Post-dissection Thoracoabdominal Aneurysms Research Articles

Post-dissection Thoraco-abdominal Aortic Aneurysm Managed with Fenestrated or Branched Endovascular Aortic Repair

Fenestrated or branched endovascular repairs (f/bEVAR) are valuable treatments in patients with chronic post-dissection thoraco-abdominal aneurysms (PD-TAAA). This study aimed to analyse early and follow up outcomes of f/bEVAR. Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with f/bEVAR in a tertiary centre over 8 years were retrospectively analysed. All patients presenting with PD-TAAA and managed with f/bEVAR, were eligible. Modified Crawford's classification system was used. Thirty day mortality and major adverse events (MAE) were analysed. Time to event data were estimated with Kaplan-Meier survival analysis. Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with fEVAR, nine (16%) with fenestrations and branches, and 31 (56%) with bEVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. Thirty day mortality was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (SE 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in fEVAR at the 12 month follow up (p = .006) compared with bEVAR. Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost one-half of patients needed an unscheduled re-intervention within 24 months after f/bEVAR.

Visceral Aorta Electrocautery Septotomy to Allow Branched Endovascular Aortic Repair in Ruptured Chronic Post-Dissection Thoraco-Abdominal Aneurysm.

Endovascular repair of chronic post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) presents specific technical challenges due to the presence of chronic septum. Small true lumen diameter and false lumen visceral vessel origin can make branched endograft prohibitive. Septotomy may allow to overcome these challenges in cases of high complex anatomy. We describe the application of electrocautery septotomy to the visceral aorta segment to deploy an off-the-shelf branched endograft in a chronic PD-TAAA rupture with true lumen collapse. Electrocautery septotomy can be an effective adjunctive technique to facilitate branched endograft, overcoming technical challenges associated with the endovascular treatment of chronic PD-TAAA. Electrocautery septotomy is an adjunctive technique that can facilitate endovascular treatment of post-dissection thoraco-abdominal aneurysm. By creating a common lumen, this technique might reduce the number of re-interventions associated with PD-TAAA endovascular exclusion.

Off-the-Shelf Branched Device for the Treatment of Post-Dissection Thoracoabdominal Aneurysms: A Case Series

Off-the-Shelf Branched Device for the Treatment of Post-Dissection Thoracoabdominal Aneurysms: A Case Series

Erasing narrow paravisceral true lumen with endoseptostomy to favor adequate expansion of branched endograft during postdissection thoracoabdomimal aortic aneurysm endovascular repair

Narrow paravisceral aortic true lumen in postdissection thoracoabdominal aneurysm, represents a challenging situation when branched endovascular aneurysm repair is required; it may be responsible for intraprocedural technical difficulties, such as inadequate main endograft deployment, difficult vessels catheterization, or long-term branch instability related to compression. We describe the case of a 56-year-old man with post-type B thoracoabdominal aortic aneurysm and a severely narrow true lumen (10 mm) at the paravisceral segment. Endovascular aortic septostomy was performed first, to erase the narrow paravisceral aortic true lumen, and subsequently allow branched endograft adequate expansion and regular vessels catheterization.

Evaluation of false lumen occluders implanted in the abdominal aorta false lumen

ObjectiveManagement of postdissection thoracoabdominal aneurysms with a fenestrated and/or branched endograft (F/BEVAR) is associated with favorable outcomes. Treatment should include both true lumen endografting and false lumen occlusion (FLO). Favorable results have recently been reported for FLO in the false lumen of the thoracic aorta. The purpose of this study is to analyze the results of FLO of the abdominal aorta in patients treated for post dissection thoracoabdominal aneurysm. MethodsA multicenter retrospective analysis of prospective data of consecutive patients managed for post dissection thoracoabdominal aortic aneurysm from April 2019 to December 2022 with F/BEVAR associated with FLO in the abdominal false lumen was conducted. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) was followed. Baseline demographics, operative details, and early outcomes (mortality, length of stay) were recorded. Primary endpoints were technical and clinical success. FLO technical success was defined as complete occlusion of false lumen backflow above the FLO on completion angiogram. ResultsDuring the 3-year study, 23 patients were treated for post dissection thoracoabdominal aneurysm with F/BEVAR and the use of abdominal FLO. Twenty-one patients (91.3%) had received prior endovascular treatment. The technical and clinical success was 95.7%. The abdominal FLO had a technical success rate of 78.3%. The median diameter of the FLO was 34 mm. No patient died during the perioperative period, and one patient had spinal cord ischemia (4.3%) with partial recovery. Six patients (26.1%) required early reintervention. The median duration of hospitalization in the intensive care unit and overall was 1 day (interquartile range, 0-3 days) and 7.5 days (interquartile range, 2-22 days), respectively. During the mean follow-up of 9.9 ± 9.0 months, no patient died. False lumen occlusion was complete or partial in nine (39.1%) and nine (39.1%) patients, respectively. No aortic rupture occurred during follow-up. Maximum aortic diameter decreased in 48% and remained stable in 39% of cases. ConclusionsAbdominal aorta FLO during endovascular treatment of post dissection thoracic abdominal aortic aneurysm is associated with favorable outcomes. It offers an additional staging therapeutic option before extensive aorto-bi-iliac coverage, associated with low spinal cord ischemia rates. FLO also provides high rates of false lumen occlusion and false lumen remodeling during follow-up. Longer follow-up and larger cohorts are required to confirm these very promising early findings.

Endovascular Treatment of Chronic Post-Dissection Thoraco-Abdominal Aneurysms Using Inner Branch Device (Ibevar): A Preliminary Single Center Experience

Abstract Background Although open surgery remains the gold standard for the treatment of post-dissection thoraco-abdominal aneurysms (TAAAs), the endovascular approach using fenestrated or branched endografts has emerged as a valid alternative for patients considered at high risk for surgery. The use of inner branch devices (iBEVAR) combining benefits of fenestrations and outer branches could offer an ideal configuration in this context. Aims Our aim was to report our preliminary monocentric experience with iBEVAR in the treatment of post-dissection TAAAs. Methods A retrospective analysis of prospective data retrieved from 1 center between Mars 2020 and January 2023 was done. Endpoints were immediate technical success, postoperative morbidity, rate of endoleaks, re-intervention and mortality. Results During this period, 18 patients (mean age 66,5 years, range 41-80) were identified. All were asymptomatic and operated in a 2-steps procedure with a TEVAR first. There were 5 off-the-shelf E-nside (28%) and 13 custom-made Extra-Design grafts (72%). Despite successful endograft deployment in all patients and branch catheterization in 68/70 cases (97%), the technical success was 94% due to an open conversion for ilio-mesenteric bypass. The 30-days mortality was 0%. During the post-operative period, 17% of patients (3/18) presented complications with 1 case of mesenteric ischaemia requiring a visceral resection and 2 cases of paralytic ileus, treated conservatively. No spinal cord ischemia was observed. During the median follow-up of 16 months (range 1-36), 4 patients (22%) had a re-intervention: one case of type-Ic endoleak treated with an additional renal stent and 3 cases of type-III endoleaks in the celiac trunk requiring a relining. The overall target vessel patency was 100%. In all cases, the sac diameter remained stable. Conclusions The use of iBEVAR appears to be safe and effective for the treatment of post-dissection TAAAs with an acceptable rate of complications. Further patients and longer follow-up are needed.

Intimal tear closure by false lumen stent graft placement for postdissection thoracoabdominal aortic aneurysm

We report a false lumen (FL) stent graft technique to close the intimal tears at the visceral segment for a postdissection thoracoabdominal aneurysm after initial thoracic endovascular aortic repair. Following endovascular abdominal aortic repair, a stent graft was deployed in the FL, overlapping the main bodies from both previous repairs just after a bare metal stent was implanted in the FL proximal to the target lesion to prevent overdilation. A reentry tear at the iliac level was intentionally preserved to protect spinal cord perfusion and develop a collateral network and will be closed in the future staged procedure.

Multi-Branched Thoracoabdominal Endovascular Aortic Repair With Branch Access Through a Left Thoracotomy and Descending Thoracic Aortic Conduit: A Novel and Effective Alternative Access

Purpose: To demonstrate an alternative access to perform directional branch catheterization during complex endovascular aortic repair. Technique: Urgent endovascular aortic repair was indicated to treat a symptomatic post dissection thoracoabdominal aneurysm with large infrarenal dilatation with an off-the-shelf t-Branch endograft (Cook Medical, Bloomington, IN, USA). Traditional proximal arterial accesses were not suitable due to a previous aortic arch endograft. A novel approach was performed through a left postero-lateral thoracotomy, isolation of the descending thoracic aorta and anastomosed a polyester graft conduit to allow sheaths passage to the thoracoabdominal aorta with subsequently directional branch catheterization. Conclusion: The descending thoracic aortic conduit technique is an effective alternative for directional branch catheterization and should be considered whenever traditional proximal arterial accesses are not suitable and other endografts configurations not considered due to anatomic limitations.

Post-Dissection Thoraco-Abdominal Aneurysms: Results from Open and Endovascular Repair

Objective: Repair of post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) is a complex challenge. Choosing the correct approach to manage these aneurysms is not straightforward as both open and endovascular strategies are valid. The aim of this study was to analyse and compare the results of PD-TAAA treated by endovascular or open surgery.

Physician-modified fenestrated Navion endograft for the treatment of a symptomatic postdissection thoracoabdominal aneurysm.

We report the case of a physician-modified four-fenestration endograft for the emergent treatment of a 65-year-old patient with postdissection thoracoabdominal aneurysm deemed unfit for open surgery. The patient, after elective thoracic endovascular aneurysm repair as the first stage of a preplanned two-stage total thoracoabdominal endovascular repair, presented acute onset of dyspnea and thoracic pain. Computed tomography angiography (CTA) showed signs of contained rupture. The Valiant Navion thoracic endograft was used for the creation of a physician-modified four-fenestration stent graft. A diameter-reducing wire technique was used to constrain posteriorly the prosthetic graft and to allow intraprocedural partial deployment. The modified stent graft was finally folded into its original sheath and implanted; four balloon-expandable stent grafts were used as bridging components. Postoperative CTA showed a residual type IIIc endoleak that was treated with a relining procedure 4 months later. At the 20-month follow-up, the patient is alive and well and CTA shows complete seal of the thoracic aneurysm with persisting small type IIIc endoleak in the abdominal aneurysm. A physician-modified endograft can be considered a valuable option in case of urgent treatment of TAAA in patients deemed unfit for open surgery when off-the-shelf devices are not available or contraindicated.

Fenestrated/Branched Endovascular Repair for Postdissection Thoracoabdominal Aneurysms: A Systematic Review with Pooled Data Analysis.

Patients who have survived an acute aortic dissection remain at risk for postdissection thoracoabdominal aortic aneurysms (PD-TAAAs). Fenestrated/branched endovascular repair for PD-TAAA is increasingly used in some high-volume centers, but outcomes are still limited because of the additional challenges compared to atherosclerotic thoracoabdominal aneurysms. This study was performed to evaluate the literature on fenestrated/branched endovascular repair for PD-TAAAs. PubMed, Embase, and the Cochrane Database were searched for relevant studies published until September 2019. Outcome data were extracted to evaluate the technical success, 30-day mortality, later survival, major complications, endoleaks, target vessel patency, and reintervention. Studies were analyzed in a pooled proportion meta-analysis. In total, 143 patients from 4 studies were identified for the pooled data analysis. The pooled technical success rate was 98% (95% CI: 86%-100%). After the treatment, the overall estimated 30-day mortality rate was 3% (95% CI: 1%-8%), early spinal cord ischemia rate was 10% (95% CI: 4%-21%), early renal injury rate was 5% (95% CI: 1%-19%), endoleak rate was 33% (95% CI: 22%-47%), reintervention rate at a median follow-up of 22.5 months was 34% (95% CI: 27%-42%), and all-cause mortality rate was 12% (95% CI: 6%-24%). The use of fenestrated/branched stent grafts for the treatment of PD-TAAA appears generally feasible based on the limited literature, but endoleaks and reinterventions are frequent.

Emergency use of Physician-modified Fenestrated Endograft in a Symptomatic Patient Who was Waiting for a Manufactured Graft to Treat Chronic Post-dissection Thoracoabdominal Aneurysm

Introduction - Fenestrated-branched endovascular repair (F-BEVAR) using custom manufactured devices (CMDs) has been applied to treat post-dissection thoracoabdominal aortic aneurysms (TAAA), but the long wait period for device manufacturing limits its application in patients with symptomatic or contained ruptured aneurysms. Methods - A 59-year-old female patient who was waiting for CMD (Cook Medical, Brisbane, Australia) presented with a symptomatic post-dissection TAAA. The patient had undergone a successful first stage thoracic endovascular repair with creation of a fenestration in the distal aortic septum to perfuse the right kidney, which originated from the false lumen. Repeat computed tomography angiography revealed compression of the true lumen below the level of the fenestration with pressurization of the false lumen (Figure A). The patient was treated emergently using a physician-modified endovascular graft (PMEG) with four fenestrations and preloaded guidewires. The technique of PMEG using low-profile Zenith Alpha™ Thoracic stent graft (Cook Medical, Copenhagen Denmark) is presented with video and illustrations. Results - The thoracic stent-graft was modified onsite under strict sterile technique using the same measurements obtained for the original CMD request. The active fixation bards were removed to facilitate re-sheathing. Four fenestrations were created with ophthalmologic cautery and reinforced using a double layer of nitinol wire (Figure B). Radiopaque markers were added for orientation. Four 0.014-inch preloaded guidewires were added exiting via the top of the delivery system (Figure C). Diameter-reducing sutures were applied and the device was reintroduced into the original 18Fr sheath. Using bilateral femoral and right brachial approach, a long 5Fr sheath was introduced via the brachial approach exiting via the femoral approach. The PMEG was loaded into a through-and-through wire, while the four preloaded guidewires were loaded into a long 5Fr brachial sheath. The device and sheath were advanced into position and deployed in a stepwise fashion allowing sequential catheterization of the celiac axis, superior mesenteric artery and both renal arteries in the compressed true lumen (Figure D). Once all vessels were catheterized, the bifurcated device and iliac limbs were added and flow was restored to the lower extremities. Sequential renal-mesenteric stenting was done. A completion cone beam computed tomography revealed successful aneurysm exclusion. The repair was completed with a total endovascular time of 133 minutes and the patient was dismissed on postoperative day 10. Follow-up CTA showed patent stent-graft with type 2 endoleak. A total of 6 PMEG repairs with low profile Zenith Alpha™ Thoracic stent grafts were performed at our institution between 2016 and 2018, representing 2% of the 280 patients treated by F-BEVAR during this period. All six patients who had PMEGs did not meet inclusion criteria for an ongoing prospective study using CMDs Conclusion - PMEGs remain a valuable option to treat TAAAs, including chronic post-dissection aneurysms, in patients with symptoms or contained rupture who are not ideally suited for off-the-shelf devices. Compared to tighter stainless-steel Z stents, the widely spaced nitinol stents of the Zenith Alpha™ Thoracic endograft offer more space for fenestration placement.

Mid-term Results of Fenestrated/Branched Stentgrafting to Treat Post-dissection Thoraco-abdominal Aneurysms

Mid-term Results of Fenestrated/Branched Stentgrafting to Treat Post-dissection Thoraco-abdominal Aneurysms

Total Endovascular Management of a Symptomatic Post-dissection Thoracoabdominal Aneurysm with the New Physician Modified Fenestrated Thoracic Endograft

Total Endovascular Management of a Symptomatic Post-dissection Thoracoabdominal Aneurysm with the New Physician Modified Fenestrated Thoracic Endograft

Fenestrated or branched endovascular aortic repair for postdissection thoracoabdominal aortic aneurysm

ObjectiveFenestrated or branched endovascular aortic repair (FB-EVAR) usually represents the last stage in endovascular treatment of postdissection aneurysm after thoracic endograft coverage of entry tear and false lumen embolization. MethodsThe study was a retrospective analysis of all patients with postdissection thoracoabdominal aneurysm treated with FB-EVAR in a single center. Short-term outcomes included technical success, operative mortality, and morbidities. Midterm outcomes included secondary intervention, false lumen thrombosis rate, aneurysm size regression, and subsequent survival. ResultsTwenty patients (95% male with a mean age of 64 ± 9 years) were treated between January 2014 and December 2017. The technical success was 100%. There was one death (5%) within 30 days. Postoperative complications included two patients with spinal cord ischemia (10%; one partial and one full). The median follow-up period was 12 months (range, 0-31 months). A secondary intervention was required in six patients, including thoracic stent graft relining for type III endoleak (n = 2), covered stent relining for junctional leak between main body and renal stent (n = 2), and iliac false lumen embolization (n = 2). Twelve patients completed the 1-year follow-up computed tomography angiogram, and their mean aneurysm diameters were 71 ± 18, 66 ± 19, and 62 ± 19 mm preoperatively, immediate postoperatively, and at 1 year, respectively; the corresponding false lumen thrombosis rates were 0% (0/20), 58% (7/12), and 92% (11/12), respectively. One more patient died during follow-up from a non-aneurysm-related cause. The estimated overall survival rates were 95 ± 5%, 88 ± 8%, and 88 ± 8% at 6, 12, and 18 months, respectively. ConclusionsFB-EVAR was feasible for postdissection thoracoabdominal aneurysm. Despite the associated perioperative risk and high probability of planned or unplanned reintervention, the procedure led to favorable aortic remodeling with false lumen thrombosis and aneurysm regression.

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms

Patients surviving acute aortic dissection are at risk of developing a post-dissection thoraco-abdominal aortic aneurysm (PD-TAAA) during follow up, regardless of the type of treatment in the acute setting. Fenestrated and branched stent grafting (F/B-TEVAR) has been used with success to treat PD-TAAA, albeit reported only with short-term results. The aim of this study was to report mid-term results in a cohort of 71 patients. This was a retrospective analysis of a prospectively maintained database including all patients with PD-TAAAs who underwent F/B-TEVAR within the period January 2010 - April 2017at two vascular institutions experienced in endovascular techniques. A total of 71 consecutive patients (56 male, mean age 63.8±10.6 years) were treated. Technical success was achieved in 68/71 (95.8%) patients. In hospital mortality was four (5.6%) patients. Peri-operative morbidity was 19.6%. Three (4.2%) patients developed severe spinal cord ischaemia, one of these patients 12 months post-operatively. Mean follow up was 25.3 months (1-77 months). Cumulative survival rates at 12, 24, and 36 months were 84.7±4.5%, 80.7±5.1%, and 70.0±6.7%, respectively. Estimated freedom from re-intervention at 12, 24, and 36 months was 80.7±5.3%, 63.0±6.9%, and 52.6±8.0%, respectively. The main reasons for re-intervention were endoleak from visceral/renal arteries and iliac endoleak requiring extension. Target vessel occlusion occurred in 8/261 (3.1%) vessels (renal artery n=4; superior mesenteric artery n=2; coeliac artery n=2). Mean aneurysm sac regression during follow up was 9.2±8.8mm, with a false lumen thrombosis rate of 85.4% for patients with a follow up longer than 12 months. No ruptures occurred during follow up. F/B-TEVAR for post-dissection TAAA is feasible and associated with low peri-operative mortality and peri-operative morbidity. Mid-term results demonstrate a high rate of aneurysm sac regression. Rigorous follow up is required because of the significant re-intervention rate. Longer bridging covered stents for target vessels are advised.

Technical Note: Dissection Flap Perforation with Use of a TIPS-Needle During Fenestrated Endografting for Post-dissection Thoracoabdominal Aneurysms.

Fenestrated/branched thoracic endovascular aneurysm repair (F/Br-TEVAR) is a new minimal invasive treatment option for patients with post-dissection thoracoabdominal aortic aneurysms. This specific pathology is challenging to F/Br-TEVAR, especially when target vessels originate from the false lumen. Crossing from the true lumen into the false lumen to catheterize such target vessels may prove cumbersome in the usually thickened dissection flap. We describe a bailout technique when standard catheterization techniques fail, by using a transjugular intrahepatic portosystemic shunt (TIPS)-needle to perforate the dissection flap. The fenestration is subsequently dilated using balloon angioplasty to allow for insertion and deployment of the bridging stent graft. When other catheterization techniques fail in vessel originating from the false lumen, TIPS-needle perforation of the dissection flap is a useful bailout tool.

Endovascular aortic repair of a postdissecting thoracoabdominal aneurysm using intraoperative fusion imaging

Computer-aided imaging can aid complex endovascular repair of aortic dissections in locating the narrow true lumen and identifying perfusion of visceral vessels by the true and/or false lumen. Although these anatomic data are available for analysis during planning, they are not readily available during the procedure with conventional imaging systems. We report the use of "fusion imaging" to facilitate the treatment of a postdissection thoracoabdominal aneurysm. The preoperative computer tomographic angiograms were processed, and the true and the false lumens were individually color labeled. These data were then superimposed on the fluoroscopic images in order to facilitate deployment of a fenestrated endograft.

Fenestrated and Branched Stent-Grafts to Treat Post-Dissection Chronic Aortic Aneurysms After Initial Treatment in the Acute Setting

To present our initial experience treating post-dissection thoracoabdominal aneurysms with fenestrated and branched grafts. Six patients (all men; mean age 62 years, range 44-71) with post-dissection thoracoabdominal aortic aneurysms were selected for treatment with fenestrated and branched grafts. All patients were initially treated with open surgery or endovascular treatment for their acute dissection. In total, 21 visceral arteries were targeted (3 celiac arteries, 6 superior mesenteric arteries, 12 renal arteries). Technical success was achieved in all cases, with no mortality or paraplegia. At completion angiography, all target vessels were patent, and no type I endoleak was seen. A type II endoleak was present in 4 patients, with the false lumen still partially perfused. During follow-up (mean 9 months, range 3-15), no patients died. One targeted renal artery occluded at 1 month. One type Ib endoleak in a left renal artery was successfully treated with additional stenting. Five of the 6 patients had a 6-month follow-up. On abdominal ultrasound, 3 type II endoleaks were still seen. In 2 of these patients, the endoleak was resolved, the false lumen was completely thrombosed, and the maximum aortic diameter had regressed on the 1-year CTA. Although longer follow-up results are needed, treatment with fenestrated and branched stent-grafts seems feasible and may be a promising option for the treatment of chronic post-dissection aortic aneurysms.