Dissection Repair Research Articles

Total Arch Replacement with Concomitant Retrograde Stent Graft Deployment via Ministernotomy in Acute Aortic Dissection.

Acute aortic dissection is one of the most fatal conditions, with high surgical risks and severe postoperative complications. Treatment modalities vary from center to center, and a total arch replacement sometimes is not sufficient to provide a good result. Frozen elephant trunk (FET) offers a good option for a more complete repair. Because of its complexity and expense, however, this excellent technique is not always available. In this article, we present our hybrid technique including total arch replacement and retrograde thoracic endovascular aortic repair (TEVAR) for acute aortic dissection via a ministernotomy. Our study aimed to estimate the safety, early results, and some midterm outcomes of total arch replacement in combination with retrograde TEVAR for acute aortic dissection from August 2013 to May 2017. We analyzed the intraoperative variables (duration of cross-clamp, circulatory arrest, ventilation, and intensive care unit stay), 30-day mortality, and early complications as well as the midterm results of these patients. From August 2013 to May 2017, 22 patients (17 male) diagnosed with acute aortic dissection were treated with total arch replacement and concomitant retrograde endovascular repair via an upper ministernotomy. Mean age (± SD) was 60.8 ± 10.7 years. Thirty-day mortality was 4.5%: 1 patient died of acute renal failure. One patient had a postoperative stroke. The average number of stents used intraoperatively was 1.83. Midterm mortality was 1 patient (4.5%). Complete thrombosis of the false lumen in the thoracic aorta was achieved in 18 patients (90%). Retrograde TEVAR in combination with total arch replacement via an upper ministernotomy might be safe and effective in treating acute type A aortic dissection, with fairly low mortality and perioperative complications, and a very good rate of total false lumen thrombosis in midterm follow up.

Anesthetic Management of Patients Undergoing Aortic Dissection Repair With Suspected Severe Acute Respiratory Syndrome COVID-19 Infection

Severe acute respiratory syndrome coronavirus-2 is still active in Wuhan, China, and is spreading to the rest of the world. Recently, perioperative anesthetic management in patients with suspected or confirmed coronavirus-2 has been reported. However, little has been reported on the anesthetic management of patients undergoing aortic dissection repair in patients with suspected severe acute respiratory syndrome coronavirus-2 infection. During the outbreak in Wuhan, the authors’ team completed 4 cases of aortic dissection repair successfully in patients with suspected severe acute respiratory syndrome coronavirus-2 infection. The purpose of the present report is to summarize current knowledge and experiences on anesthetic management in this patient population and to provide clinical practice guidelines on anesthetic management and infection prevention and control in these critically ill patients.

Cardiac interventions in patients with achondroplasia: a systematic review.

Patients with achondroplasia and other causes of dwarfism suffer from increased rates of cardiovascular disease relative to the remainder of the population. Few studies have examined these patients when undergoing cardiac surgery or percutaneous intervention. This systematic review examines the literature to determine outcomes following cardiac intervention in this unique population. An electronic search was performed in the English literature to identify all reports of achondroplasia, dwarfism, and cardiac intervention. Of the 5,274 articles identified, 14 articles with 14 cases met inclusion criteria. Patient-level data was extracted and analyzed. Median patient age was 55.5 [interquartile ranges (IQR), 43.8, 59.8] years, median height 102.0 [98.8, 112.5] cm, median BMI 32.1 [27.0, 45.9], and 57.1% (8/14) were male. Of these 14 patients, nine had the following documented skeletal abnormalities: 66.7% (6/9) had scoliosis, 66.7% (6/9) had kyphosis, 11.1% (1/9) had lordosis, 11.1% (1/9) pectus carinatum and 11.1% (1/9) spinal stenosis. Coronary artery disease was present in 53.8% (7/13), and 30.8% (4/13) patients previously suffered a myocardial infarction. Of the eight patients who underwent cardiac surgery, 37.5% (3/8) underwent multivessel coronary artery bypass grafting, 37.5% (3/8) underwent aortic valve replacement, 25.0% (2/8) underwent type A aortic dissection repair, and the remaining 12.5% (1/8) underwent pulmonary thromboendarterectomy. Six patients underwent percutaneous intervention. Median cardiopulmonary bypass time was 136.5 [110.0, 178.8] minutes. Median arterial cannula size was 20.0 [20.0, 24.0] Fr. Bicaval cannulation was performed in all cases describing cannulation strategy (5/5). Median superior vena cava cannula size was 28.0 [28.0, 28.0] Fr, and inferior vena cava cannula size was 28.0 [28.0, 28.0] Fr. No mortality was reported with a median follow up time of 6.0 [6.0, 10.5] months. In conclusion, Common cardiac procedures can be performed with reasonable safety in this patient population. Operative adjustments may need to be made with respect to equipment to accommodate patient-specific needs.

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Aortic progression and reintervention in patients with pathogenic variants after a thoracic aortic dissection

ObjectiveTo evaluate aortic disease progression and reintervention after an initial thoracic aortic dissection in pathogenic variant carriers. MethodsOf 175 participants diagnosed with thoracic aortic dissection, 31 had a pathogenic variant (pathogenic group) across 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, TGFBR2) identified by whole exome sequencing. Those with benign or normal variants (benign/normal group, n = 144) comprised the control group. Clinical data were collected through medical record review (1985-2018) and supplemented with the National Death Index database (December 2018). ResultsThe entire cohort (n = 175) consisted of 108 type A aortic dissections and 67 type B aortic dissections, similarly distributed between groups. The pathogenic group was significantly younger (43 vs 56 years, P < .0001) and had significantly more aortic root replacements and similar extents of arch replacement at initial type A aortic dissection repair. The median follow-up time was 7.5 (4.6-12) years. After initial treatment, the pathogenic group required significantly more aortic reinterventions (median 1 vs 0, P < .0001) and mean cumulative aortic reinterventions for each patient (10 years: 1 vs 0.5, P = .029). Both incidence rate (12%/year vs 1.2%/year, P = .0001) and cumulative incidence of reinterventions (9 years: 70% vs 6%, P < .0001) for the preserved native aortic root were significantly higher in the pathogenic group, but were similar for the preserved native aortic arch and distal aorta between groups. Ten-year survival was similar in the pathogenic and benign/normal groups (92% vs 85%). ConclusionsAggressive aortic root replacement and similar arch management should be considered in pathogenic variant carriers at initial type A aortic dissection repair compared with benign/normal variant carriers.

Stent-assisted balloon dilatation of chronic aortic dissection

BackgroundThe treatment of complicated chronic aortic dissection remains controversial. We previously reported encouraging early results with the stent-assisted balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) technique for treating complicated acute aortic dissections. However, to date there have been no specific reports on the treatment of complicated chronic aortic dissections with this technique. The aim of this study was to assess the results of the STABILISE technique to treat complicated chronic aortic dissection. MethodsA single-center prospectively maintained database enrolled all patients hospitalized for aortic dissection at our institution. Inclusion criteria for the STABILISE procedure at the chronic stage of dissection (>3 months) were postdissection aneurysm with a diameter >55 mm or rapid aortic diameter growth >5 mm/6 months. We reviewed all patients treated for complicated chronic aortic dissection with the STABILISE technique. Patients were monitored at 3, 6, and 12 months and annually thereafter with clinical, imaging, and laboratory studies. Outcome analyses included survival, rupture, spinal cord ischemia, endoleak, morbidity (cardiac, renal, or pulmonary), reinterventions, false lumen patency, and aneurysm growth. ResultsBetween September 2015 and December 2018, 17 patients underwent a STABILISE procedure for complicated chronic aortic dissection of the descending aorta. Fifteen patients were treated for remaining chronic distal thoracoabdominal aortic dissection after acute DeBakey type I aortic dissection repair, and 2 patients were treated for chronic type B aortic dissection. The median patient age was 61 years (range, 46-67 years). The median interval between the onset of acute symptoms and the procedure was 9 months (range, 3-67 months). Indications for the STABILISE procedure were a rapidly growing dissected aortic diameter >5 mm/6 months in 13 patients and aneurysmal evolution of the descending thoracic aorta >55 mm in 4 patients. There were no cases of in-hospital death, stroke, spinal cord ischemia, ischemic colitis, or renal failure necessitating dialysis. The median duration of follow-up was 17 months (range, 5-28.5 months). At the last computed tomography scan, 15 patients (88%) had complete false lumen thrombosis of the treated thoracoabdominal aorta down to the renal arteries. None of the patients had aortic growth at treated thoracoabdominal aorta level. One patient developed a proximal type 1 endoleak and required reintervention. Regarding the untreated aortoiliac level below the renal arteries, 11 patients had persistent false lumen patency, and 1 patient developed a common iliac artery aneurysm. All the other patients had stable infrarenal aortoiliac diameters. No late deaths were reported during follow-up. ConclusionsThe STABILISE technique is a safe and effective means of performing immediate, complete aortic remodeling of the thoracoabdominal aorta in patients with complicated chronic aortic dissection, stabilizing the diameter of the dissected aorta.

Management of Dilated Aortic Root in Patients Undergoing Repair of Acute Type-A Aortic Dissection

Management of Dilated Aortic Root in Patients Undergoing Repair of Acute Type-A Aortic Dissection

Restenosis After Tack Implantation is Associated with Less Complex Patterns of Restenosis Compared to Stent Implantation

In-stent restenosis is complex, difficult to treat and has led to a ‘leave less metal behind’ approach to femoropopliteal intervention. Postangioplasty dissection often requires scaffolding to maintain patency. The Tack Endovascular System provides minimal-metal dissection repair that preserves future treatment options. Tack implants are designed to minimise the inflammation and neointimal hyperplasia that lead to in-stent restenosis. An independent angiographic core laboratory evaluated the restenosis patterns in clinically driven target lesion revascularisation (CD-TLR) during the 12 months following the index procedure in the Tack Optimized Balloon Angioplasty (TOBA) II study and compared these results to those published for nitinol stent implantation. Of the 213 patients in TOBA II, 31 (14.6%) required a CD-TLR. Of these, 28 had angiograms that were evaluated by the core laboratory, and 45.2%, 16.1%, and 29% were graded as Tosaka class I, II and III, respectively. There were no significant differences (p&gt;0.05) in lesion length, degree of calcification or dissection class between the three groups. Tack restenotic lesion classification and analysis show a prevalence of both class I and shorter lesions relative to in-stent restenosis, which may be beneficial to long-term patient outcomes.

Technical eligibility for endovascular treatment of the aortic arch after open type A aortic dissection repair

ObjectiveThe objective was to report on the technical eligibility of patients previously treated for Stanford type A aorta dissection for endovascular aortic arch repair based on contemporary anatomic criteria for an arch inner-branched stent graft. MethodsAll patients treated for type A aorta dissection from 2004 to 2015 at a single aortic center were identified. Extent of repair and use of circulatory arrest were reported. Survival and reoperation were assessed using Kaplan–Meier and competing risk models. Anatomic assessment was performed using 3-dimensional computed tomography imaging software. Primary outcome was survival of 1 year or more and fulfillment of the arch inner-branched stent graft anatomic criteria. ResultsA total of 198 patients were included (158 DeBakey I, 32 DeBakey II, and 8 intramural hematoma). Mortality was 30 days (16.2%), 1 year (16.3%), and 10 years (45.0%). A total of 129 patients had imaging beyond 1 year (mean, 47.8 months), and 89 patients (69.0%) were eligible for arch inner-branched stent grafting. During follow-up, 19 patients (14.7%) met the threshold criteria for aortic arch treatment, of whom 14 (73.7%) would be considered eligible for arch inner-branched stent graft. Patients who underwent type A aorta dissection repair with circulatory arrest and no distal clamp were more often eligible for endovascular repair (88.8%) than those operated with a distal clamp (72.5%; P = .021). Among patients who did not meet the arch inner-branched stent graft anatomic criteria, the primary reasons were mechanical valve (40%) and insufficient proximal seal (30%). ConclusionsMore than two-thirds of patients post–type A aorta dissection repair are technically eligible for endovascular arch inner-branched stent graft repair. The development of devices that can accommodate a mechanical aortic valve and a greater awareness of sufficient graft length would significantly increase availability.

Current status in decision making to treat acute type A dissection: limited versus extended repair.

Type A dissection is a clinical emergency and the extent of repairing the damaged tissue is variable and depends on several factors including the expanse of dissection, entry tear, surgeon's experience, and unit resource availability and performance. The conservative surgeon prefers to perform aortic root up-to hemi arch replacement while the patient recovers planning onward for the second stage approach, however, the aggressive school prefers to replace the entire aortic arch with the deployment of a frozen elephant trunk and control intimal tear and alter false lumen natural history. Data to date remains debatable in terms of short- and long-term outcomes with equivocal results between both approaches. Through our manuscript, we aim to highlight the indifferences, challenges, resultant optimum outcomes from the surgeon and patients' perspectives, plus we will mull over the evidence best practice in limited versus extended type A aortic dissection repair.

A modified axillo-femoral perfusion for acute type a aortic dissection accompanied with lower limb malperfusion

BackgroundLower limb malperfusion accompanied with acute type A dissection (AAD) is reported to be an independent predictor for mortality. Timely treatment is required. However, staged approach to restore the perfusion of the ischemic leg before aortic repair has a continuously increase risk of aortic rupture. Aortic repair under isolated axillary artery perfusion also has the risk of prolonging leg ischemia. Here we introduce our experience in performing axillo-femoral perfusion, which is supposed to bring benefits for treating lower limb malperfuison.MethodsThirty patients who suffered AAD accompanied by lower limb ischemia enrolled in our study. All patients received aortic repair as soon as possible using the modified axillo-femoral perfusion approach. The cardiopulmonary bypass and cooling started with the right axillary artery perfusion. Then the femoral artery of the ischemic side was exposed and sewn to a graft connected with another inflow cannula. The rectal temperature was about 31 °C when the femoral perfusion started. The perfusion of the ischemic legs preoperative was estimated after the surgery by the clinical signs, the saturation of the distal-limb, and computed tomography scan.ResultsTwenty-eight patients got good perfusion of the lower body after the surgery. Two patients received femoral-femoral artery bypass immediately after surgery because of the thrombosis in the right common iliac artery, without further injury. No peripheral vessels damage occurred, and no compartment fasciotomy or amputation needed. One patient died for the sepsis and the subsequent multi organ failure 28 days postoperative.ConclusionsThe modified axllio-femoral perfusion could restore the lower limbs’ perfusion simultaneously during the aortic surgery without neither delaying dissection repair nor prolonging the ischemic time. It is a simple, but safe and effective technique.

Pre and Post-Operative Computer Tomography Findings of a patient with a Type A Aortic Dissection Extending from the Aortic Valve to Iliac Vessels

Aortic dissection is a high morbidity, high mortality, medical catastrophe. It is twice as common as ruptured abdominal aortic aneurysm and the mortality following acute aortic dissection is often quoted in hours. The presentation of Aortic Dissection is variable and can be diagnostically challenging, which can have a direct effect on mortality in often young and relatively healthy patients. We present the case of a young man who presented to the emergency departments with central chest pain and ST depression laterally on his ECG. A computer tomography (CT) scan revealed The CT scan showed a proximal Type A dissection involving the aortic valve and the coronary arteries, extending down to the iliac vessels. The patient was transferred to a cardiothoracic centre to undergo emergency surgery and had repair of the aortic dissection, he made a good post-operative recovery and has no residual neurological deficit. A further computer tomography scan was performed 8 months later which showed no change in the patient vascular anatomy.

Association Between Targeted Aortic Segment Tortuosity and Stent-Graft-Induced New Entry After Thoracic Endovascular Aortic Repair for Aortic Dissection or Intramural Hematoma.

OBJECTIVE. The aim of this study was to investigate the association between the tortuosity of the targeted aortic segment (TAS) for stent-graft implantation and distal stent-graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) for aortic dissection or intramural hematoma. MATERIALS AND METHODS. We retrospectively analyzed data from 70 patients who underwent TEVAR using a single stent-graft between 2006 and 2016, and the tortuosity index of the TAS was measured. The patients were divided into high and low TAS tortuosity groups according to the median value of the tortuosity index. The incidence of distal SINE was compared between the two groups. RESULTS. The cumulative incidence of distal SINE at 2 years after TEVAR was 39% in patients in the high TAS tortuosity group and 7% in patients in the low TAS tortuosity group. The incidence of distal SINE was higher in patients in the high TAS tortuosity group than in those in the low TAS tortuosity group (p < 0.01, log-rank test). Multivariate Cox regression showed a higher risk of distal SINE in the high TAS tortuosity group (adjusted hazard ratio, 4.56 [95% CI, 1.40-14.86]; p = 0.01). CONCLUSION. Patients with high TAS tortuosity have a higher incidence of distal SINE after TEVAR. More caution must be exercised during follow-up of patients with high TAS tortuosity after TEVAR.

The Impact of a Reentry Tear After Open Repair of Nonsyndromic Acute Type I Aortic Dissection

The role of a reentry tear in the descending thoracic aorta (DTA) after repair of acute aortic dissection is not well known. We therefore investigated the impact of reentry tear location on late aorta reintervention and the aortic expansion rate after open repair of acute type I aortic dissection. We analyzed 309 nonsyndromic acute type I aortic dissection patients who were treated with a repair to the proximal aorta between 1994 and 2017. The locations of reentry tears, identified with predischarge computed tomography, were the proximal DTA in 119 patients (38.5%), distal DTA in 78 (25.2%), and abdominal aorta in 129 (41.7%). Patients who had a proximal DTA reentry tear were defined as the PDR group (119 [38.5%]), and the others were defined as the non-PDR group (190 [61.5%]). The 15-year freedom from aorta reintervention was significantly lower in the PDR group (51.5% ± 0.7% vs 90.4% ± 4.4%, P < .001). The aortic expansion rates of the proximal DTA (7.6 ± 16.1 mm/y vs 0.1 ± 2.5 mm/y, P < .001) and distal DTA (6.8 ± 15.5 mm/y vs 0.3 ± 3.1 mm/y, P < .001) were significantly higher in the PDR group. The 15-year freedom from significant aortic expansion was significantly lower in the PDR group (34.6% ± 6.9% vs 83.6% ± 7.9%, P < .001). Multivariate analysis showed that a proximal DTA reentry tear was an independent risk factor for aorta reintervention (hazard ratio, 4.955; 95% confidence interval, 1.691-14.523; P= .004) and significant aortic expansion (HR, 4.214; 95% CI, 1.691-10.498; P= .002). A proximally located DTA reentry tear was associated with an increased risk of late aorta reintervention and distal aortic dilatation.

False Lumen Embolization in Chronic Aortic Dissections to Improve Results of Thoracic Endovascular Aortic Repair: Early Experience of 21 Consecutive Cases

Introduction - The failure of endovascular repair of chronic aortic dissections can be explained by the back flow in the false channel through distal re-entry tears. After implantation of a thoracic stent-graft, the false lumen thrombosis occurs in only about 50% of the cases. We evaluated the feasibility of embolization of the false channel in chronic aortic dissections. Methods - Between June 2015 and January 2017, 21 patients with chronic aortic dissection were treated for aneurysmal dilatation of the descending thoracic aorta. They were considered high surgical risk. They were treated by the placement of a thoracic stentgraft and embolization of the false lumen or embolization alone. This was done by placing vascular plugs or coils inside the false lumen. This study is a retrospective analysis of a prospectively collected database. We studied the technical feasibility, the post-operative courses as well as the quality of exclusion of the false channel (determined on late phase CTA). Results - The mean age of the patients was 61 +/- 14 years, 6 patients had residual type A dissection after cardiac surgery, and 15 patients had type B dissection. Five patients were suffering from Marfan disease (24%). Six patients (28%) were symptomatic (painful) preoperatively. Seven patients (33%) had prior aortic arch replacement with elephant trunk procedure. The mean maximum diameter of the thoracic aorta was 63 +/- 14 mm. Spinal fluid drainage was used in 71% of cases (15/21 patients). The embolization was possible in 100% of the cases. Thrombosis of the false lumen at the level of the thoracic dilatation was obtained in 100% of cases but required sometime several sessions. In 81% of cases it was obtained after the 1st embolization. One patient required 2 sessions of embolization and 2 patients required 3 sessions. One patient presented a type A retrograde dissection in relation to the erosion of the arterial wall by the proximal bare stent of a stent-graft. He was operated (open conversion) with simple post-operative course. Only one patient had postoperative medullary ischemia (partially resolving paraparesis). Finally, 2 patients had a replacement of the distal aorta below the stent-graft for a preexisting thoracoabdominal dilatation. The mean follow-up is 10,5 +/- 7 months. Twelve patients (57%) had an aneurysmal shrinkage bigger than 5 mm during follow-up. Conclusion - The embolization of the false lumen of chronic aortic dissections is technically feasible and is easily obtained in the majority of cases. It allows efficient endovascular repair of aortic dissections. The result on aortic remodeling requires longer follow-up. This technique may therefore improve the results of thoracic aortic endovascular repair in chronic aortic dissections.

Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies.

Acute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. s were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.

1-Year Follow-Up Study of Preemptive TEVAR for Residually Dissected Aortas after Proximal Open Repair of Acute Type A Aortic Dissection in High-Risk Patients for Late Re-Intervention

Introduction - Disease progression often occurs in residually dissected aorta after proximal open repair of acute type A aortic dissection (ATAD), requiring distal reoperations, with high mortality and morbidity(1). Unlike type B dissection, the efficacy of preemptive thoracic endovascular aneurysm repair (TEVAR) on the residual disease remains to be seen. We hypothesized that patients who were likely to develop late aneurysmal dilatation of false lumen would benefit from this preemptive approach. Methods - Initially, to analyze risk factors for late aortic events, 108 patients who survived proximal repair for ATAD from 2001 to 2010 were reviewed. During mean follow-up of 40 months, 12 patients required 14 distal re-interventions. On statistic analysis, we identified age < 60 years (p<0.01), aortic diameter > 46mm (p<0.01), and patent false lumen (p<0.05) as factors that predisposed patients who underwent the proximal repair to require late re-interventions. In 2015, we began performing preemptive TEVARs. From April 2015 to January 2016, 11 patients (mean age, 56 years; 72% men) who met the criterion of the aforementioned 3 risk factors underwent preemptive TEVARs. Devices used consisted of a proximal covered stent graft and a distal bare metal stent (Zenith Dissection Endovascular system). Simultaneously, subclavian revascularization was performed in 4 patients and 2 debranching in 2 patients. The interval between proximal repair and TEVAR averaged 122 days (range, 50-297). All patients received 12-month surveillance, including computed tomography (CT). Results - Successful graft deployment and coverage of the primary entry tear was achieved in all patients with no early deaths or intraprocedural conversions. One patient required coil occlusion of the left subclavian artery 5 days post-procedure for retrograde perfusion of the false lumen. No other serious adverse events occurred within 12 months. Survival was 100% at 1 year. Surveillance CT data showed the false lumen was completely (n=8) or partially (n=3) thrombosed in the thoracic aorta at the 12-month visit. Of the 7 patients who underwent the preemptive TEVAR within 3 months, all had complete false lumen thrombosis at the thoracic level. Six of the 7 patients experienced complete shrinkage of false lumen of the thoracic aorta. From pre-treatment to the 12-month visit, the average true lumen area increased by 203 mm2 (p<0.01), and the average false lumen decreased by 276mm2 (p<0.05), at the level of the maximum aortic diameter. Conclusion - TEVAR for residually dissected aortas after proximal open repair of acute type A aortic dissection can be done with a high rate of thoracic aortic remodeling in high-risk patients for late re-intervention. Especially, results of TEVAR within 3 months after open repair are promising. The encouraging results will stimulate further research to define the utility of the preemptive TEVAR. References(1)Geirsson A, Bavaria JE, Swarr D, Keane MG, Woo YJ, Szeto WY, Pochettino A. Fate of the residual distal and proximal aorta after acute type A dissection repair using a contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007:84;1955-64.

Endovascular Repair of a Complicated Acute Type B Aortic Dissection Using a Combination of the STABILISE and CERAB Techniques

Introduction: Endovascular treatment of type B aortic dissection has focused on covering the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained acceptance. We describe a case report in which the STABILISE technique was used in addition with the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique for complete aortic remodeling. Methods: Clinical data were collected from the hospital's records. Results: A 34-year-old male, with a history of hypertension was admitted at the emergency department for acute-onset back pain, severe hypertension and right lower limb ischemia. A CT-Angiography confirmed a type B aortic dissection with true lumen compression and right common iliac artery occlusion. At first, blood pressure and pain were controlled with IV drugs, however the lower limb ischemia persisted. A plan was made to first treat the limb ischemia and delay the aortic repair for the sub-acute phase, if necessary. A common iliac artery kissing stent was performed using Atrium Advanta V12® (10mm) stents and a self-expandable uncovered stent to the external iliac on the right side. The patient recovered well, however, 5 days later, refractory chest pain and hypertension developed. A CT-Angiography showed severe true lumen compression at the visceral aorta and we decided to perform an urgent repair of the aortic dissection. After true lumen catheterization, a TEVAR was performed landing over the left subclavian artery (COOK®ZTA P-32-201) followed by deployment of a bare-metal dissection stent ending 2 cm below the renal arteries (COOK®ZDES 36-180). A control angiography showed false lumen exclusion at the proximal aorta, however the distal aortic true lumen was still severely compressed. For that reason, a STABILISE was performed using a non-compliant 28mm balloon proximally and a 23mm balloon distally. Because the true lumen was still compressed at the infra-renal aorta, we decided to proceed with a CERAB technique, using a Bentley® Aortic BeGraft (18x48mm) deployed just distal to the renal arteries. Proximal flaring of the stent was performed using the 23mm non-compliant balloon. Two 10x59mm Atrium Advanta® V12 stents were used for the iliac extensions ending inside the previous iliac kissing stents. Angiographic control was optimal, and the patient recovered well. However, the patient was still dependent on 4 oral anti-hypertensive drugs, so a new CT-Angiography was performed and showed an intimal flap inside the right renal artery. Under local anesthesia, a Cordis® Palmaz Blue (6x18mm) stent was deployed in the right renal artery through the aortic dissection stent. The patient was latter discharged with adequate hypertension control under two oral anti-hypertensive drugs and the control CT one month after treatment showed complete remodeling of the aorta and perfusion of all visceral branches. Conclusion: We report a case of a combination of the STABILISE and CERAB techniques used to treat an acute type B aortic dissection. This combination allowed for a covering of both the entry tear and the distal re-entry tears resulting in a complete flap apposition, false lumen obliteration and optimal remodeling. Disclosure: Nothing to disclose

Repeat Surgery in Chronic Aortic Dissection: A New Technique without Touching the Native Aorta.

Background Repeat surgery of the chronically dissected aorta following repair of a Type-A acute aortic dissection (AAD) still represents a challenge. The proposed surgical options are as follows: (1) staged procedure with elephant trunk (ET) technique, (2) traditional frozen elephant trunk (FET) intervention, and (3) beating heart cerebral vessel debranching followed by thoracic endovascular aortic repair (TEVAR). However, a marked enlargement of the proximal descending thoracic aorta might make it difficult to perform FET/ET intervention. Furthermore, because in conventional surgery for AAD, a prosthetic graft replacement is generally limited to the ascending aorta, and in repeat surgery, this short Dacron graft rarely provides enough room to allow a beating heart cerebral vessel debranching and obtaining a reliable landing zone for the implantation of a firmly anchored stent graft. Methods We retrospectively reviewed all the five consecutive patients treated in our institution, between 2014 and 2017, for chronic aortic dissection after successful surgical treatment of acute Type-A aortic dissection with graft replacement limited to the ascending aorta. The five patients underwent repair utilizing a modified FET technique with total aortic arch and upper descending aorta exclusion without touching the native dissected aorta. Results No early- or midterm mortality was observed. Mean time interval between the initial and the reoperative procedure was 26 months (range, 3–80 months). No patient had a minor/major neurologic event. Mean circulatory arrest time was 16 minutes (range, 11–25 minutes). Mean follow-up time was 22 months (range, 9–42 months). Conclusions We report our initial experience with a modified FET technique realized by anastomosing the stent graft with the previously implanted ascending aortic graft in Hishimaru's zone 0 and by rerouting all cerebral vessels without “touching” the native chronically dissected aorta. A larger number of patients and a longer follow-up will be required to confirm these initial encouraging results.

Treating Post-Angioplasty Dissection in the Femoropopliteal Arteries Using the Tack Endovascular System: 12-Month Results From the TOBA II Study

ObjectivesThe aim of this study was to evaluate the Tack Endovascular System (Intact Vascular, Wayne, Pennsylvania) for treating dissections following angioplasty in the superficial femoral artery and/or proximal popliteal artery. BackgroundDissection after angioplasty of femoropopliteal arteries with either a plain balloon or a drug-coated balloon (DCB) can negatively affect both short- and long-term outcomes. MethodsTOBA (Tack Optimized Balloon Angioplasty) II is a prospective, single-arm, multicenter study enrolling 213 patients, all with dissection following angioplasty. Eligibility included Rutherford classification 2 to 4 with a de novo or nonstented restenotic lesion in the superficial femoral artery or proximal popliteal artery undergoing plain balloon or DCB angioplasty. Following dilation, lesions with <30% residual stenosis and presence of ≥1 dissection were enrolled. The 12-month efficacy endpoint was primary patency (freedom from duplex-derived binary restenosis and clinically driven target lesion revascularization. ResultsPatients’ mean age was 68 ± 9 years, and 43.2% had diabetes. Twenty-three percent of lesions were chronic total occlusions, and ∼60% had moderate to severe calcium. The mean lesion length was 74.3 ± 40.6 mm. Severe dissection (grade ≥C) was present in 69.4%. By operator choice, 57.7% of patients underwent DCB angioplasty. Most (92.1%) dissections resolved completely, and only 1 bailout stent was required. There were no 30-day major adverse events. The 12-month efficacy endpoint was met, with Kaplan-Meier primary patency and freedom from clinically driven target lesion revascularization of 79.3% and 86.5%, respectively. At 12 months, there were no device fractures or clinically significant migrations, and significant improvements were noted in Rutherford category, ankle-brachial index, and quality of life. ConclusionsTOBA II demonstrated the safety and efficacy of the Tack Endovascular System for focal dissection repair following standard and DCB angioplasty.