Endovascular strategies for post-dissection aortic aneurysm (PDAA)

Abstract

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.

Differences in the Area of Proximal and Distal Entry Tears at CT Angiography Predict Long-term Clinical Outcomes in Aortic Dissection

“…On the other hand, the false lumen is patent in 13%-60% of patients with TBAD after endovascular repair (6,20) and in 31%-77% of patients with TAAD after initial surgery (5,10,21,24), and remaining tears have been related to long-term AAEs (19)(20)(21). Several endovascular techniques for achieving thrombosis of the postsurgical false lumen through DT repair have been developed as an alternative to open surgery (30). The absence of tear dominance can help in identifying patients with uncomplicated TBAD that can be safely managed without endovascular repair, as well as in identifying treated patients with either TBAD or TAAD who are at a low risk of developing late complications.…”

Reverse Cheese-Wire Septotomy to Create a Distal Landing Zone for Thoracic Endovascular Aortic Repair

“…The development of late aneurysms in aortic dissection is a challenging issue, and endovascular repair in this scenario often requires creative solutions. 3 Here, we describe the successful treatment of a large false lumen aneurysm in the thoracic aorta using a novel retrograde modification of the cheese-wire endovascular septotomy technique. Cheese-wire septotomy aims to create a single lumen suitable for endovascular sealing by dividing the chronic dissection flap to merge the true and false lumens.…”

Distal Aortic Remodeling after Type A Dissection Repair: An Ongoing Mirage

“…Remodeling is a process of stabilization of the overall aortic dimensions by slow obliteration of the FL and maintenance of true lumen (TL) patency. However, in the majority of the cases, this obliteration is incomplete and variable, which leads to aneurysmal dilatation of the aorta in 13.4%–62.5% of these patients after the index repair [ 7 ]. Aortic remodeling does not have an official definition, but it has been described by various surgical groups as favorable or unfavorable depending upon the occurrence of regression or progression with a >10% volumetric difference in the aortic dimensions (TL, FL, or total aortic lumen) [ 8 ].…”

“…Other investigators have suggested using the aortic lumen diameter, as it correlates well with the cross-sectional area and could be used to assess aortic remodeling [ 9 ]. In most cases, favorable remodeling of the TL and FL is limited to the segment of the proximal thoracic aorta with the stent-graft in-situ, whereas volume changes of the TL and FL in the distal thoracic and abdominal aorta remain either stable or unpredictable [ 7 , 8 ]. Ulcer-like projections (ULPs) are examples of favorable remodeling seen in 62.3% of cases on computed tomography (CT) angiography scans [ 10 ].…”

“…The extension of the FL has been divided into 3 segments in relation to the stent-graft (the stented segment of the FET in the descending aorta is defined as segment A, the segment from the distal end of the stent-graft to the level of the coeliac trunk as segment B, and the segment from the coeliac trunk to the aortic bifurcation as segment C); this division is prognostic, as FL thrombosis is variable after FET deployment [ 6 ]. The incidence of persistent residual flow increases as the FL extends away from the stent-graft (90% FL thrombosis at segment A and only 20% at segment C or at the coeliac axis origin) [ 7 ]. Another reported advantage of the FET is that it reduces the rate of annual aortic growth in the covered part of the distal aorta, but does not stop dilatation in the distal aorta near the diaphragm and in the abdominal aorta, which eventually may lead to future aortic interventions [ 51 ].…”