Reply

Abstract

In reply to the comments made by Dr Civilini [1Civilini E. PETTICOAT technique to prevent distal stent graft-induced new entry tears.Ann Thorac Surg. 2017; 103 (letter): 2023Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar] regarding our article [2Pantaleo A. Jafrancesco G. Buia F. et al.Distal stent graft-induced new entry: an emerging complication of endovascular treatment in aortic dissection.Ann Thorac Surg. 2016; 102: 527-533Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar], in which he recommends an extended use of the provisional extension to induce complete attachment (PETTICOAT) technique to achieve better aortic remodeling, avoiding at the same time the risk of stent graft–induced new entry (SINE) tear as a late distal adverse event, we respectfully offer the following observations and itemized response. First, the superiority of the PETTICOAT technique versus traditional thoracic endovascular aneurysm repair (TEVAR) techniques has not been demonstrated, especially in terms of false lumen thrombosis, as the article by Canaud and colleagues [3Canaud L. Patterson B.O. Peach G. Hinchliffe R. Loftus I. Thompson M.M. Systematic review of outcomes of combined proximal stent grafting with distal bare stenting for management of aortic dissection.J Thorac Cardiovasc Surg. 2013; 145: 1431-1438Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] cited by Civilini points out. The PETTICOAT technique improves true lumen perfusion and diameter, but it fails to suppress false lumen patency completely, with comparable but not superior results in terms of positive aortic remodeling and especially false lumen thrombosis. Indeed, the ideal role of this technique is in the treatment of type B dissection with severe malperfusion syndrome to obtain a better and easier recovery from true lumen compression, although many concerns still remain about its extended use in other clinical subsets. In their review, Canaud and colleagues [3Canaud L. Patterson B.O. Peach G. Hinchliffe R. Loftus I. Thompson M.M. Systematic review of outcomes of combined proximal stent grafting with distal bare stenting for management of aortic dissection.J Thorac Cardiovasc Surg. 2013; 145: 1431-1438Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] show, for example, that the PETTICOAT approach has higher morbidity rates in terms of neurologic adverse events and aortic rupture, and they also cite concerns about devices, like bare stent fracture or misalignment. If those adjunctive adverse events are acceptable in patients with severe acute disease with threatening malperfusion syndrome, in chronic type B dissection it is not advisable. Regarding the SINE, PETTICOAT may help reduce its risk, but the bare stent does not completely prevent this adverse event because the radial forces of the covered stent graft still act against the intimal flap (because of the bare stent mesh holes). We personally had the experience of a SINE occurrence at the level of covered and bare stent overlap in a patient with chronic dissection. Indeed, SINE has only recently been recognized as a distinct adverse event of TEVAR, and it is probably underestimated in many series because it can often be incorrectly interpreted as a distal type I endoleak. In our experience, the high rate of SINE was partly a consequence of that. By the time we had demonstrated this late adverse event and clearly understood the related risk factors, we had adopted accurate aortic measuring algorithms to prevent it, with optimal results by using a traditional TEVAR approach. In conclusion, in our opinion, the PETTICOAT technique is an optimal option in an acutely ill patient with severe malperfusion syndrome, but many concerns still remain about its extended use, especially in chronic dissection. PETTICOAT Technique to Prevent Distal Stent Graft-Induced New Entry TearsThe Annals of Thoracic SurgeryVol. 103Issue 6PreviewIn the article by Pantaleo and coworkers [1], they investigated on mechanism and predictive factors of late stent graft–induced new entry (SINE) following endovascular treatment of aortic dissection. SINE seems to be related to the stress yielded by an oversized endograft onto the fragile aortic wall, but its occurrence is found in up to 28% of dissections treated despite the clinical use of tapered endografts and accurate aortic measuring algorithms. Full-Text PDF