Invited commentary

Abstract

There is little consensus or data on how to manage chronic complicated dissection where the aorta has failed to remodel. The thickened and stiffened dissection flap makes management extremely difficult for those patients in whom the true lumen and branches are compromised or the false lumen has become increasingly aneurysmal, or both. The study by Stefanov et al offers some insight by investigating clinical outcomes and computational analysis on the same group of patients to study the efficacy of the Streamliner Multilayer Flow Modulator (SMFM; Cardiatis, Isnes, Belgium) for chronic complicated type B dissection. This small study involves 12 patients who were declined current endovascular techniques because of anatomical complexity and high-risk status. Selectively invited physicians performed heterogeneous SMFM procedures entered nonsequentially in a multicenter registry across the globe through an online platform. The registry lacked audit function because the data were received “as is” from participating sites. What is incredible, despite the small number of patients, is that during the follow-up period of the study, no complications were reported, such as rupture or stent fractures, no spinal or visceral ischemia, no cerebral vascular stroke, no lower limb ischemia, and no retrograde type A dissection. Complete thrombosis of the false lumen with aortic remodeling was observed in all patients. The mean maximum aortic diameter and volume increased after SMFM. Alarming at first sight, the authors have demonstrated that the true lumen wall is supported by the SMFM, which takes all the systemic pressure and that the false lumen wall is no longer subjected to high pressure, thus decreasing the risk of aortic rupture. There was an increase in the mean true lumen volume (25%) and a reduction in the mean false lumen volume (16%). The false lumen index was not statistically different between the preoperative and postoperative states. The real value of SMFM may be to increase perfusion to the branch arteries with a demonstrated increase of 78% to suprarenal and to 124% to renal vessels, potentially increasing its role in preventing spinal, mesenteric, and renal ischemia. The authors are to be commended for obtaining and comparing pathophysiologic data to impressive clinical outcomes. A larger data set, removal of selection bias, robust patient selection, and outcome reporting will add weight to the hypotheses proposed by the authors. Unfortunately, SMFM is burdened by its controversial history. SMFM was introduced as a potential “game-changing technology” but has yet to establish itself as a standard endovascular modality for the treatment of aortic aneurysms because of inconsistent results after years of trials. Computational fluid analysis of symptomatic chronic type B aortic dissections managed with the Streamliner Multilayer Flow ModulatorJournal of Vascular SurgeryVol. 65Issue 4PreviewManaging symptomatic chronic type B aortic dissection (SCTBAD) by the Streamliner Multilayer Flow Modulator (SMFM) stent (Cardiatis, Isnes, Belgium) is akin to provisional structural support to induce complete attachment of the dissection flap, but with the ability of aortic remolding. This study investigated the SMFM's capability to enact healing of SCTBAD. Full-Text PDF Open Archive