Complete False Lumen Thrombosis Research Articles

Long-Term Outcomes of PETTICOAT Technique-Assisted Thoracic Endovascular Aortic Repair for the Treatment of Acute and Subacute Complicated Type B Aortic Dissection.

To evaluate the long-term outcomes of the provisional extension to induce complete attachment technique (PETTICOAT) for the treatment of acute and subacute complicated type B aortic dissection (TBAD). We retrospectively collected and analyzed the clinical data of patients with acute and subacute TBAD who were treated using the PETTICOAT technique at our center between March 2014 and March 2023. The primary endpoint was all-cause mortality; secondary endpoints were a composite of complications, such as entry flow, stent-graft-induced new entry (SINE), and re-intervention. The technical success was 92% (46/50). The perioperative mortality was 2% (1/50), and the procedure-related re-intervention was also 2% (1/50). The mean follow-up time was (74.9±33.9) months. The mortality was 4.1% (2/49). The incidence of aortic-related complications was 8.2% (4/49), including new entry flow, 2 retrograde type A aortic dissections, and 1 distal stent graft-induced new entry SINE. The procedure-related re-intervention rate was 4.1% (2/49). After 5 years of follow-up, the total aortic diameter at the renal artery level was reduced from that at the third year of follow-up but was still significantly larger than preoperatively (26.9±6.6 mm vs. 24.1±4.2 mm, p=0.013). While at the covered stent, bare stent, stentless, and celiac artery (CA) levels, the total aortic diameters did not change significantly compared with preoperative values, whereas true lumen (TL) diameters and TL ratios were maintained at obviously higher levels than preoperative. The rate of complete thrombosis of false lumen in the thoracic aortic segment was significantly higher than that in the abdominal aortic segment (79.6% vs 30.6%, p=0.0001). The results indicated that the PETTICOAT technique is safe and effective and could promote positive remodeling of the aorta from the level of the covered stent to the CA. Remodeling of the distal abdominal aorta may fluctuate and requires close follow-up review. The long-term results from our center suggest that the PETTICOAT technique promotes positive remodeling of the aorta from the level of the covered stent to the CA; whereas this advantage does not seem to be significant in the more distal segment of the abdominal aorta, mainly at the level of RA and distal. Therefore, further procedures may be required for aortic dissection of the abdominal segment. In addition, aortic remodeling may fluctuate to some extent during the follow-up period, especially in the abdominal visceral region, so close follow-up review is quite important, and prompt re-intervention is required if necessary.

Transcatheter electrosurgical aortic septostomy optimizes distal landing zone in chronic dissection

ObjectiveEfficacy of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection (CTBAD) is dependent on eliminating retrograde false lumen perfusion and remodeling the aorta. We describe the efficacy of a novel transcatheter electrosurgical technique to fenestrate the dissection flap and create a distal seal zone for TEVAR in CTBAD. MethodsA retrospective review of the Emory Aortic Database from 2016 to 2023 identified 33 patients who underwent TEVAR with intentional endovascular rupture of the dissection flap (Knickerbocker; KNICK) for CTBAD. In 11 patients, we performed transcatheter electrosurgical aortic septostomy (TECSAS) before KNICK. The technical aspects of TECSAS + KNICK are described and results compared with TEVAR + KNICK alone. ResultsDissection chronicity, aortic size, and preoperative demographics were similar between groups. Technical success was 100%, with zero stroke or paraplegia in both groups. Thirty-day mortality for TECSAS versus KNICK was 0% versus 13.6% (P = .199). Median follow-up was shorter after TECSAS versus KNICK, although not statistically significant (14.6 months vs 21.9 months; P = .065). Elimination of retrograde false lumen perfusion (TECSAS 100% vs KNICK 68.2%; P = .035) and complete false lumen thrombosis or obliteration (TECSAS 91.9% vs KNICK 54.6%; P = .037) were more frequent after the TECSAS procedure. Aortic reinterventions were less frequent after TECSAS versus KNICK (0% vs 13.6%, P = .199), although not statistically significant. ConclusionsThe addition of TECSAS to intentional endovascular rupture of the dissection flap in CTBAD improves distal seal, eliminating retrograde false lumen perfusion. This technique is a safe and precise method to fenestrate a dissection flap and optimize TEVAR in CTBAD.

Long-term results of the frozen elephant trunk technique in primary chronic type B aortic dissection.

The aim of this study is to analyze long-term results of the total aortic arch replacement with the frozen elephant trunk technique for primary chronic type B aortic dissection. Among 322 patients who had the frozen elephant trunk technique, 43 (13.4%) patients (median age, 64.0years) with primary chronic type B aortic dissection were analyzed. The patients underwent surgery at a median of 27.0months after the onset of aortic dissection. The false lumen was patent in 30 (69.8%) patients preoperatively. Two patients suffered paraplegia and another died of cerebral infarction. Complete thrombosis of the peri-stent false lumen was achieved in 36 (83.7%) patients. Overall survival, freedom from aortic events, and freedom from aortic reintervention were 83.5%, 37.2%, and 42.2% at 5years, respectively. Survival rates of the patients with or without aortic events were 75.0% and 95.8% at 5years (Log-rank, p = 0.22). Late aortic events occurred in 19 (44.2%) patients including distal stent graft-induced new entry, type Ib endoleak, and false lumen dilation. The ratio of the stent graft diameter to the preoperative short axis diameter of the true lumen (hazard ratio, 1.90; 95% confidence interval, 1.01-3.59), and the maximal diameter of a postdissection aneurysm (1.07; 1.01-1.12) were the significant multivariate risk predictors of late aortic events. Late aortic events occurr fairly frequently, and new strategies need to be explored to enhance the effectiveness of this procedure in the future.

Extended thoracic endovascular aortic repair is optimal therapy in acute complicated type B dissection

BackgroundThoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including the optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta. MethodsReview of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012 to 2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, and overall and aortic-specific mortality were reviewed. ResultsExtended TEVAR (n = 52) required a greater length of coverage vs standard TEVAR (n = 40) (240 ± 32 mm vs 183 ± 23 mm; P < .01). In-hospital mortality occurred in 5.4% of patients (7.7% vs 2.5%; P = .27) owing to mesenteric malperfusion (n = 3) or rupture (n = 2). The overall incidences of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs 7.5%; P = .38), 3.2% (5.8% vs 0%; P = .18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range, 3.5-8.6 years). There were significantly higher rates of complete thrombosis or obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs 51.5%; P = .04). Distal aortic reinterventions were less frequent after extended TEVAR (5.8% vs 20%; P = .04). Late aorta-specific survival was 98.1% after extended TEVAR vs 92.3% for standard TEVAR (P = .32). ConclusionsExtended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage.

Staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection: a series of 10 cases

Objective: To examine the efficacy and experience of staged and segmented two hybrid surgeries for total repair of Debakey type Ⅰ aortic dissection (TIAD). Methods: This study was a retrospective case series. The clinic data of 10 patients with acute TIAD who were admitted to the Department of Cardiac Surgery, Second Hospital of Lanzhou University or the First People's Hospital of Lanzhou, between January 2016 and August 2022, were retrospectively studied. Ten patients underwent hybrid surgeries in two hospitalizations (stages), including 7 males and 3 females with an age of (60±7) years (range: 49 to 71 years). In stage 1, the first type Ⅱ hybrid arch repair was performed to treat the ascending, total arch, and descending thoracic aorta for acute TIAD without circulatory arrest. In stage 2, the second hybrid surgery including infrarenal abdominal aorta replacement, visceral arteries bypass and endovascular thoracoabdominal aortic repair was performed to treat residual thoracoabdominal aortic dissection after the first hybrid operation (segmented). Basic data, preoperative concomitant diseases, high-risk factors, surgical approaches and postoperative complications of all important organs, as well as CT imaging were analyzed. Results: There was no death in the 20 hybrid surgical procedures. In stage 1 type Ⅱ hybrid surgery, 4 cases underwent reconstruction of the aortic sinutubular junction, while Bentall and David surgery was performed for 3 cases, respectively. A patient received coronary artery bypass grafting. Then all patients were sequentially treated with arch debranching and thoracic aortic endovascular repair. Postoperative complications included renal insufficiency (4/10), hemofiltration (1/10), hypoxemia (4/10), neurologic event (1/10) and type Ⅱ endoleak (1/10). Complete false lumen thrombosis occurred in 9/10 of the patients. All complications recovered successfully at discharge and the average hospital stay was (21±4) days (range: 16 to 28 days) in the first hospitalization. At stage 2, the second hybrid surgery was successfully performed in all patients. No paraplegia, hepatic or renal insufficiency, or endoleak occurred. However, branch graft embolism of the left renal artery was found in one patient 3 days after laparotomy, as well as of superior mesenteric artery in another. Superior mesenteric artery occlusion was successfully treated by endovascular recanalization. Complete false lumen thrombosis occurred in all patients. Although all patients had different degrees of intestinal dysfunction, they were gradually relieved at discharge, and the average hospital stay was (19±2)days (range:16 to 21 days) in the second hospitalization. During follow-up, CT angiography showed aortic remodeling in all patients. Conclusion: Staged and segmented two hybrid surgeries are safe and feasible for total repair of Debakey type Ⅰ aortic dissection and are associated with acceptable early and midterm outcomes.

Pre-emptive False Lumen Embolization to Prevent Persistent Type II Endoleak in Fenestrated-Branched Endovascular Repair of Post-Dissection Thoracoabdominal Aortic Aneurysms.

The purpose was to describe a technique to promote false lumen (FL) thrombosis in post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs) managed by fenestrated/branched endografting (F/B-EVAR). A 5/6Fr-90 cm length sheath is advanced from the true lumen (TL) to FL through the most distal entry tear of the infrarenal aorta or iliac arteries. It is parked in the most cranial portion of the FL in the thoracic aorta. Aortic endografts are deployed in the TL excluding all the para-visceral/distal entry tears and target visceral vessels bridging stenting is performed. A selective FL angiography is performed through the 5/6Fr sheath to detect the origin of all segmentary arteries. Embolization of FL is performed from above to below by M-reye pushable coils, obtaining the packaging of FL. After completion angiography, the 5/6Fr sheath is retrieved in external iliac artery and molding ballooning of the distal segment of the aortic/iliac endograft is performed. Between 2019 and 2023, this technique was applied in 11cases with a median number of 73 (interquartile range [IQR=12) coils. Out of 8 (72%) patients with available radiological follow-up at 1 year, 7 exhibited complete FL thrombosis. The FL coiling in PD-TAAAs managed by F/B-EVAR is feasible, safe, and effective to promote the complete FL thrombosis. Preemptive false lumen embolization is a feasible, safe, and effective technique for preventing persistent type II endoleaks after fenestrated-branched endovascular repair of post-dissection thoracoabdominal aortic aneurysms. This technique may be routinely recommended to promote FL thrombosis and aortic remodeling after FB-EVAR in PD-TAAAs, thereby reducing the incidence of reinterventions during follow-up.

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

Thoracic endovascular repair for type IIIb aortic dissection results in the disappearance of false lumen perfusion in the abdominal aorta in only about 20% of cases, with concern for expansion in the long term. Staged endovascular therapy with intervention on all re-entries can lead to complete false lumen thrombosis and remodelling of the entire aorta. This approach could be an option in cases in which long-term expansion is anticipated.

Outcomes of fenestrated endovascular abdominal aortic repair in distal entry tears of chronic debakey IIIb aortic dissection.

Currently, there have been very few reports within the literature which specifically address using fenestrated and branched stent grafts to completely isolate and repair distal entry tears of chronic DeBakey IIIb aortic dissection. This study aimed to evaluate the clinical outcomes of a 3-dimensional (3D) printed aortic model-guided fenestrated stent in the treatment of distal tears of chronic DeBakey IIIb aortic dissection after thoracic endovascular aortic repair (TEVAR). The study was a one-center retrospective study comprising 36 patients who underwent TEVAR and fenestrated endovascular abdominal aortic repair (F-EVAR) between April 2014 and December 2022. Patient data was compiled and analysed for preoperative, intraoperative, and perioperative characteristics. In total, 36 patients (12 females and 24 males) were incorporated into this study. All of the patients included in this study had hypertension, and among them, the leading cause for undergoing II-stage F-EVAR was the progression of a false lumen, accounting for 24 cases (66.7% of the total). The technical success rate was 97.2% and there were no cases of 30-day mortality, myocardial infarction, permanent paraparesis, or organ failure. One year post-F-EVAR treatment, surviving patients showed significant false and true lumen remodelling with 100% complete false-lumen thrombosis. A total of five patients died during the follow-up, two patients died related to aorta complications and three patients died of heart failure, multiple organ failure, or septic shock. II-stage F-EVAR was safe and feasible operation to repair all distal tears of chronic DeBakey IIIb aortic dissection.

A narrative review on endovascular false lumen management options in chronic aortic dissection

ObjectiveData on false lumen (FL) evolution after endovascular repair for aortic dissection showed discouraging findings in terms of complete FL thrombosis. Persistent flow from collateral arteries and distal entry points may prevent FL exclusion. This review aims to present the current techniques and available evidence on endovascular FL management in patients treated for chronic aortic dissection. MethodsA review of the English literature was undertaken using the MEDLINE and Embase databases from January 2000 to February 2023. Studies reporting on technical and clinical findings of the available endovascular techniques for FL exclusion were considered eligible. Only descriptive data are presented, and no comparison was attempted. ResultsThe available techniques dedicated to preventing FL retrograde flow are (1) the “Cork in the Bottle technique,” (2) physician-modified aortic occluders, (3) the Knickerbocker technique, and (4) FL endografts (FLEs; the Candy-Plug technique). The “Cork in the Bottle technique” has been related to a 24-month follow-up positive aortic remodeling rate at 80%. The Knickerbocker technique showed technical success at 94% but with a secondary reintervention rate at 31%. Follow-up imaging confirmed aortic diameter regression in 75% of patients. Physician-modified and custom-made FLEs (the Candy-Plug technique) have been used for FL backflow interruption. Published experience on the use of custom-made generation I to III FLEs showed a 94% technical success rate and an 80% complete FL thrombosis. During the midterm follow-up, positive aortic remodeling was detected in up to 90% of patients. ConclusionsExclusion of FL’s backflow is mandatory in patients managed for chronic aortic dissections and can be achieved with various techniques. All options are associated with high technical success in experienced hands; however, further advancements and long-term follow-up data are needed.

Aortic remodeling following hybrid arch repair with zone 0 to 5 thoracic endovascular aortic repairs for complex arch and descending thoracic aortic pathologies

ObjectiveFor high-risk patients with aortic arch pathology, hybrid aortic arch repair with simultaneous or staged thoracic endovascular repair of the descending aorta may be a viable alternative to open repair. However, data on postintervention aortic remodeling remain limited. We report the short-term outcomes of remodeling of the thoracoabdominal aorta after hybrid arch repair + thoracic endovascular repair. MethodsAll patients undergoing hybrid arch repair with planned zones 0 to 5 thoracic endovascular repair from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after hybrid aortic arch repair, and on long-term follow-up were analyzed for thoracoabdominal aorta remodeling. Mean change in aortic true luminal diameter and full luminal diameter was calculated at every level, and paired-samples t test was used to compare means. ResultsOf 39 patients, 38 had follow-up data at a mean duration of 14.9 months. There were a total of 3 (7.7%) deaths, 0 (0.0%) strokes, and 0 (0.0%) paralysis. For the 35 patients undergoing thoracic endovascular repair for aortic dissection, at follow-up, there was a significant increase in the mean true luminal diameter at each level (P < .05), except at the aortic bifurcation and common iliac arteries. The largest increase in mean true luminal diameter (P < .01) was observed at the level of the left inferior pulmonary vein (mean difference +13.22 mm, 95% CI, 10.38-16.07), tracheal carina (mean difference +13.06 mm, 95% CI, 10.05-16.07), and inferior left atrium (mean difference +11.19 mm, 95% CI, 7.84-14.53). ConclusionsHybrid arch repair with zones 0 to 5 leads to improved true lumen augmentation in zones 0 to 8 with complete false lumen thrombosis down to zone 5 at short-term follow-up. Zones 9 to 11, if involved, may require adjunctive treatment strategies for total aortic remodeling and complete false lumen obliteration.

Abstract 13748: Safety and Efficacy of Extended Endovascular Treatment for Acute Type B Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection

Introduction: Prior studies reported that extended TEVAR could improve false lumen remodeling in acute type B aortic dissection (TBAAD). However, extended aortic coverage is also a risk factor for spinal cord ischemia (SCI). This study aimed to evaluate the safety and efficacy of extended TEVAR for TBAAD. Methods: Patients who underwent TEVAR for TBAAD between 01/2002-01/2023 in the IRAD Interventional Cohort were analyzed and stratified based on treatment extent: “extended” if aortic coverage &gt; 200 mm, “not-extended” if ≤ 200 mm. Patients with prior aortic repair were excluded. We assessed postoperative SCI and mortality with univariate analysis. Secondly, we compared mid-term outcomes with cumulative incidence function (Gray's test) and Kaplan-Meier estimate (log-rank test). Results: Of 4,146 TBAADs, 350 met inclusion criteria. Compared with not-extended patients (173, 50.3%), patients with extended TEVAR (171, 49.7%) were more frequently Black (29.9% vs. 16.6%; p=.006) and less frequently had aortic valve disease (1.4% vs. 6.5%; p=.03). The indication for extended TEVAR was more frequently extension of incident dissection (15.5% vs. 5.5%; p=.02). Extended TEVAR more frequently had proximal seal in the arch (60.6% vs. 48.2%; p=.03), and distal seal in the thoraco-abdominal (22.1% vs. 7.6%; p=.002), or infrarenal aorta (10.8% vs. 3.5%; p=.02). Extended TEVAR had higher rates of postoperative SCI (6.7% vs. 3.8%; p=.31) and mortality (9.9% vs. 6.4%; p=.24), although the difference was small and not significant. Moreover, after median follow-up of 23.8 months, extended TEVAR had different estimates (albeit not significant) for 3-year complete false lumen thrombosis (48.9% vs. 40.2%; p=.79), 4-year reoperation (13.3% vs. 7.7%; p=.35), and aortic growth (74.6% vs. 47.0%; p=.70), but similar survival (84.7% vs. 83.0%; p=.84). Conclusions: Extension of incident dissection was more common in the extended TEVAR patients.. Although these patients had almost double the rate of SCI, this wasn’t significant. Our findings suggest that extended and not extended treatment for TBAAD may have similar postoperative and mid-term outcomes. Further studies with bigger sample size, and longer follow-up are needed to confirm these results.

False lumen thrombosis and aneurysmal transformation of the non-operated aorta after surgical treatment of proximal dissection

Background: One of the most feared long-term complications of surgical treatment of proximal aortic dissections is an aneurysm of the non-operated compartments of the aorta.Objective: To conduct a comparative analysis of different methods for surgical treatment of proximal aortic dissections in relation to false lumen thrombosis development in non-operated compartments.Methods: We conducted a simple observational retrospective multicenter study to study the effectiveness of the frozen elephant trunk technique compared with a standard surgical intervention (aggressive hemiarch anastomosis or total aortic arch replacement with a multibranched prosthesis). Our study included 101 patients grouped based on the method of treatment: group 1 for frozen elephant trunk (n = 31); group 2 for thoracic aorta reconstruction by the standard methods (control group, n = 70). Due to the retrospective nature of the study and the disparity of groups by certain characteristics, we used propensity score matching to increase the reliability of the results. All patient data were collected in the preoperative period, from the protocols of surgical interventions, in the postoperative and long-term periods (3-6 months, 1 year, 2 years, 3 years after surgery). All statistical calculations were conducted in the RStudio software, version 0.99.879 (RStudio Inc., Boston, USA).Results: The absence of false lumen thrombosis at the thoracic aorta level persisted after the surgical treatment in half of the patients in the control group (n = 13; 52%) and was not determined in the frozen elephant trunk group. Complete false lumen thrombosis at the thoracic aorta level (level of stent graft placement and distal to the diaphragm) was achieved in more than half of the patients in the frozen elephant trunk group and only in 3 (12%) control patients. Aneurysmal transformation of the non-operated aorta occurred in 12 (48%) patients from group 2 and was absent in group 1.Conclusion: The frozen elephant trunk technique reduces the frequency of aorto-related events to 0% within 3 years compared with the standard approach (32%, P &lt; .005). Patients operated on for proximal aortic dissection using the frozen elephant trunk technique are significantly more likely to have false lumen thrombosis in the thoracic aorta (P = .004), significantly lower incidence of aneurysmal transformation or thoracic aorta growth rate of &gt;5 mm per year in the long-term period (P = .016) compared with those who underwent the standard methods. Received 15 February 2023. Revised 31 July 2023. Accepted 4 August 2023. Funding: The study was carried out within the framework of the grant of the President of the Russian Federation НШ-5096.2022.3 (agreement No. 075-15-2022-823 dated 12.05.2022). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.M. Chernyavskiy, M.M. Lyashenko Data collection and analysis: M.M. Lyashenko, A.A. Shadanov, D.S. Panfilov, E.V. SkurikhinaStatistical analysis: M.M. LyashenkoDrafting the article: M.M. LyashenkoCritical revision of the article: A.M. Chernyavskiy, D.A. Sirota, B.N. KozlovFinal approval of the version to be published: A.M. Chernyavskiy, M.M. Lyashenko, D.A. Sirota, A.A. Shadanov, B.N. Kozlov, D.S. Panfilov, E.V. Skurikhina

Thoracoscopic Clipping of Intercostal Artery for Treatment of Type II Endoleak Following Frozen Elephant Trunk Procedure: Case Report.

A 38-year-old man with history of Crawford extent I thoracoabdominal aneurysm and chronic type B1,10 aortic dissection underwent a hybrid repair using the frozen elephant trunk technique. The patient was followed up annually, and type II endoleak of the descending thoracic aorta was diagnosed, leading to negative aortic remodeling. The endoleak was managed by performing intercostal artery clipping using minimally invasive thoracoscopic technique under transesophageal echocardiography control. The computed tomography scan showed no endoleak and complete false-lumen thrombosis with positive remodeling in the distal aortic segments.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Uncomplicated Type B Aortic Dissection with Measurement of Intra–False Lumen Pressure

This study aimed to evaluate the mid-term results of zone 2 thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) by measuring the intra-false lumen pressure (IFLP) during TEVAR. Fifteen patients (9 men; mean age, 57 years) who underwent zone 2 TEVAR for uncomplicated TBAD were reviewed. Delta systolic pressure (defined as the difference between systemic pressure and IFLP) was measured before and after primary entry closure, and aortic remodeling and thrombo-occlusion of the false lumen (FL) were evaluated 12 months after TEVAR at five different levels of the aorta. Median duration from onset to TEVAR was 34 days. The left subclavian artery was preserved in 13 patients (87%) by using stent graft fenestration. Although one patient (6%) had a transient cerebral infarction, there were no severe TEVAR-related complications. Entry closure significantly reduced delta systolic pressure (mmHg) compared to preoperative pressure at all levels (distal arch: -22.2±10.8 vs -5.2±9.6; Th8: -20.1±12.4 vs -6.9±7.2; Th10: -14.3±14.6 vs -4.7±7.5; Th12: -14.4±14.5 vs -4.9±7.8; L2: -14.5±14.2 vs -3.4±6.9). The percentages of aortic remodeling with expansion of the true lumen (distal arch: 82%; Th8: 80%; Th10: 54%; Th12: 45%; L2: 50%) and complete false lumen thrombosis (distal arch: 100%; Th8: 100%; Th10: 67%; Th12: 11%; L2: 0%) were approximately consistent with the change in delta systolic pressure. During a follow-up of 41 months, distal stent-induced new entry occurred in two patients (13%) requiring secondary intervention; however, there were no cases of FL enlargement or aorta-related mortality. Zone 2 TEVAR for uncomplicated TBAD may prevent TEVAR-related complications. Measuring IFLP could be a new predictive marker for assessing the extent of aortic remodeling.

Outcomes of abdominal false lumen embolization for chronic aortic dissection after prior proximal repair with stent-graft.

Persistent false lumen (FL) perfusion with aneurysmal formation is common after thoracic endovascular aortic repair (TEVAR) for typical extended aortic dissection and is associated with poor outcomes. Endovascular FL embolization (FLE) has recently been tried for treatment of postdissection aortic aneurysm (PDAA). However, most reports address thoracic rather than abdominal FLE. In this study, we present the results of abdominal FLE in patients with residual patent abdominal FL following stent-graft repair for aortic dissection. Between 2015 and 2019, 24 patients (mean age: 56.7 ± 11.8 years, range: 40-84 years, 18 male) received endovascular abdominal FLE using vascular plugs, coils, or candy plugs as the main surgery (5 patients) or auxiliary procedure (19 patients) after earlier stent-graft repair for aortic dissection (Type A: 9, Type B: 15). The medical records were reviewed and aortic remodeling was examined comparing the preembolization computed tomography (CT) and the most recent CT before reintervention. Technical success was achieved without any intraoperative complications, early morbidity, or mortality. Median follow-up was 34.4 months (range: 12-71). Regarding thoracic FL, 15 patients exhibited complete thrombosis before the procedure and did not change status thereafter except for 1 patient with distal stent-graft-induced new entry. In the other 9 patients, 6 exhibited increased thrombosis. With regard to the abdominal aorta, increased FL thrombosis only occurred in 8 patients with 3 (12.5%) achieving complete thrombosis. The maximal thoracic aortic diameter did not change (1.4 ± 5.6 mm) statistically, but the abdominal diameter increased significantly (4.3 ± 3.7 mm, p < 0.005). From our results, abdominal FLE is a safe procedure. However, covering all the re-entry tears is complex and the possibility of complete FL thrombosis is low. The abdominal aortic diameter appears to become enlarged in these patients. Continuous follow-up is necessary after FLE.

Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis

Purpose: The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. Materials and Methods: Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. Results: In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was −5 mm (interquartile range [IQR]=−28 to 8 mm), –11 mm (IQR=−53 to 10 mm), and 7 mm (IQR=−13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen. Conclusions: Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. Clinical Impact In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.

Techniques and outcomes of percutaneous aortic anastomosis leak closure after frozen elephant trunk procedure for aortic dissection.

The aim of our study was to provide a summary of applied percutaneous aortic anastomosis leak (AAL) closure techniques after frozen elephant trunk (FET) procedure for aortic dissection and describe the procedural and mid-term outcomes in a consecutive cohort of patients at our center. All patients who underwent percutaneous closure of AAL after FET between January 2018 and December 2020 were identified. Three different strategies were employed: (I) the retrograde technique; (II) the true-to-false lumen loop technique; and (III) the antegrade technique. Procedural and short-term results were assessed. A total of 34 AAL closure procedures were performed in 32 patients. The mean age was 44.3±9.1 years, and 87.5% of patients were male. Successful device deployments were achieved in 36 leaks (100%). Immediate residual leaks were mild and moderate in 37.5% and 9.4% of patients, respectively. After a mean follow-up of 47.1±24.6 months, reduction in AAL to mild or less was accomplished in 90.6% of patients. Complete thrombosis and basically complete thrombosis of the FET's segment false lumen were achieved in 75.0% and 15.6% of patients, respectively. The maximal diameter of FET's segment false lumen significantly decreased by 13.6±8.7 mm (from 33.0±9.4 to 19.4±16.2 mm, P<0.001). Percutaneous closure of AAL after FET procedure was associated with false lumen reduction of aortic dissection. The magnitude of benefit was greatest with AAL reduction to a grade of mild or less. Therefore, attempts should be made to reduce AAL as much as possible.

Multi-constituent simulation of thrombosis in aortic dissection

Aortic dissection is a major aortic catastrophe with a high morbidity and mortality risk, and thoracic endovascular repair (TEVAR) has recently been established as the preferred treatment option for promoting false lumen (FL) remodeling and improving hemodynamics in the true lumen. Complete thrombosis of the FL has been thought to be a prerequisite for healing of the aorta postdissection, whereas flow and pressurization of the FL caused by partial thrombosis are thought to contribute to late dilation and rupture. Therefore, it is important to anticipate FL remodeling outcomes of different TEVAR procedures to determine which one will favor complete FL thrombosis. In this paper, a spatio-temporal mathematical model is proposed to simulate thrombosis in dissection. Blood is treated as a multi-constituent mixture consisting of a linear fluid phase and a thrombus (solid) phase. The transport and reactions of chemical and biological species are incorporated using a system of coupled convection-reaction-diffusion equations to represent two interacting sub-processes in thrombosis: coagulation cascade and platelet activity. Computational fluid dynamic simulations of two in vivo problems were performed using the libraries of OpenFOAM: thrombus growth in an injured straight blood vessel and TEVAR induced thrombosis in a patient-specific acute type B aortic dissection for which multiple follow-up scans are available. For both problems, the simulated thrombus formation was consistent with experimental or clinical observations, indicating the potential applicability of this modeling approach to predict the progression of dissection in patient-specific phantoms and its further use to help surgeons personalize treatment strategy for dissection patients in the future.

Balloon Inducted Re-Lamination and False Lumen Thrombosis in Chronic Type B Aortic Dissection: Technique and Long-Term Results

To evaluate the safety, feasibility, and effectiveness of the BAlloon Inducted re-Lamination and false lUmen Thrombosis (BAILOUT) as a simple technique to address the retrograde false lumen (FL) perfusion and subsequent aneurysmatic degeneration of the thoracic aorta due to a stent-graft crimped in a small true lumen in chronic Type B dissections. An observational, retrospective, single-center study analyzing a nonconsecutive cohort of 8 patients affected by chronic type B aortic dissections already treated with thoracic endovascular repair and with an FL lumen backflow corrected with BAILOUT between 2006 and 2020. After a standard distal extension of the previously implanted graft, the distal end of the graft area was ballooned to completely rupture the dissection lamella to relaminate the aorta hindering the FL backflow. Computed tomography was routinely performed within the first postoperative week before discharge and then at 3months, at 6months, and yearly thereafter. The technical and clinical success rates were analyzed. Primary outcomes were safety and feasibility of the technique, secondary ones included FL thrombosis evaluation, and total aortic diameter analysis at the above-defined levels during the follow-up. Safety was defined if clinical success was reached. Feasibility was intended as technical success obtention. The technical and clinical success achieved was 100% with the complete interruption of FL backflow stating the safety and feasibility of the BAILOUT technique. No early procedure reinterventions were recorded and during a median follow-up of 62.5months [interquartile range 43.2-94.1], only 1 death unrelated to the procedure was recorded. Freedom from aortic-related adverse events at 1 month, 3 months, 1year, 5, and 7years was 87.5%, 62.5%, 62.5%, 62.5%, and 62.5%, respectively. During the follow-up, no one increment of the diameter of the thoracic aorta was documented and all the patients at 3 years of computed tomography angiography showed a complete FL thrombosis. The BAILOUT technique demonstrates to be safe and feasible in this small cohort of patients as a simple and quick way to overcome the issue of FL backflow in chronic type B dissection. Small cohort and retrospective designs were limitations of the study.

A Case of Complete False Lumen Thrombosis of Chronic Dissecting Aortic Aneurysm Followed by Endovascular Entry/Re-entry Closure and Internal Iliac Artery Embolization

A Case of Complete False Lumen Thrombosis of Chronic Dissecting Aortic Aneurysm Followed by Endovascular Entry/Re-entry Closure and Internal Iliac Artery Embolization