Distal Bare Stent Research Articles

The necessity evaluation of distal bare stent for treating type B aortic dissection using image-based computational flow analysis

This study aims to verify the necessity of the provisional extension to induce complete attachment (PETTICOAT) technique, by comparing the clinical outcomes with traditional thoracic endovascular repair (TEVAR) procedure. 40 patients with a total of 120 computed tomography angiography examinations (including Pre, Post1, and Post2 for each case) were included and divided into PETTICOAT group (n = 20) and TEVAR group (n = 20) according to the employed intervention technique. The potential risk factors for distal stent-induced new entry (SINE) and morphological and hemodynamic indices related to the aortic remodeling were computed and compared between two groups. All computed potential risk factors for distal SINE showed insignificant difference between PETTICOAT and TEVAR groups. There is no statistically significant difference in the morphological parameters when assessing the aortic remodeling. Regarding hemodynamic factors, the percentage of high relative residence time of Post2 was greater in PETTICOAT group than that of TEVAR group (median, 0.22; interquartile range (IQR), [0.00–0.56] in PETTICOAT vs median, 0.01; IQR, [0.00–0.10] in TEVAR; p = 0.01). The first balance position of computed luminal pressure difference shifted more distally from Post1 to Post2 for patients underwent PETTICOAT than those underwent TEVAR (median, 1.04 cm; IQR, [0.00–6.29 cm] in PETTICOAT vs median, 0.00 cm; IQR, [−1.66 to 1.28 cm] in TEVAR; p = 0.02). PETTICOAT procedure could effectively enhance false lumen thrombosis and aortic remodeling when assessed from functional perspective. However, there is a lack of evidence to support that PETTICOAT can prevent distal SINE.

True lumen expansion but no aortic remodeling following thoracic endografting and distal bare stent for subacute complicated type B aortic dissection.

The effects of thoracic endovascular aneurysm repair (TEVAR) with additional distal bare metal stents (BMSs) in patients with subacute complicated type B aortic dissection (cTBAD) are unclear and are investigated in this retrospective study. The medical records of 67 patients who received TEVAR due to subacute cTBAD were reviewed. Areas of true lumen (TL) and false lumen at five levels-pulmonary artery (PA), diaphragm, renal artery (RA), middle of the infrarenal aorta, and aortic bifurcation-were measured using computed tomography before and 3, 6, and 12 months after surgery. The TL ratio (TL area/total aortic area) and total aortic area at each time point were compared between the TEVAR + BMS (n = 37) and TEVAR-only (n = 30) groups. The effects of BMS use and time were evaluated using generalized estimating equations and generalized linear regression models. Baseline characteristics, remodeling types, and clinical outcomes did not differ significantly between the two groups. Postoperative TL ratios at the diaphragm and RA were significantly higher in the TEVAR + BMS group than in the TEVAR-only group ( p < 0.05). BMS use and time had significant interaction effects at the PA, diaphragm, and RA (all p < 0.05), but effects on total aortic area were not significant at any of the five parts. TL ratios at the diaphragm and RA exhibited greater improvement in the TEVAR + BMS group than in the TEVAR-only group at postoperative months 6 and 12 (all p < 0.001). Aortic diameters at all five parts were significantly smaller in the TEVAR + BMS group than in the TEVAR-only group (all p < 0.05). In patients with subacute cTBAD, TEVAR with BMS implantation effectively expands the TL from the thoracic aorta to the RA but neither enhances aortic remodeling nor elicits any change in total aortic area in whole dissected aorta relative to TEVAR only.

The false lumen problem.

The false lumen problem.

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

Five-year results of the STABLE II study for the endovascular treatment of complicated, acute type B aortic dissection with a composite device design

To provide the 5-year outcomes of the use of a composite device (proximal covered stent graft+ distal bare stent) for endovascular repair of patients with acute, type B aortic dissection complicated by aortic rupture and/or malperfusion. Study of Thoracic Aortic Type B Dissection Using Endoluminal Repair (STABLE) II was a prospective, multicenter study of the Zenith Dissection Endovascular System (William Cook Europe). Patients were enrolled between August 2012 and January 2015 at sites in the United States and Japan. Five-year follow-up was completed by January2020. In total, 73 patients (mean age: 60.7± 10.9years; 65.8% male) with acute type B dissection complicated by malperfusion (72.6%), rupture (21.9%), or both (5.5%) were enrolled. Patients were treated with either a composite device (79.5%) or the proximal stent graft alone (no distal bare stent, 20.5%). Dissections were more extensive in patients who received the composite device (408.9± 121.3mm) than in patients who did not receive a bare stent (315.9± 100.1mm). The mean follow-up was 1209.4± 754.6days. Freedom from all-cause mortality was 80.3%± 4.7% at 1year and 68.9%± 7.3% at 5years. Freedom from dissection-related mortality remained at 97.1%± 2.1% from 1-year through 5-year follow-up. Within the stent-graft region, the rate of either complete thrombosis or elimination of the false lumen increased over time (82.1% of all patients at 5years vs 55.7% at first postprocedure computed tomography), with a higher rate at 5years in patients who received the composite device (90.5%) compared with patients without the bare stent (57.1%). Throughout the follow-up, overall true lumen diameter increased within the stent-graft region, and overall false lumen diameter decreased. At 5years, 20.7% of patients experienced a decrease in maximum transaortic diameter within the stent-graft region, 17.2% experienced an increase, and 62.1% experienced no change. Distal to the treated segment (but within the dissected aorta), 23.1% of patients experience no change in transaortic diameter at 5years; a bare stent was deployed in all these patients at the procedure. Five-year freedom from all secondary intervention was 70.7%± 7.2%. These 5-year outcomes indicate a low rate of dissection-related mortality for the Zenith Dissection Endovascular System in the treatment of patients with acute, complicated type B aortic dissection. Further, these data suggest a positive influence of composite device use on false lumen thrombosis. Continuous monitoring for distal aortic growth is necessary in all patients.

Five-year results of the STABLE II study for the endovascular treatment of complicated, acute type B aortic dissection with a composite device design: Presented at the 2021 Vascular Annual Meeting of the Society for Vascular Surgery, San Diego, CA, August 19, 2021.

Objective: To provide the 5-year outcomes of the use of a composite device (proximal covered stent graft + distal bare stent) for endovascular repair of patients with acute, type B aortic dissection complicated by aortic rupture and/or malperfusion.

Five-Year Results of STABLE II Study for Endovascular Treatment of Complicated, Acute Type B Aortic Dissection With a Composite Device Design

The STABLE II (Zenith Dissection Clinical Trial) study's objective was to assess the safety and effectiveness of a composite device (proximal covered stent-graft plus distal bare stent) for endovascular repair for acute, type B aortic dissection complicated by aortic rupture and/or malperfusion.

Midterm results after covered stenting of the superior mesenteric artery

ObjectiveDespite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. MethodsBetween January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. ResultsDuring the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. ConclusionsMesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.

Satisfactory Long-term Outcomes of Thoracic Endovascular Aortic Repair With a Bare Stent for Acute Complicated Type B Aortic Dissections

Purpose To compare the clinical outcomes after thoracic endovascular aortic repair (TEVAR) with a bare stent to those after TEVAR alone in patients with complicated acute type B aortic dissection (cATBAD). Materials and Methods A prospective, randomized trial was conducted at 2 medical centers in China between 2010 and 2013. Patients with cATBAD were randomly assigned to receive TEVAR with a bare stent (n=42) or TEVAR only (n=42). Patients were scheduled to undergo computed tomography angiography at 3, 6, and 12 months and then annually to 5 years. The primary endpoint was all-cause mortality at 5 years; secondary outcomes were a composite of complications (endoleak, stent-graft–induced new entry, aortic rupture, and secondary intervention) and aortic remodeling at 1 and 5 years. Results All-cause death occurred in 1 (2.4%) patient in the TEVAR with bare stent group (lung cancer) and 5 patients (11.9%) in the TEVAR group (4 aorta-related) during the 5-year follow-up (log-rank p=0.025). The 1- and 5-year rates of complications and secondary interventions did not differ between the groups. Patients in the TEVAR with bare stent group had higher increases in the thoracic true lumen diameter (19.7±3.6 vs 17.0±6.2 mm, p=0.018) and abdominal true lumen diameter (13.7±4.8 vs 7.2±6.1 mm, p<0.001) and a higher incidence of complete false lumen thrombosis (80.9% vs 47.6%, p=0.005) at the 1-year follow-up. However, no between-group differences in the changes of aortic remodeling parameters were observed between the 1- and 5-year follow-up periods. Conclusion The addition of a distal bare stent to a thoracic stent-graft during TEVAR was associated with significantly improved long-term survival in cATBAD patients vs TEVAR only, likely due to the prevention of true lumen collapse and improvement of complete false lumen thrombosis of the dissected aorta.

Distal bare metal stent implantation during thoracic endovascular aortic repair is beneficial to treat complicated type B aortic dissection: A systematic review and meta-analysis.

To explore whether thoracic endovascular aortic repair (TEVAR) plus distal bare metal stent (BMS) implantation leads to favorable clinical outcomes compared with standard TEVAR in treating acute complicated type B aortic dissection. Relevant publications were found through a precise search of PubMed, Cochrane Library, and EMBASE. Count data were calculated as the odd ratio (OR)and 95% confidence interval (CI) using the Mantel-Haenszel statistical method, quantitative data were calculated as mean difference and 95% CI using Inverse Variance statistical method. When the data heterogeneity was large, with an I2 > 50%, a random-effects model and sensitivity analysis were performed. The analysis tool we used was the software Revman 5.3 and G*power 3.1. There were 7 publications involving 958 patients who were enrolled ultimately. The incidence of unplanned secondary intervention and postoperative adverse events in the TEVAR + BMS were lower than standard TEVAR (OR, 0.42, (95% CI, 0.23 to 0.75); OR, 0.57, (95% CI, 0.37 to 0.90)), and the pooled number needed to treat was 15 for unplanned secondary intervention and 15 for postoperative adverse events. There were no significant difference in the aortic-related or all-cause 30-day mortality (OR, 0.81, (95% CI, 0.25 to 2.61); OR, 0.47, (95% CI, 0.18 to 1.22)), aortic-related, all-cause mortality at least 6 months or incidence of the postoperative endoleak (OR, 0.47, (95% CI, 0.17 to 1.32); OR, 0.42, (95% CI, 0.17 to 1.06); OR, 0.81, (95% CI, 0.32 to 2.05)). There is no significant outcome difference except for reduced reintervention but this does not seem to adversely affect survival. It is unclear whether this justifies the additional cost of placing it in every complicated type B aortic dissection regardless of anatomy after standard TEVAR alone. Besides, more data are needed to verify the adjunctive distal bare metal stents' performance at different dissection stages.

Dissection Flap as Bailout Navigator in Complicated Acute Type B Aortic Dissection (Case Presentation)

Introduction: Background: This is a case of threatening right limb ischemia due to complicated acute type B aortic dissection was reperfused utilizing reversed petticoat technique to recanalize totally collapsed infra-renal true lumen. Case presentation: A male patient 55 years old known to be deaf-mutism presented to emergency department with acute onset chest pain persisting for 2 days that was diagnosed as unstable angina, clinical examination revealed blood pressure 195/130 mm. investigations was negative for unstable angina including ECG and cardiac enzyme. Patient was admitted for treating hypertensive crisis; 2 days later patient complained right lower limb severe pain with cold extremity and raised creatinine level. Vascular consultation was done and we provisionally diagnosed the patient as acute type B aortic dissection complicated with right limb malperfusion. CT angiography confirmed the diagnosis of type B aortic dissection with intimal tear 1cm distal to left subclavian artery; all visceral branches were perfused from true lumen except renal vessels were perfused from both true and false lumen. The infra-renal true lumen (TL) was totally collapsed causing right lower limb threatening ischemia and left lower limb was perfused through false lumen. Methods: after stabilization and control of blood pressure, we made our sizing plan and strategy based on preoperative CTA with three-dimensional multiplaner reconstruction. After detecting proximal and distal landing zones, under general anaesthesia patient underwent left carotid-left subclavian bypass. Reperfusion technique utilized dual vascular access, left brachial access (percutaneous) and right femoral access (cut down). After several trials to pass the wire through totally collapsed infra-renal true lumen, we utilized the dissection flap as a navigator to guide the wire into TL then to right common iliac artery. Reversed petticoat technique was utilized (the distal bare stent (Zenith dissection metal stent) was first placed into the compressed TL and deployed at the predetermined position allowing 50-55 mm for overlap with the proximal covered stent (Zenith thoracic alpha). Completion aortography was then performed to ensure coverage of the proximal entry tear and visualization of side branches, reperfusion of the right lower limb. Results: immediate technical success was proved by successful obliteration of the intimal tear with no Type I endoleak and successful reperfusion of right lower limb with adequately perfused visceral aortic branches. The patient had an uneventful recovery in the postoperative period and discharged 24 hours after the procedure. Conclusion: thinking outside the box utilizing nonstandard techniques may be helpful in solving technically challenging complicated cases. In our case, we employed reversed petticoat technique after navigation along the dissection flap to reperfuse totally collapsed infra-renal true lumen that resulting right lower limb threatening ischemia in acute type B aortic dissection with immediate technical success in sealing of intimal tear waiting for follow up to evaluate aortic remodeling.

Surgical Outcomes And Postoperative Descending Aorta Morphologic Remodeling After Thoracic Endovascular Aortic Repair For Acute And Chronic Type B Aortic Dissection.

BackgroundThis study aims to investigate the descending aortic morphological alterations caused by pathological changes in acute and chronic Type B aortic dissection (TBAD) and morphological remodeling after thoracic endovascular aortic repair (TEVAR).Patients and methodsFrom February 2012 to January 2016, 86 TBAD patients undergoing TEVAR were divided into an acute group (n=63) and a chronic group (n=23). The areas of the true, false and maximal lumen and descending aorta morphological parameters, including the taper ratio (TR), oversizing ratio (OR), mismatch ratio (MR), radius of curvature (RoC) and tortuosity index (TI), were evaluated. Follow-ups were performed postoperatively before discharge, at 1 and 6 months, and yearly thereafter.ResultsBefore TEVAR, the TR (0.57 (0.49) vs 0.74 (0.60); P < 0.05), OR (2.75 ± 1.89 vs 3.96 ± 2.27; P < 0.05) and TI (1.22 (1.19) vs 1.41 ± 0.17; P < 0.05) were significantly higher in the chronic group than in the acute group. The TEVAR technical success rate was 100%. No differences were found in 30-day and >30-day mortality between the two groups. Pathology-specific devices, such as tapered stent grafts and distal bare stents, were used more frequently in the chronic group than in the acute group (47.8% vs 23.8%, P = 0.03; 43.5% vs 12.7%, P = 0.002, respectively). The OR and TI changes that occurred after TEVAR were significantly higher in the chronic group than in the acute group (1.80 ± 0.86 vs 2.98 ± 1.85, P = 0.028; 0.00 ± 0.09 vs 0.09 ± 0.10, P < 0.001, respectively).ConclusionTEVAR is a safe and effective therapy for acute and chronic TBAD. Compared to acute TBAD, chronic TBAD resulted in an adverse preoperative descending aorta morphology. Pathology-specific devices may be a feasible treatment option for endovascular repair of chronic TBAD. A larger series of cases with longer follow-up are needed to draw definitive conclusions.

Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection

ObjectiveThis study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections. MethodsTwenty patients with chronic type B aortic dissection with aneurysmal degeneration qualified for an expanded Petticoat strategy (stent graft in the thoracic, plus additional distal bare stent into the abdominal and infrarenal aorta, followed by parallel stent grafts into common iliac arteries). Computed tomography was performed preoperatively and at 1, 6, and 12 months after surgery. ResultsThe primary technical success was 100%. The 30-day mortality rate was 0%. At 12 months, favorable aortic remodeling and complete false lumen (FL) thrombosis were noted as 100% in the thoracic and infrarenal aorta. The volume of contrast-enhanced FL decreased from 186 ± 75.4 mL all along the dissection preoperatively (range, 70-360 mL), to 6.32 ± 5.4 mL postoperatively (range, 0.0-19.6 mL) and was only observed in the visceral aorta (P = .000089). Despite persistent flow in a small area of the FL, the maximal aortic size was stable in follow-up. Neither paraplegia nor visceral branch occlusion were noted in the follow-up. ConclusionsThe treatment of aortic dissections with an expanded Petticoat strategy seems to be safe and offers good early results. It significantly reduced the volume of contrast enhanced FL. Further investigation of any subsequent results will be necessary.

Thoracic endovascular aortic repair with stent grafts alone or with a composite device design in patients with acute type B aortic dissection in the setting of malperfusion

ObjectiveThe objective of this study was to compare short-term outcomes in patients who underwent thoracic endovascular aortic repair (TEVAR) with stent grafts alone or with a composite device design (stent graft plus bare-metal aortic stent) for acute type B aortic dissection in the setting of malperfusion. MethodsThis retrospective analysis included patients with acute (≤14 days of symptom onset) complicated type B dissection in the setting of malperfusion who were treated with stent grafts alone (TEVAR cohort) at two European institutions vs those who underwent TEVAR with a composite device design (Cook Medical, Bloomington, Ind) in the investigational STABLE I feasibility study and STABLE II pivotal study (STABLE cohort). Preoperative characteristics and 30-day outcomes (including mortality, malperfusion-related mortality, morbidity, and secondary interventions) were compared between the two groups. ResultsThe TEVAR cohort (41 patients; mean age, 58.8 ± 12.7 years; 78.0% male) and the STABLE cohort (84 patients; mean age, 57.8 ± 11.7 years; 71.4% male) were largely similar in preoperative medical characteristics, with more STABLE patients presenting with a history of hypertension (79.8% vs 58.5%; P = .018). The TEVAR and STABLE groups had similar lengths of dissection (451.8 ± 112.7 mm vs 411.8 ± 116.4 mm; P = .10) and similar proximal and distal extent of dissection. At presentation, the two groups exhibited comparable organ system involvement in malperfusion: renal (53.7% TEVAR, 57.1% STABLE), gastrointestinal (41.5% TEVAR, 44.0% STABLE), lower extremities (34.1% TEVAR, 52.4% STABLE), and spinal cord (9.8% TEVAR, 2.4% STABLE). The 30-day rate of all-cause mortality was 17.1% (7/41) in the TEVAR group and 8.3% (7/84) in the STABLE group (P = .22). The 30-day rate of malperfusion-related mortality (deaths from bowel/mesenteric ischemia or multiple organ failure) was 12% (5/41) in the TEVAR group and 2.4% (2/84) in the STABLE group (P = .038). The 30-day morbidity, for the TEVAR and STABLE groups, respectively, included bowel ischemia (9.8% [4/41] vs 2.4% [2/84]; P = .09), renal failure requiring dialysis (7.3% [3/41] vs 9.5% [8/84]; P > .99), paraplegia or paraparesis (4.9% [2/41] vs 3.6% [3/84]; P = .66), and stroke (2.4% [1/41] vs 10.7% [9/84]; P = .16). The occurrence of 30-day secondary intervention was similar in the TEVAR and STABLE groups (7.3% [3/41] vs 7.1% [6/84]; P > .99). True lumen expansion in the abdominal aorta was significantly greater in the STABLE group. ConclusionsIn patients with acute type B aortic dissection in the setting of branch vessel malperfusion, the use of a composite device with proximal stent grafts and distal bare aortic stent appeared to result in lower malperfusion-related mortality than the use of stent grafts alone. The 30-day rates of morbidity and secondary interventions were similar between the groups.

New technical approach for type B dissection: from the PETTICOAT to the STABILISE concept.

Endovascular treatment of acute complicated type B aortic dissection (TBD) has recently acquired a primary therapeutic role when anatomically feasible. However, strategies meant to simply close the proximal entry tear leave the risk of persistent perfusion of the false lumen (FL) through additional tears in the thoracoabdominal aorta, and therefore the potential for aneurysmal degeneration remains significant over the years. Thus, additional bare stent implantation in the thoracoabdominal aorta has been proposed to promote true lumen (TL) expansion, malperfusion relief, and intimal lamella stabilization. This technique, also known as the Provisional Extension To Induce Complete Attachment Technique (PETTICOAT) offers good short- and mid-term results, but some degree of perfusion of the FL is still maintained, and the aorta showed a tendency to grow distally to the stent-graft. An evolution of PETTICOAT, mainly including aggressive ballooning of the covered stent-graft and of the distal bare stents deployed in the TL, in order to obtain full expansion of the stents in a single channeled aorta, has been proposed in 2012 and named Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE) technique. Although this approach produced excellent early results in single-center series, it did not gain immediate acceptance in the community, mainly because of concerns regarding the potential risk of rupturing the aorta during ballooning. In this review, we summarize the current evidence on the results of these strategies, we present a recently modified approach of the STABILISE technique, and report the early results in a cohort of patients treated in the last two years at our institution.

Urgent Endovascular Treatment for Non-traumatic Descending Thoracic Aortic Rupture.

To evaluate the efficacy of endovascular repair of non-traumatic rupture of the descending thoracic aorta. From January 2011 to August 2017, 22 consecutive patients (16 men, mean age 73.7years, range 63-92years) with non-traumatic rupture of the descending thoracic aorta were treated endovascularly. Thirty-day mortality as well as procedure-related morbidity including stroke, renal, pulmonary and spinal complications were retrospectively assessed. Median follow-up was 29months (range 6-65months). Nine patients had type B dissections, and 13 had atherosclerotic aortic aneurysms. The technical success was 100%; 86.3% of patients (19/22) were treated percutaneously. Thirteen patients (59%) received a single endograft, 8 (36%) received 2 endografts, and 1 received 3 endografts. The endograft diameters ranged between 28 and 46mm. Two dissection patients received additional distal bare metal true lumen stents. Eleven patients required additional drainage of thoracic hematoma. Three primary percutaneous sites (15.7%) required surgical revision. No spinal cord ischemic or renal complications were observed. Stroke was observed in 2 patients (9%), both with full coverage of left subclavian artery origin. Four patients (18%) required tracheostomy with prolonged respiratory support (range 10-15days). The median intensive care unit stay was 5days (range 1-27days). The 30-day mortality was 18.1% (4/22). Endoluminal repair of non-traumatic rupture of the descending thoracic aorta can be performed percutaneously. It showed a 30-day mortality of 18.1%, and no spinal cord injury or renal complications were observed in surviving patients at follow-up. Level 4, case series.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results.

To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required.

Modified Petticoat Technique with Pre-placement of a Distal Bare Stent Improves Early Aortic Remodeling After Complicated Acute Stanford Type B Aortic Dissection

This study evaluates the safety and efficacy of pre-placement of a distal bare stent as an adjunct to thoracic endovascular aortic repair (TEVAR) in the setting of complicated acute Stanford type B aortic dissection (cTBAD). The records of all patients diagnosed with cTBAD at the institution between 2010 and 2013 were reviewed. Indications for the pre-placement of a distal bare stent included symptomatic malperfusion and/or radiological evidence of true lumen collapse. Computed tomography angiography was performed post-operatively to assess aortic remodeling. 148 patients were treated for cTBAD: 113 patients (76.4%) were treated with standard TEVAR and 35 (23.6%) were treated by combined proximal TEVAR with pre-placement of an adjunctive distal bare stent. Primary technical success was 95.9%. The 30 day mortality rate was 4.1% and was not different between groups. The 30 day morbidity included transient renal failure (10.1%), endoleak (7.4%), and paraplegia (2.7%), and was not different between groups. The mean follow up was 10 months (range 2-12 months). No late stent complications were observed; patients with an adjunctive bare stent had less distal re-dissection (0% vs 15%; P = .01) and fewer endovascular re-interventions (5.7% vs 20.4%; P = .04). At 1 year, patients treated with TEVAR and an adjunctive distal bare stent had increased true lumen volume (166 vs 110 mL; P = .022), decreased false lumen volume (60 vs 90 mL; P = .043), and increased complete false lumen thrombosis in the thoracic (76.5% vs 29.5%; P < .001) and abdominal (20.6% vs 3.8%; P = .002) segments. Combined pre-placement of a distal bare stent as an adjunct to proximal TEVAR to treat cTBAD restricts oversizing of the distal stent graft, reducing the potential for distal true lumen collapse and visceral malperfusion, and improving remodeling of the dissected thoracic aorta. Long-term follow up and prospective studies are needed to assess the overall effectiveness of this treatment strategy.

Modified Petticoat Technique with Pre-placement of a Distal Bare Stent Improves Early Aortic Remodeling after Complicated Acute Stanford Type B Aortic Dissection

This study evaluates the safety and efficacy of pre-placement of a distal bare stent as an adjunct to thoracic endovascular aortic repair (TEVAR) in the setting of complicated acute Stanford type B aortic dissection (cTBAD). The records of all patients diagnosed with cTBAD at the institution between 2010 and 2013 were reviewed. Indications for the pre-placement of a distal bare stent included symptomatic malperfusion and/or radiological evidence of true lumen collapse. Computed tomography angiography was performed post-operatively to assess aortic remodeling. 148 patients were treated for cTBAD: 113 patients (76.4%) were treated with standard TEVAR and 35 (23.6%) were treated by combined proximal TEVAR with pre-placement of an adjunctive distal bare stent. Primary technical success was 95.9%. The 30 day mortality rate was 4.1% and was not different between groups. The 30 day morbidity included transient renal failure (10.1%), endoleak (7.4%), and paraplegia (2.7%), and was not different between groups. The mean follow up was 10 months (range 2-12 months). No late stent complications were observed; patients with an adjunctive bare stent had less distal re-dissection (0% vs. 15%; p = .01) and fewer endovascular re-interventions (5.7% vs. 20.4%; p = .04). At 1 year, patients treated with TEVAR and an adjunctive distal bare stent had increased true lumen volume (166 vs. 110 mL; p = .022), decreased false lumen volume (60 vs. 90 mL; p = .043), and increased complete false lumen thrombosis in the thoracic (76.5% vs. 29.5%; p < .001) and abdominal (20.6% vs. 3.8%; p = .002) segments. Combined pre-placement of a distal bare stent as an adjunct to proximal TEVAR to treat cTBAD restricts oversizing of the distal stent graft, reducing the potential for distal true lumen collapse and visceral malperfusion, and improving remodeling of the dissected thoracic aorta. Long-term follow up and prospective studies are needed to assess the overall effectiveness of this treatment strategy.

Fenestrated Endografting After Bare Metal Dissection Stent Implantation

Purpose: To present a case that demonstrates the ability to deploy a 4-fenestrated endograft in an aorta previously treated with an endovascular graft and additional distal bare stents for acute type B dissection. Case Report: Five years ago, a 61-year-old man had a Zenith TX2 endovascular graft and 2 distal bare metal stents deployed for acute type B dissection. In follow-up, a distal extension endograft was deployed below the bare stent for false lumen reperfusion and aortic growth. The ascending aorta and the arch were replaced surgically at 3 years, with the distal end of the graft sewn to the existing endograft. At the current admission, a Crawford type III thoracoabdominal aortic aneurysm was found and excluded with a 4-fenestration endograft. Using 3-dimensional fusion imaging, there was no major conflict with the struts of the bare dissection stent during catheterization and bridging stent placement. A distal bifurcated endograft was also implanted. The total procedure time was 240 minutes, the radiation dose was 8066 cGy·cm2, and the contrast volume was 100 mL. The patient was discharged on the sixth postoperative day and continues to do well at 9 months. Conclusion: Prior dissection stent deployment within the thoracoabdominal segment does not preclude further fenestrated endograft placement. Intraoperative fusion imaging can be very helpful to the successful completion of these complex procedures.