The incidence of distal SINE seemed to be high; however, there were also low rates of death and complications after TEVAR for aortic dissection using stainless steel-based stent grafts. Complicated distal SINE can successfully be resolved by distal endograft implantation. Excessive oversizing of the distal stent graft, as measured by the true lumen area, may be a significant factor causing delayed distal SINE. Precise size selection is crucial for the distal end of the stent, especially for high taper ratio dissection pathology in which the implantation sequence of a distal small-sized stent graft first might be considered to prevent future distal SINE.

We found that taper ratio is not an optimal criteria for stent graft size selection and distal oversizing calculated by true-lumen area is a significant factor causing delayed distal SINE. Use of the prestenting area oversizing ratio should be limited.

Minimizing the preprocedure distal oversizing ratio with a distal small graft-first procedure could reduce the risk of late distal SINE for Stanford type B aortic dissection. Furthermore, the area ratio is a potentially more sensitive modality for size assessment and prediction of distal SINE occurrence.

III.

Use of VRC shortened operative time and improved bleeding control incorporating standard methods for aortic anastomoses during acute type A aortic dissection repair by total arch replacement and antegrade frozen elephant trunk procedure. Long-term follow-up and randomized comparison are needed to confirm VRC efficacy.