Aortic remodelling and late outcomes following thoracic endovascular repair with a bare-metal stent distal extension among patients with complicated type-B aortic dissection

Abstract

Objectives The aim of this study was to describe the factors affecting mid- and late aortic remodelling following TEVAR with PETTICOAT technique among patients with complicated acute or subacute type B aortic dissection. Methods A retrospective single center study that evaluates clinical and morphological outcomes among 65 consecutive patients. The area and diameter of the true- and false-lumen, overall aortic diameter, as well as false lumen perfusion were trended. Results Concomitant direct visceral artery stenting was conducted in 32 (49%) patients. There was one (1.5%) postoperative stroke, three (4.6%) patients developed spinal cord ischaemia, two (3%) patients suffered retrograde Type A dissection and two (3%) patients had mesenteric ischaemia despite successful reperfusion, requiring bowel resection. Median post-operative follow-up was 63.1 (IQR is 32.1– 91.8) months. The probability of survival was 96.9% (95% CI 88.3%—99.2%) at 30 days, 93.9% (95% CI 84.4%—97.6%) at 1 year, 78.0 (95% CI 64.2%—87.0%) at 5 years and 72.8% (95% CI at 57.9%—83.2%) at 10 years postoperatively. There was a statistically significant postoperative increase in true-lumen area, diameter, and true-lumen index in all the five aortic levels measured. Complete false lumen (FL) thrombosis at the coeliac trunk, renal arteries and aortic bifurcation levels was observed in 47%, 15% and 24% of patients at midterm (6–15 months) and 29%, 21% and 29% on late (later than 21 months) CT angiograms. Persistent FL perfusion at the coeliac level was associated with a larger extent of late aortic growth (p = 0.042), and was in the majority of cases caused by iliac re-entries either alone (28.57), or in combination with visceral and lumbar (28.57%) or distal aortic (10.71%) re-entries. A larger abdominal aortic diameter at midterm was associated with an increased probability of distal aortic reinterventions (HR 7.26, 95% CI 2.41–21.9, p < 0.001). Conclusions Persistent FL perfusion of the distal aorta at midterm following TEVAR with PETTICOAT technique among patients with acute and subacute type B dissection, is caused mainly by illiac, visceral, lumber and distal aorta re-entries. Patients with persistent FL perfusion have an increased risk for aortic aneurysmal growth on late follow-up.

Repeated endovascular approaches achieve successful complete remodelling for type IIIb acute aortic dissection

“…Although PETTICOAT demonstrates effective true lumen expansion in the thoracic aorta, the remodelling rate is limited to about 20% in the thoraco-abdominal and infrarenal aortas, often resulting in aneurysmal dilatation [ 1 ]. Long-term follow-up indicates that around 8% of cases require thoraco-abdominal aortic graft replacement [ 2 ]. Challenges arise during the removal of the bare stent in thoraco-abdominal aortic replacement, particularly in separating abdominal branch orifices without intimal damage, adding complexity to the procedure [3].…”

“…However, although the PETTICOAT method encourages remodelling in the thoracic region, its effects on abdominal remodelling are limited, and there is also a restricted decrease in false lumen flow [ 2 ]. As a result, there have been reported cases of remote thoraco-abdominal aortic replacement in the long term [ 3 ].…”

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

“…Nevertheless, long-term results with this approach showed progressive dilatation of the distal aorta prompting the need for additional options. 5,6 The multilayer stent (Intressa Vascular; Isnes, Belgium) is a self-expanding, multilayer, cobalt alloy stent consisting of a three-dimensional braided wire mesh. Despite inconsistent results in aortic aneurysm, 7 the stent has raised physician's interest for the treatment of dissection due to its mechanical properties, reopening the true lumen by approximating the dissection flap to the aortic wall and providing mechanical support to the aortic wall.…”

“…Nevertheless, long-term results with this approach showed progressive dilatation of the distal aorta prompting the need for additional options. 5,6…”