Factors Portending Endoleak Formation After Thoracic Aortic Stent-Graft Repair of Complicated Aortic Dissection

Abstract

Background-Endoleaks after stent-graft repair of aortic dissections are poorly understood but seem substantially different from those seen after aneurysm repair. We studied anatomic and clinical factors associated with endoleaks in patients who underwent stent-graft repair of complicated type B aortic dissections. Methods and Results-From 2000 to 2007, 37 patients underwent stent-graft repair of acute (Յ14 days; nϭ23), subacute (15 to 90 days; nϭ10) or chronic (Ͼ90 days; nϭ4) complicated type B aortic dissections using the Gore Thoracic Excluder (nϭ17) or TAG stent-grafts (nϭ20) under an investigator-sponsored protocol. Endoleaks were classified as imperfect proximal seal, flow through fenestrations or branches, or complex (both). Variables studied included coverage of the left subclavian artery, aortic curvature, completeness of proximal apposition, dissection chronicity, and device used. Endoleaks were found during follow-up (mean, 22 months) in 59% of patients, and they were associated with coverage of the left subclavian artery (complex, PϽ0.001), small radius of curvature (type 1 and complex, Pϭ0.05), and greatest length of unapposed proximal stent graft (complex, PϽ0.0001). During follow-up, 10 endoleaks resolved spontaneously, 6 required reintervention for false lumen dilatation, and 2 were stable without clinical consequences. Conclusions-Endoleaks are common after stent-graft repair of aortic dissection and may lead to false lumen enlargement necessitating reintervention. Anatomic complexities such as acute aortic curvature and covered side branches were associated with endoleaks, illustrating the need for dissection-specific device development.

Examination of factors in type I endoleak development after thoracic endovascular repair

“…Different predictors of endoleak have been analyzed in the literature, 5,6,8,9,[20][21][22] including male gender, larger aneurysm size, length of aorta covered by the stent graft, number of stents used, proximal landing zone, and aortic arch morphology. The predictive value of a number of these factors is still controversial, notably aorta length covered by stent graft, considered protective of proximal endoleak by Verhoye et al 9 and, on the contrary, predictive of endoleak by Parmer et al and Morales et al 21,22 In all these studies, results were based only on univariable analysis.…”

“…These findings have led some authors to modify their criteria of proximal aortic neck length in case of zone 1 endografting to 30 mm or more. 24,25 Furthermore, numerous studies 5,6,8,21 report landing zone 2 as anatomically unsuitable for stent graft implantation because it can favor endoleak. These authors argue, first, that LSA overstenting exposes the stent graft to abrupt angulation with, in consequence, excessive mechanical stress acting on the stent and incomplete apposition of the devices, thus incurring a risk of type I endoleak.…”

“…Whereas studies reporting the incidence of endoleak after thoracic endovascular aortic repair (TEVAR) [3][4][5][6][7][8][9] include data of both emergently and electively treated patients, the impact of an emergency indication on endoleak occurrence has not yet been extensively analyzed. This study aimed to investigate the effect of the emergency setting on occurrence of persistent or new developing type I endoleak and to analyze the role played by different morphologic and stent graft-related factors as potential determinants of endoleak.…”

Coil embolization of persistent false lumen after stent graft repair of type B aortic dissection

“…Usually, the therapeutic goal for patients with complicated type B dissections is not so much to eliminate all blood flow in the false lumen as to reperfuse the lower body and prevent thoracic aortic rupture. 5,6 The remaining pressurized false lumen has been a critical problem in chronic phase type B dissection, and several investigators have suggested that the single most significant cause of death related to aortic dissection is expansion of the false lumen leading to aneurysm and rupture. 4,7 Akutsu et al 4 reported that in the chronic period patients with a thrombosed false lumen had a significantly better outcome in terms of dissection-related death and dissection-related events.…”

Type IIIb Endoleak after Thoracic Endovascular Aortic Repair Caused by Endoanchor Dislocation

“…1 Experimental and clinical data have shown that poor endograft apposition within the aortic arch increases the risk of technical failure after TEVAR. 2 Endoanchors represent a feasible option to enhance proximal and/or distal endograft alignment. Although the risk of embolic debris caused by endoanchor placement has been emphasized, endoanchor dislocation from the endograft after TEVAR has not yet been described.…”