. The bovine arch was found in 10/84(12%) and the type III arch was most common (43/84;51%). IMH maximum extent was found in zones 0, 1, 2, and 3 in 14/84 (17%), 17/84 (20%), 18/84 (21%), and 6/84 (7%), respectively. Sealing was achieved in zone II in 71/84 (85%) and LSA was revascularized in 66/84 (79%) of the overall cohort. Early mortality and paraplegia were 2/84 (2%) each; stroke rate was 3/84 (4%). During the 22 months median follow-up (22;4;43) no RTAD was observed. Migration ≥10 mm (IMH: 11/82; no-IMH: 10/82; P = 1.0) and bird-beaks (IMH: 10/82; no-IMH: 12/82; P = 0.8036) were comparable in both groups and accompanied by a low aorta related mortality (1/82) in both groups.

Conclusion

The presence of the IMH in the proximal TEVAR sealing zone is frequent and may not be relevant for the occurrence of the RTAD, stent-graft migration, or bird-beak formation.

Case Report: Successful endovascular treatment of acute type A aortic dissection

Introduction

Open surgical repair remains the current gold standard for the treatment of acute type A aortic dissection. However, especially elderly patients with relevant comorbidities who are deemed unfit for open surgery may benefit from a minimally invasive endovascular approach.

Methods

We report a case of an 80-year-old male with retrograde acute type A aortic dissection and peripheral malperfusion after receiving thoracic endovascular aortic repair due to thoracic aortic aneurysm. Our individualized endovascular approach consisted of left carotid-subclavian bypass, proximal extension of thoracic endovascular aortic repair using a covered stent graft and a single covered stent graft for the ascending aorta in combination with an uncovered stent for the aortic arch.

Results

Postoperative computed tomographic angiography demonstrated excellent outcome with no signs of endoleak or patent false lumen. Follow-up after 3.5 years showed a stable result with no signs of stent failure or dissection progress. No aortic re-interventions were needed in the further course.

Discussion

An individualized endovascular approach may be justified for acute type A aortic dissection in elderly patients with high surgical risk if performed in specialized aortic centers. Additional short-length stent graft devices are needed to address the anatomical challenges of the ascending aorta. For enhanced remodeling of the dissected aorta, the use of an additional uncovered stent may be advisable.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma

BACKGROUND

The current treatment for retrograde ascending aortic intramural hematoma (RAIMH) remains challenging. This study aims to summarize the short-term results of endovascular repair in the treatment of retrograde ascending aortic intramural hematoma.

METHODS

Between June 2019 and June 2021, 21 patients (16 males and 5 females) with a retrograde ascending aortic intramural hematoma, aged 53 ± 14years, received an endovascular repair in our hospital. All cases involved an ascending aortic or aortic arch intramural hematoma. 15 patients had an ulcer on the descending aorta combined with an intramural hematoma in the ascending aorta and 6 patients had typical dissection changes on the descending aorta combined with an intramural hematoma in the ascending aorta. All patients had a successful endovascular stent-graft repair, with 10 cases operated on in the acute phase (<14 days) and 11 cases in the chronic phase (14-35 days).

RESULTS

A single-branched aortic stent graft system was implanted in 10 cases, a straight stent in 2 cases, and a fenestrated stent in 9 cases. All surgeries were technically successful. One of the patients developed a new rupture 2 weeks after surgery and was converted to a total arch replacement. No perioperative stroke, paraplegia, stent fracture or displacement, limb or abdominal organ ischemia occurred. The intramural hematomas started being absorbed on CT angiography images before discharge. There was no incidence of postoperative 30-day mortality, and the intramural hematomas in the ascending aorta and aortic arch were fully or partly absorbed.

CONCLUSION

Endovascular repair of retrograde ascending aortic intramural hematoma was shown to be safe and effective, and correlated with favorable short-term results.

Rapid Morphological Measurement Method of Aortic Dissection Stent Based on Spatial Observation Point Set

OBJECTIVES

Post-operative stent morphology of aortic dissection patients is important for performing clinical diagnosis and prognostic assessment. However, stent morphologies still need to be manually measured, which is a process prone to errors, high time consumption and difficulty in exploiting inter-data associations. Herein, we propose a method based on the stepwise combination of basic, non-divisible data sets to quickly obtain morphological parameters with high accuracy.

METHODS

We performed the 3D reconstruction of 109 post-operative follow-up CT image data from 26 patients using mimics software. By extracting the spatial locations of the basic morphological observation points on the stent, we defined a basic and non-reducible set of observation points. Further, we implemented a fully automatic stent segmentation and an observation point extraction algorithm. We analyzed the stability and accuracy of the algorithms on a test set containing 8 cases and 408 points. Based on this dataset, we calculated three morphological parameters of different complexity for the different spatial structural features exhibited by the stent. Finally, we compared the two measurement schemes in four aspects: data variability, data stability, statistical process complexity and algorithmic error.

RESULTS

The statistical results of the two methods on two low-complexity morphological parameters (spatial position of stent end and vascular stent end-slip volume) show good agreement (n = 26, P₁, P₂ < 0.001, r₁ = 0.992, r₂ = 0.988). The statistics of the proposed method for the morphological parameters of medium complexity (proximal support ring feature diameter and distal support ring feature diameter) avoid the errors caused by manual extraction, and the magnitude of this correction to the traditional method does not exceed 4 mm with an average correction of 1.38 mm. Meanwhile, our proposed automatic observation point extraction method has only 2.2% error rate on the test set, and the average spatial distance from the manually marked observation points is 0.73 mm. Thus, the proposed method is able to rapidly and accurately measure the stent circumferential deflection angle, which is highly complex and cannot be measured using traditional methods.

CONCLUSIONS

The proposed method can significantly reduce the statistical observation time and information processing cost compared to the traditional morphological observation methods. Moreover, when new morphological parameters are required, one can quickly and accurately obtain the target parameters by new "combinatorial functions." Iterative modification of the data set itself is avoided.

Risk factors for distal stent graft-induced new entry after endovascular repair in uncomplicated type B aortic dissection

OBJECTIVE

We investigated the risk factors for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair for patients with uncomplicated type B aortic dissection (TBAD) and reported the outcomes of using a tapered stent graft and dSINE reintervention.

METHODS

A total of 226 patients with uncomplicated TBAD who had undergone thoracic endovascular aortic repair between January 2010 and December 2018 were analyzed retrospectively. The global features of the thoracic aorta and the local features of the proximal and distal landing zones were evaluated and compared between the dSINE and non-dSINE groups. A multivariate Cox model was used to identify the independent risk factors for dSINE. The cumulative incidence of reintervention was estimated using competing risk models.

RESULTS

After a median follow-up of 4.6 years, 16 patients (7.1%) had developed dSINE. Multivariable Cox regression analysis demonstrated that a type III aortic arch, decreased angle, increased distal oversizing, and increased distal mismatch ratio were significant risk factors for dSINE. Of the patients with tapered stent grafts, five with a ≤4-mm taper had developed dSINE. However, no dSINE was seen in the >4-mm taper group (P = .024). Reintervention was performed for 7 of the 16 patients with dSINE (43.8%). The mean time from the initial detection of dSINE to reintervention was 6.43 ± 4.62 months. The competing risk analyses showed that the cumulative incidence of reintervention in the dSINE group at 1, 3, and 5 years was 25.0%, 37.5%, and 43.5%, respectively.

CONCLUSIONS

A type III aortic arch, excessive distal oversizing and mismatch ratio, and severe angulation were associated with dSINE in patients with uncomplicated TBAD. The use of a tapered stent graft with a >4-mm taper could help prevent dSINE in patients with a high taper ratio. Aggressive reintervention was associated with favorable long-term outcomes for patients with progressive dSINE.

Dynamic Morphology of the Ascending Aorta and Its Implications for Proximal Landing in Thoracic Endovascular Aortic Repair

In this study, we assessed the dynamic segmental anatomy of the entire ascending aorta (AA), enabling the determination of a favorable proximal landing zone and appropriate aortic sizing for the most proximal thoracic endovascular aortic repair (TEVAR). Methods: Patients with a non-operated AA (diameter < 40 mm) underwent electrocardiogram-gated computed tomography angiography (ECG-CTA) of the entire AA in the systolic and diastolic phases. For each plane of each segment, the maximum and minimum diameters in the systole and diastole phases were recorded. The Wilcoxon signed-rank test was used to compare aortic size values. Results: A total of 100 patients were enrolled (53% male; median age 82.1 years; age range 76.8−85.1). Analysis of the dynamic plane dimensions of the AA during the cardiac cycle showed significantly higher systolic values than diastolic values (p < 0.001). Analysis of the proximal AA segment showed greater distal plane values than proximal plane values (p < 0.001), showing a reversed funnel form. At the mid-ascending segment, the dynamic values did not notably differ between the distal plane and the proximal segmental plane, demonstrating a cylindrical form. At the distal segment of the AA, the proximal plane values were larger than the distal segmental plane values (p < 0.001), thus generating a funnel form. Conclusions: The entire AA showed greater systolic than diastolic aortic dimensions throughout the cardiac cycle. The mid-ascending and distal-ascending segments showed favorable forms for TEVAR using a regular cylindrical endograft design. The most proximal segment of the AA showed a pronounced conical form; therefore, a specific endograft design should be considered.

Longitudinal morphological changes of the aorta and the endograft position before and after distal stent graft-induced new entry in aortic dissections

OBJECTIVES

The aim of this study was to assess the endograft position and aortic geometry changes after thoracic endovascular aortic repair (TEVAR) and frozen elephant trunk (FET) in distal stent-induced new entry (dSINE) patients.

METHODS

In this retrospective cohort study, the baseline demographic and the follow-up data were extracted from the hospital records, and computed tomography scans of dSINE patients after TEVAR or FET between 2011 and 2021 were analysed regarding endograft oversizing, length and migration, taper ratio, aortic diameter at the endograft end, aortic elongation (thoracic inner and outer curvature), wedge apposition angle and tortuosity angle in the distal landing zone.

RESULTS

dSINE was found in 22/213 (10%) of TEVAR and 10/31 (32%) of FET patients. The total follow-up time was 45 (27; 59) months. TEVAR was mainly performed with Relay NBS endograft (77%) and FET with Evita open prosthesis (80%). Paraplegia and stroke rates were 3%. dSINE occurred 17 (7; 35) months post-TEVAR and was instantly treated in 18 patients (56%) or followed up for 21 (11; 34) months (n = 14). Migration [+5 mm (1; 11; P < 0.001)], birdbeak angle [+9° (0; 27; P = 0.039)] and aortic diameter +5 mm (1; 11; P < 0.001) increased after dSINE, whereas aortic elongation increased already before [+12 mm (0; 27; P = 0.015)] and peaked after dSINE [+30 mm (9; 38; P < 0.001)]. The aortic elongation was more pronounced in the outer aortic curvature before and after dSINE (before: P = 0.039, after: P = 0.024). Postoperative wedge apposition [17° (12; 20)] increased before dSINE [21° (16; 35; P < 0.001)] and peaked thereafter [31° (21; 40; P < 0.001)].

CONCLUSIONS

Aortic elongation may influence the endograft position and provoke TEVAR failure in the distal and proximal landing zones.

False lumen patency status and outcomes after endovascular repair of uncomplicated chronic type B dissection

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) remains a controversial treatment for uncomplicated chronic type B aortic dissection (cTBAD). This study was performed to investigate the postoperative outcomes of TEVAR, such as survival and reintervention, and the risk factors for prognoses.

METHODS

In total, 41 patients with uncomplicated cTBAD who underwent TEVAR from 2014 to 2021 were reviewed. The patients were divided into two groups: those with false lumen complete thrombosis (FLCT) and false lumen partial thrombosis (FLPT) based on computed tomography angiography (CTA) images. Kaplan-Meier analysis was performed to estimate survival and freedom from reintervention. Binary logistic analysis was performed to estimate risk factors for partial thrombosis.

RESULTS

During a mean follow-up of 31 (1-78) months, five deaths and six reinterventions had occurred at 5 years. By 1 week, thoracic FLCT had occurred in 23 (56.1%) patients and thoracic FLPT had occurred in 18 (43.9%). The rate of freedom from reintervention was significantly lower in the FLCT than in the FLPT group (p = 0.04). The 5-year survival rate of the two groups was not statistically significant (p = 0.14). Risk factors for thoracic FLPT were the distance between the re-entry site and the graft (p = 0.02) and the proximal oversizing ratio (p = 0.04).

CONCLUSIONS

TEVAR is an effective and safe treatment for uncomplicated cTBAD and has a low mortality rate. Thoracic FLCT is associated with less reintervention, but overall survival is not impacted by this difference. Patients treated with TEVAR without certain risk factors can have a good prognosis.

Predictive factors of distal stent graft-induced new entry after frozen elephant trunk procedure for aortic dissection

OBJECTIVES

The incidence rate of distal stent graft-induced new entry after frozen elephant trunk technique for aortic dissection remains controversial. The aim of this study was to investigate the incidence and seek the clinical and anatomical predictive factors.

METHODS

This study is a retrospective multicenter evaluation of complications including distal stent graft-induced new entry, aortic events, and re-intervention after the frozen elephant trunk procedure for aortic dissection.

RESULTS

Our cohort included total 177 consecutive patients who underwent the frozen elephant trunk procedure for acute and chronic aortic dissection at five centers in Japan from May 2014 to March 2021. The incidence rate of distal stent graft-induced new entry was 14.1% (25/177 patients). The cumulative incidence of d-SINE was 7.1%, 12.4%, 21.4% after 12, 36, and 60 months, respectively. Distal stent graft-induced new entry was not associated with mid-term survival rate. After competing risk regression analysis, onset time > 48 hours (subdistribution hazard ratio, 3.80; 95% confidence interval, 1.13-12.79; P=0.031) was detected as an independent predictor.

CONCLUSIONS

Awareness that there is a relatively higher incidence of distal stent graft-induced new entry after frozen elephant trunk procedures is important. Non-hyperacute phase was detected as an independent risk factor. Preemptive endovascular repair may be appropriate to protect new entry in high-risk patients.

Surgical Repair of Two Kinds of Type A Aortic Dissection After Thoracic Endovascular Aortic Repair

Background

Retrograde dissection is now recognized as an important complication following thoracic endovascular aortic repair (TEVAR). The purpose of this study is to describe two different situations of TAAD after TEVAR. We will introduce the surgical methods used to repair TAAD following TEVAR at our center, and evaluate its long-term prognosis.

Methods

Between January 2010 and October 2019, 50 patients who had previously received TEVAR treatment for TBAD were admitted to our center for repair of a type A aortic dissection. According to the patients’ CT angiographies and intra-operative findings, we identified two distinct groups: a retrograde group (stent-induced new aortic injury, with retrograde extension involving the ascending aorta) and an antegrade group (entry tear located in the aortic root, ascending aorta or the aortic arch, away from the edges of the stent grafts). The options for treatment of the proximal aorta were Bentall procedure (12/50, 24.0%) and ascending aorta replacement (38/50, 76.0%). All patients underwent total arch replacement (TAR) and frozen elephant trunk (FET) implantation. Survival over the follow-up period was evaluated with the Kaplan–Meier survival curve and the log-rank test.

Results

The median interval time from prior TEVAR to reoperation was 187 days (IQR: 30.0, 1375.0 days). 18.0% of TAAD after TEVAR did not have any obvious symptoms at the time of diagnosis, most of which were found on routine follow-up imaging. The patients in the retrograde group were younger than those in the antegrade group (44.0 ± 9.4 vs. 51.4 ± 10.5 years, P = 0.012). No significant differences in the incidence of post-operative complications or mortality were noted between the two groups. The mean follow-up time was 3 years. No late death or complications occurred after one year following surgery upon follow-up. The asymptomatic survival rate one year after surgery was 90.0%.

Conclusion

The TAR and FET technique was feasible and effective for complicated TAAD after TEVAR. The surgical success rate and long-term prognosis of patients undergoing the timely operation are satisfactory.

Influence of measurement and sizing techniques in thoracic endovascular aortic repair on outcome in acute complicated type B aortic dissections

OBJECTIVES

Thoracic endovascular aortic repair (TEVAR) is the first-line therapy in acute complicated type B aortic dissections (cTBAD). Nevertheless, no evidence-based consensus on the optimal measurement technique and sizing for TEVAR in cTBAD exists. The aim was to evaluate how different measurement and sizing techniques for TEVAR affect long-term outcomes.

METHODS

Retrospective analysis investigating the association between sizing and postoperative results after TEVAR in patients with cTBAD, treated between January 2003 and December 2020. Diameter measurements were performed perpendicular to a centreline in pre-interventional Computed tomography angiographies. Oversizing was determined by measuring aortic diameter in zone 2 of the aortic arch in relation to the implanted stent graft, and categorized into 2 sizing groups (≤10% and >10%). The primary outcome was freedom from aortic-related events. Secondary outcomes included mortality and a comparison of 3 alternative measurement techniques considering the estimated pre-dissection diameter.

RESULTS

Fifty-seven patients (median age 69, interquartile range 59.6-78.2 years) were included. Stent graft oversizing by ≤10% showed a trend towards fewer aortic-related events hazard ratio 0.455 (95% confidence interval 0.128-1.624, P = 0.225).The 3 measurement techniques using the pre-dissection aortic diameter differed by a mean of 1.7-4.0 mm with a variability of up to 8.4 mm. In none of the 57 patients, the same stent graft would have been chosen based on the different measurement techniques using an oversizing ≤10%.

CONCLUSIONS

TEVAR oversizing of ≤10% in patients with cTBAD might reduce aortic-related events up to 50%. Consensus on measurement techniques of the pre-dissection aortic diameter and stent graft sizing is of paramount importance.

Influence of thoracic endovascular aortic repair on true lumen helical morphology for Stanford type B dissections

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) can change the morphology of the flow lumen in aortic dissections, which may affect aortic hemodynamics and function. This study characterizes how the helical morphology of the true lumen in type B aortic dissections is altered by TEVAR.

METHODS

Patients with type B aortic dissection who underwent computed tomography angiography before and after TEVAR were retrospectively reviewed. Images were used to construct three-dimensional stereolithographic surface models of the true lumen and whole aorta using custom software. Stereolithographic models were segmented and co-registered to determine helical morphology of the true lumen with respect to the whole aorta. The true lumen region covered by the endograft was defined based on fiducial markers before and after TEVAR. The helical angle, average helical twist, peak helical twist, and cross-sectional eccentricity, area, and circumference were quantified in this region for pre- and post-TEVAR geometries.

RESULTS

Sixteen patients (61.3 ± 8.0 years; 12.5% female) were treated successfully for type B dissection (5 acute and 11 chronic) with TEVAR and scans before and after TEVAR were retrospectively obtained (follow-up interval 52 ± 91 days). From before to after TEVAR, the true lumen helical angle (-70.0 ± 71.1 to -64.9 ± 75.4°; P = .782), average helical twist (-4.1 ± 4.0 to -3.7 ± 3.8°/cm; P = .674), and peak helical twist (-13.2 ± 15.2 to -15.4 ± 14.2°/cm; P = .629) did not change. However, the true lumen helical radius (1.4 ± 0.5 to 1.0 ± 0.6 cm; P < .05) and eccentricity (0.9 ± 0.1 to 0.7 ± 0.1; P < .05) decreased, and the cross-sectional area (3.0 ± 1.1 to 5.0 ± 2.0 cm²; P < .05) and circumference (7.1 ± 1.0 to 8.0 ± 1.4 cm; P < .05) increased significantly from before to after TEVAR. The distinct bimodal distribution of chiral and achiral native dissections disappeared after TEVAR, and subgroup analyses showed that the true lumen circumference of acute dissections increased with TEVAR, although it did not for chronic dissections.

CONCLUSIONS

The unchanged helical angle and average and peak helical twists as a result of TEVAR suggest that the angular positions of the true lumen are constrained and that the endografts were helically conformable in the angular direction. The decrease of helical radius indicated a straightening of the corkscrew shape of the true lumen, and in combination with more circular and expanded lumen cross-sections, TEVAR produced luminal morphology that theoretically allows for lower flow resistance through the endografted portion. The impact of TEVAR on dissection flow lumen morphology and the interaction between endografts and aortic tissue can provide insight for improving device design, implantation technique, and long-term clinical outcomes.

Mid-Term Results of Thoracic Endovascular Aortic Repair for Complicated Acute Type B Aortic Dissection at a Single Center

Background

Complicated acute type B aortic dissection is a life-threatening condition with high morbidity and mortality. The aim of this study was to report a single-center experience with endovascular stent-graft repair of acute type B dissection of the thoracic aorta and to evaluate the mid-term outcomes.

Methods

We reviewed 18 patients treated for complicated acute type B aortic dissection by thoracic endovascular aortic repair (TEVAR) from September 2011 to July 2017. The indications for surgery included rupture, impending rupture, limb ischemia, visceral malperfusion, and paraplegia. The median follow-up was 34.50 months (range, 12–80 months).

Results

The median interval from aortic dissection to TEVAR was 5.50 days (range, 0–32 days). There was no in-hospital mortality. All cases of malperfusion improved except for 1 patient. The morbidities included endoleak in 2 patients (11.1%), stroke in 3 patients (16.7%), pneumonia in 2 patients (11.1%), transient ischemia of the left arm in 1 patient (5.6%), and temporary visceral ischemia in 1 patient (5.6%). Postoperative computed tomography angiography at 1 year showed complete thrombosis of the false lumen in 15 patients (83.3%).

Conclusion

TEVAR of complicated type B aortic dissection with a stent-graft was effective, with a low morbidity and mortality rate.

Hybrid Repair With Endovascular Debranching of the Aberrant Right Subclavian Artery for Complicated Type B Aortic Dissection in Patients With Kommerell's Diverticulum

PURPOSE

Aberrant right subclavian artery (ARSA) associated with Kommerell's diverticulum (KD) is a common congenital arch anomaly. It can be complicated by type B aortic dissection (TBAD) or aneurysmal formation at its ostium. Recently, hybrid repair with thoracic endovascular aortic repair (TEVAR) has appeared to be more favorable. Due to the normal anatomic proximity of the ARSA to the left subclavian artery (LSA) orifice in KD, coverage of the bilateral subclavian arteries (SCAs) to obtain an adequate proximal landing zone (PLZ) is usually required, and double cervicotomy for SCA revascularization potentially increases the risk of complications.

TECHNIQUE

This technique was demonstrated on a 50-year-old man presenting with progressive aneurysmal formation of KD with ARSA after chronic TBAD. A 3-step technique, namely left cervical debranching with a left common carotid artery to LSA bypass graft, TEVAR, and an LSA-to-ARSA endovascular debranching with a self-expanding covered stent by a through-and-through wire from the right brachial artery to the bypass graft, was performed in a 1-stage repair to cover the primary tear of TBAD and preserve the bilateral SCAs. The postoperative course was uneventful.

CONCLUSION

This technique can prevent complications from double cervicotomy and achieve an adequate PLZ with preservation of the bilateral SCAs for TEVAR.

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.

Endovascular ascending aortic repair in type A dissection: A systematic review

PURPOSE

Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD.

METHODS

A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma).

RESULTS

A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%).

CONCLUSION

This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.

Preoperative Planning for EndoAnchor Use During Thoracic Endovascular Aortic Repair in the Distal Aortic Arch

PURPOSE

To describe steps related to intraoperative C-arm orientations that can be taken during preoperative planning of thoracic stent-graft repair to facilitate the deployment of EndoAnchors in the distal aortic arch.

TECHNIQUE

Previous experience from transcatheter aortic valve implantation (TAVI) may be helpful in addressing issues with C-arm orientation. In TAVI, preoperative computed tomography (CT) images are routinely obtained to generate a patient-specific curve that represents a virtually complete rotation of the C-arm perpendicular to the annulus. The curve clearly demonstrates that each adjustment in cranial or caudal view needs parallax correction in the left or right anterior oblique direction to remain perpendicular, and vice versa. This experience can be translated to the preoperative planning of EndoAnchor use in the aortic arch. By placing markers along the circumference of the proximal landing zone of the preoperative CT scan, the required C-arm orientations can be determined for each marker.

CONCLUSION

Determining the optimal C-arm orientation during preoperative planning will facilitate successful EndoAnchor deployment and may contribute to improved durability of endovascular repair in hostile necks in the aortic arch.

Diameter Changes in Traumatic Aortic Injury: Implications for Stent-Graft Sizing

OBJECTIVES

 The aim of this study was to compare aortic diameters from admission computed tomography angiography (CTA) scans to postoperative aortic diameters in patients with traumatic aortic injury (TAI) and evaluate the influence of substantial blood loss on aortic diameter.

METHODS

 The aortic databases of two tertiary university centers were retrospectively screened for patients with TAI between February 2002 and February 2019. Concomitant organ injuries, bone fractures, blood loss, and clinical outcomes were evaluated. Aortic diameters were measured in CTA upon admission and were compared with the CTA before discharge at three different aortic levels (mid-ascending, 5 cm distal to the end of the stent graft, and at the celiac trunk level).

RESULTS

 We identified 45 patients, aged 43 (first quartile; third quartile [26; 55]) years with a TAI treated by thoracic endovascular aortic repair. The most frequent cause of TAI was a car accident (n = 24). Concomitant injuries were seen in all but one patient. Bone and pelvic fractures were seen in 40 (89%) and 15 (33%) patients, respectively. Type III aortic injury was present in 25 patients (56%). Increase of aortic diameter after stabilization was +1.7 mm (-0.6 mm; 2.5 mm; p = 0.004) at the mid-ascending aorta, +2.1 mm (0.2 mm; 3.8 mm; p < 0.001) 5 cm distal to the stent graft, and +1.5 mm (0.5 mm; 3.2 mm; p < 0.001) at the celiac trunk level.

CONCLUSION

 In patients with TAI, the aortic diameter is significantly reduced as compared with the aortic diameter at discharge. The reduction of aortic diameter might be caused by hemorrhagic shock and should be kept in mind for appropriate stent-graft sizing.

Location of Reentry Tears Affects False Lumen Thrombosis in Aortic Dissection Following TEVAR

Purpose: To report a study that assesses the influence of the distance between the distal end of a thoracic stent-graft and the first reentry tear (SG-FRT) on the progression of false lumen (FL) thrombosis in patients who underwent thoracic endovascular aortic repair (TEVAR). Materials and Methods: Three patient-specific geometrical models were reconstructed from postoperative computed tomography scans. Two additional models were created by artificially changing the SG-FRT distance in patients 1 and 2. In all 5 models, computational fluid dynamics simulations coupled with thrombus formation modeling were performed at physiological flow conditions. Predicted FL thrombosis was compared to follow-up scans. Results: There was reduced false lumen flow and low time-averaged wall shear stress (TAWSS) in patients with large SG-FRT distances. Predicted thrombus formation and growth were consistent with follow-up scans for all patients. Reducing the SG-FRT distance by 30 mm in patient 1 increased the flow and time-averaged wall shear stress in the upper abdominal FL, reducing the thrombus volume by 9.6%. Increasing the SG-FRT distance in patient 2 resulted in faster thoracic thrombosis and increased total thrombus volume. Conclusion: The location of reentry tears can influence the progression of FL thrombosis following TEVAR. The more distal the reentry tear in the aorta the more likely it is that FL thrombosis will occur. Hence, the distal landing zone of the stent-graft should be chosen carefully to ensure a sufficient SG-FRT distance.

Off-the-Shelf Devices for Treatment of Thoracic Aortic Diseases: Midterm Follow-up of TEVAR With Chimneys or Physician-Made Fenestrations

Purpose: To evaluate the midterm outcomes of thoracic endovascular aortic repair (TEVAR) using chimney grafts (ch-TEVAR) or thoracic stent-grafts with fenestrations made on the back table (f-TEVAR) to treat thoracic aortic dissection (TAD) and thoracic aortic aneurysm (TAA). Materials and Methods: A retrospective analysis was conducted of 474 consecutive patients (mean age 62.3±10.7 years; 346 men) treated with either f-TEVAR (n=110) or ch-TEVAR (n=364) for 352 TADs (81 f-TEVAR and 271 ch-TEVAR) or 122 TAAs (29 f-TEVAR and 93 ch-TEVAR) from 2008 to 2016. The primary endpoints at 30 days and during follow-up were overall mortality, aorta-related mortality, and major complications. The secondary endpoints were endoleak and reintervention. The patency of the target branches, cost of hospitalization, and the use of antiplatelet drugs were also analyzed. Results: Intraoperative type I endoleaks were treated in 69 (14.6%) cases (4 f-TEVAR and 65 ch-TEVAR, p<0.01) to achieve 100% technical success. Four (0.8%) patients died within 30 days [1 (0.9%) f-TEVAR and 3 (0.8%) ch-TEVAR]. Perioperative cerebral ischemia (1 fatal stroke) occurred in 9 (1.9%) patients: (1 f-TEVAR and 8 ch-TEVAR, p=0.39). During the mean follow-up of 50.6±20.0 months (49.5±18.3 months in f-TEVAR and 50.9±20.6 months in ch-TEVAR), 11 (2.3%) patients died of an aorta-related event. Type I endoleak was present in 40 (8.4%) patients (1 f-TEVAR and 39 ch-TEVAR, p<0.01). Eleven (2.3%) patients experienced stent-graft migration and 13 (2.7%) had a retrograde dissection. One hundred (16.9%) of the 593 branch stents occluded (4/75 in the f-TEVAR group and 96/518 in the ch-TEVAR group, p<0.01). The branch reintervention rate was 7.2% (34/474). The f-TEVAR group had a significantly higher probability of freedom from branch occlusion (92%) than the ch-TEVAR group (83%, p=0.007). Conclusion: Off-the-shelf techniques employing chimney grafts and homemade fenestrations are both suitable options for TAD and TAA involving the supra-aortic branches, with a low incidence of reintervention. Fenestrated TEVAR seems to have more favorable short- and midterm outcomes. Further study of these off-the-shelf techniques for aortic arch repair is warranted.

Comparison of dynamic changes in aortic diameter during the cardiac cycle measured by computed tomography angiography and transthoracic echocardiography

OBJECTIVE

This study aimed to examine the relationship between dynamic changes in aortic diameter and corresponding measurement methods.

METHODS

Consecutive adult (nonaneurysmal) patients being surgically treated for heart disease (mean age, 51 ± 11 years; range, 29-76 years; N = 25) were included in this study. All patients underwent transthoracic echocardiography (TTE), computed tomography angiography (CTA), and intraoperative ultrasound (IOUS). Anteroposterior diameters were measured at 1 cm above the junction of the aortic sinus, the proximal 1 cm of the innominate artery, and the midpoint of the two.

RESULTS

The average diameter of the proximal ascending aorta in systole/diastole measured by IOUS was 32.07 ± 2.03/30.27 ± 2.05 mm (paired t-test: difference, 1.80 ± 0.46 mm; P < .001). The average diameters of the proximal ascending aorta measured by nonelectrocardiography-gated CTA and TTE were 31.45 ± 1.97 mm and 29.7 ± 1.84 mm, respectively. The average diameter of the mid and distal ascending aorta in systole/diastole measured by IOUS was 32.35 ± 1.95/30.57 ± 1.94 mm (paired t-test: difference, 1.78 ± 0.44 mm; P < .001) and 32.32 ± 1.92/30.67 ± 1.90 mm (paired t-test: difference, 1.65 ± 0.42 mm; P < .001), respectively. The average diameter of the mid and distal ascending aorta measured by CTA was 31.74 ± 1.92 mm and 31.59 ± 1.96 mm, respectively. At each location, the difference in the aortic diameter between systole and diastole was statistically significant (all P values <.001; paired t-test). The minimum and maximum changes in the diameter between systole and diastole were 0.90 mm and 2.70 mm. In all, 96% (24/25) of the average diameters derived from IOUS and CTA at the three locations were within the concordance limit in systole, and 92% to 100% (23/25 to 25/25) were within the concordance limit in diastole. The average diameters derived from IOUS and TTE images of the proximal ascending aorta were within the bounds of the concordance limit 92% (23/25) of the time in systole and 100% (25/25) of the time in diastole. The average diameters derived from CTA and TTE images of the proximal ascending aorta were within the bounds of the concordance limit 88% (22/25) of the time. Pearson correlation coefficients between these groups ranged from 0.905 to 0.982 (all P values <.01).

CONCLUSIONS

The ascending aorta diameters measured by nonelectrocardiography-gated CTA and TTE were consistent with the IOUS measurements.

A graft inversion technique for retrograde type A aortic dissection after thoracic endovascular repair for type B aortic dissection

Background

Retrograde type A aortic dissection (RTAD) is a rare but life-threatening complication after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). A graft inversion technique was applied to distal anastomosis in total arch replacement for this complicated dissection. We reviewed our results of the processing for this serious complication. The aim is to evaluate the feasibility of this technology.

Methods

From January 2013 to December 2017, 20 patients (80% male, mean age 50.9 ± 9.5 years) with retrograde type A aortic dissection after thoracic endovascular aortic repair for type B aortic dissection were scheduled for surgical treatment at our center. All patients underwent an ascending aorta and total aortic arch replacement procedure. The 20 patients were divided into two groups, 1 group involved 9 patients underwent surgery using stepwise technique; the graft inversion technique was performed in the other group containing the remaining 11 patients. The postoperative variables, including cardiopulmonary bypass time, the circulatory arrest time, the aortic cross clamp time, were analyzed. Meanwhile we also analyzed the postoperative mortality and complications to evaluate the early and mid-term outcomes of surgical treatment for RTAD after TEVAR.

Results

In-hospital mortality was 10% (2 of 20 patients). No patient developed postoperative paraplegia, renal failure, stroke, or distal anastomotic bleeding. Two patients developed renal insufficiency, one developed neurologic insufficiency, and one developed pulmonary infection, all of which were managed accordingly. Cardiopulmonary bypass (CPB) time, and circulatory arrest time were significantly shorter in the graft inversion group than in the stepwise group (165.8 ± 37.9 min versus 206.1 ± 46.8 min, p<0.05; 34.5 ± 5.6 min versus 42.4 ± 9.5 min, p<0.05, respectively). The 18 survivors had a mean follow-up of 25.8 ± 18.2 months, and all patients remained alive and well.

Conclusion

Graft inversion can enable a secure distal anastomosis under good surgical exposure, resulting in reduced durations of CPB, and circulatory arrest for RTAD after TEVAR. Surgical treatment could be a safe alternative for treatment of this patients.

Electronic supplementary material

The online version of this article (10.1186/s13019-019-0851-9) contains supplementary material, which is available to authorized users.

Virtual stenting with simplex mesh and mechanical contact analysis for real-time planning of thoracic endovascular aortic repair

In aortic endovascular repair, the prediction of stented vessel remodeling informs treatment plans and risk evaluation; however, there are no highly accurate and efficient methods to quantitatively simulate stented vessels. This study developed a fast virtual stenting algorithm to simulate stent-induced aortic remodeling to assist in real-time thoracic endovascular aortic repair planning.

Methods: The virtual stenting algorithm was established based on simplex deformable mesh and mechanical contact analysis. The key parameters of the mechanical contact analysis were derived from mechanical tests on aortic tissue (n=40) and commonly used stent-grafts (n=6). Genetic algorithm was applied to select weighting parameters. Testing and validation of the algorithm were performed using pre- and post-treatment computed tomography angiography datasets of type-B aortic dissection cases (n=66).

Results: The algorithm was efficient in simulating stent-induced aortic deformation (mean computing time on a single processor: 13.78±2.80s) and accurate at the morphological (curvature difference: 1.57±0.57%; cross-sectional area difference: 4.11±0.85%) and hemodynamic (similarity of wall shear stress-derived parameters: 90.16-90.94%) levels. Stent-induced wall deformation was higher (p<0.05) in distal stent-induced new entry cases than in successfully treated cases, and this deformation did not differ significantly among the different stent groups. Additionally, the high stent-induced wall deformation regions and the new-entry sites overlapped, indicating the usefulness of wall deformation to evaluate the risks of device-induced complications.

Conclusion: The novel algorithm provided fast real-time and accurate predictions of stent-graft deployment with luminal deformation tracking, thereby potentially informing individualized stenting planning and improving endovascular aortic repair outcomes. Large, multicenter studies are warranted to extend the algorithm validation and determine stress-induced wall deformation cutoff values for the risk stratification of particular complications.

Sandwich Technique for Endovascular Repair of Acute Type A Aortic Dissection

Overview: To describe a new endovascular procedure for acute type A aortic dissection (TAAD) repair. Methods: Between 2013 and 2016, 12 patients (average age 54±9.6 years; 10 men) with acute TAAD (mean EURO score 11.4%±3.2%, range 5–17) and unfit for surgery underwent thoracic endovascular aortic repair (TEVAR) with 2 periscope grafts to preserve blood supply to supra-aortic branches plus bypass grafting as needed. If the ascending aorta was dilated to >40 mm, sternotomy was performed to wrap the ascending aorta and reduce its diameter to accommodate the aortic stent-grafts. Results: All patients were successfully treated. Seven patients required bypass grafting, and most of the patients had periscope grafts to the innominate/right common carotid artery and left common carotid artery; only 3 patients had the left subclavian artery preserved. All patients exhibited good hemodynamics and normal pressures after the procedure. The mean procedure time and blood loss were 4.5±1.0 hours and 217±111.5 mL, respectively. Two patients treated emergently died shortly after surgery from multiorgan failure. The average follow-up duration was 17±14.5 months (range 2–42) in the 10 survivors. The remaining patients recovered and none experienced stent-graft thrombosis, stroke, or peripheral artery embolism during follow-up. Conclusion: A procedure that combines sandwich/periscope grafting with TEVAR, wrapping of the aorta, and supra-arch bypass grafting can be used to treat patients with acute TAAD.