Provisional Extension To Induce Complete Attachment Technique Research Articles

The false lumen problem.

The false lumen problem.

Technical Pitfalls for Fenestrated-Branched Endovascular Aortic Repair Following PETTICOAT

The Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) uses a bare-metal stent to scaffold the true lumen in patients with acute or subacute aortic dissections. While it is designed to facilitate remodeling, some patients with chronic post-dissection thoracoabdominal aortic aneurysms (TAAAs) require repair. This study describes the technical pitfalls of fenestrated-branched endovascular aortic repair (FB-EVAR) in patients who underwent prior PETTICOAT repair. We report 3 patients with extent II TAAAs who had prior bare-metal dissection stents treated by FB-EVAR. Two patients required maneuvers to reroute the aortic guidewire, which was initially placed in-between stent struts. This was recognized before the deployment of the fenestrated-branched device. A third patient had difficult advancement of the celiac bridging stent due to a conflict of the tip of the stent delivery system into one of the stent struts, requiring to redo catheterization and pre-stenting with a balloon-expandable stent. There were no mortalities and target-related events after a follow-up of 12 to 27 months. FB-EVAR following the PETTICOAT is infrequent, but technical difficulties should be recognized to prevent complications from the inadvertent deployment of the fenestrated-branched stent-graft component in-between stent struts. The present study highlights a few maneuvers to prevent or overcome possible complications during endovascular repair of chronic post-dissection thoracoabdominal aortic aneurysm following PETTICOAT. The main problem to be recognized is the placement of the aortic wire beyond one of the struts of the existing bare-metal stent. Moreover, encroachment of catheters or the bridging stent delivery system into the stent struts may potentially cause difficulties.

A Systematic Review on PETTICOAT and STABILISE Techniques for the Management of Complicated Acute Type B Aortic Dissection

Background: Extended downstream endovascular management has been applied in acute complicated type B aortic dissection (acTBAD), distally to standard thoracic endovascular aortic repair (TEVAR), using bare metal stents, with or without lamina disruption, using balloon inflation. The aim of this systematic review was to assess technical success, 30-day mortality, and mortality during follow-up in patients with acTBAD managed with the Provisional Extension To Induce Complete Attachment (PETTICOAT) or stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement was followed. A search of the English literature, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until 30th August 2022, was executed. Randomized controlled trials and observational studies (published between 2000–2022), with ≥5 patients, reporting on technical success, 30-day mortality and mortality during the available follow-up among patients that underwent PETTICOAT or STABILISE technique for acTBAD were eligible. The Newcastle-Ottawa Scale was applied to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, and secondary outcome was mortality during the available follow-up. Results: Thirteen studies were considered eligible, twelve in the quantitative analysis. In total, 418 patients with acTBAD managed with the PETTICOAT (83%) or STABILISE (17%) technique were included. Technical success ranged between 97–100%, 99% for the PETTICOAT and 100% for the STABILISE sub-cohort. Thirty-day mortality was estimated at 3.7% (12/321), 1.4% for the STABILISE and 4.4% for the PETTICOAT technique. All studies reported the mean available follow-up which was estimated at 20 months (range 3–168 months), 22 months (mean value) for the PETTICOAT and 17 months (mean value) for the STABILISE technique. Twenty-three patients died during follow-up, with an estimated mortality rate at 5.7% for the total cohort. The mortality during follow-up was 0% for the STABILISE and 7.0% for the PETTICOAT approach. Conclusions: Both, the PETTICOAT and STABILISE techniques presented less than 4% perioperative mortality in patients with acTBAD with high technical success rate. The mid-term mortality rate was at 6%. However, the heterogeneity in the available studies’ highlights the need for further prospective studies, including larger volume and longer follow-up.

Aortic remodelling and late outcomes following thoracic endovascular repair with a bare-metal stent distal extension among patients with complicated type-B aortic dissection

OBJECTIVESThe goal of this study was to describe the factors affecting mid and late aortic remodelling following thoracic endovascular aortic repair with the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique among patients with complicated acute or subacute type B aortic dissection.METHODSA retrospective single-centre study that evaluates clinical and morphological outcomes among 65 consecutive patients. The area and diameter of the true and false lumen, overall aortic diameter and false lumen perfusion were evaluated.RESULTSConcomitant direct visceral artery stenting was successfully conducted in 32 (49%) patients. There was one (1.5%) postoperative stroke; three (4.6%) patients developed spinal cord ischaemia; two (3%) patients suffered retrograde type A dissection; and two (3%) patients had mesenteric ischaemia, despite successful reperfusion, that required a bowel resection. Median postoperative follow-up was 63.1 (interquartile range, 32.1– 91.8) months. The probability of survival was 96.9% [95% confidence interval (CI) 88.3%–99.2%] at 30 days, 93.9% (95% CI 84.4%–97.6%) at 1 year, 78.0 (95% CI 64.2%–87.0%) at 5 years and 72.8% (95% CI at 57.9%–83.2%) at 10 years postoperatively. There was a statistically significant postoperative increase in true-lumen area, diameter and true-lumen index in all five aortic levels measured. Complete false lumen (FL) thrombosis at the coeliac trunk, renal arteries and aortic bifurcation levels was observed in 47%, 15% and 24% of patients at midterm (6–15 months) and in 29%, 21% and 29% on late (later than 21 months) computed tomography angiograms (CTA). Persistent false lumen (FL) perfusion at the coeliac level on midterm CTA was associated with a larger extent of late aortic growth (P = 0.042) and was, in the majority of cases, caused by iliac re-entries either alone (28.57) or in combination with visceral and lumbar (28.57%) or distal aortic (10.71%) re-entries. A larger abdominal aortic diameter at midterm was associated with an increased probability of distal aortic reinterventions (hazard ratio 7.26, 95% CI 2.41–21.9, P < 0.001).CONCLUSIONSPersistent FL perfusion of the distal aorta at midterm following TEVAR with the PETTICOAT technique among patients with acute and subacute type B dissection is caused mainly by iliac, visceral, lumber and distal aorta re-entries. Patients with persistent FL perfusion have an increased risk of aortic aneurysmal growth at late follow-up.

Concomitant distal bare-metal stenting for residual true lumen stenosis in a frozen elephant trunk technique for acute type A aortic dissection.

For acute type A aortic dissection (TAAD), we have performed aortic arch repair using a frozen elephant trunk (FET) since 20141 and observed that aortic remodeling was limited at the level below the FET stent end postoperatively.2 For acute type B aortic dissection (TBAD), the PETTICOAT (provisional extension to induce complete attachment) technique has been an option to reopen the residual true lumen (TL) collapse after thoracic endovascular aortic repair (TEVAR).3 Similarly, proximal stent grafting with distal bare-metal stenting in a 2-staged manner has been reported in repair of acute DeBakey type I aortic dissection.

Aortic remodeling of the provisional extension to induce complete attachment technique in DeBakey type IIIb aortic dissection

Data about volumetric remodeling of the provisional extension to induce complete attachment (PETTICOAT) technique on DeBakey type IIIb aortic dissection in acute and subacute phases were scarce. The proper timing to perform this technique to promote false lumen reduction was also unknown. Patients with DeBakey type IIIb aortic dissection who underwent the PETTICOAT technique between December 2005 and March 2017 were reviewed and divided into acute (treatment occurred ≦14 days after symptom onset) and subacute (15-90 days) groups. Remodeling parameters of the true and false lumens were analyzed. Receiver operating characteristic curve was used to deduce the timing of this technique. In the 2-year follow-up, the acute group (N=20) demonstrated significant true lumen expansion and false lumen regression in the thoracic, abdominal, and total aorta. However, the subacute group (N=20) only showed significant shrinkage in the false lumen of the thoracic and total aorta. Using PETTICOAT technique within 36 days after the aortic event may result in better total false lumen reduction. For DeBakey type IIIb aortic dissection, more prominent true lumen expansion and false lumen reduction were noted when using the PETTICOAT technique in the acute phase. When performed within 36 days after symptoms onset, the PETTICOAT technique may potentiate better total false lumen regression.

The extended PETTICOAT technique does not guarantee favorable remodeling after acute type B aortic dissection.

Favorable remodeling is not always observed after thoracic endovascular aortic repair (TEVAR) in acute complicated type B aortic dissection (TBAD). Existing distal re-entries might be the cause of that. Many more extensive techniques have been introduced and evaluated. None of them achieve proven benefit in long-term follow-up. A new technique called extended PETTICOAT (provisional extension to induce complete attachment) or e-PETTICOAT technique was published in 2018. It allows one to cover proximal and distal re-entries and consists of: combined implantation of a thoracic stent graft to seal the proximal entry; self-expandable stents in the visceral aorta to expand the true lumen; plus two parallel kissing iliac stent grafts below the renal arteries. Despite encouraging medium term results, it has unknown long-term consequences. The prospective observational single center study included 11 patients with complicated acute TBAD qualified for endovascular treatment using the e-PETTICOAT technique. Complicated acute TBAD was identified only in cases of clinical manifestation before or at the time of intervention; radiological findings were not sufficient to identify complications in our study. Method: The 5-year follow-up, based on clinical outcome including survival, re-interventions and angio-CT-assessed remodeling, was examined. The e-PETTICOAT technique achieves good remodeling in 38% of primary and 88% of secondary procedures. The E-PETTICOAT does not guarantee favorable remodeling during a 5-year follow-up in acute complicated TBAD. Complex aortic repair after e-PETTICOAT might be needed.

Thoracic Endovascular Aortic Repair With Additional Distal Bare Stents in Type B Aortic Dissection Does Not Prevent Long-Term Aneurysmal Degeneration

Purpose: TEVAR (thoracic endovascular aortic repair) + PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) technique has been selectively employed since 2005 at our institution during endovascular treatment of type B aortic dissection (TBD). The aim of this study is to evaluate the long-term (>5 years) clinical results and the evolution of aortic volume. Materials and Methods: All the patients receiving an endovascular treatment for TBD with the PETTICOAT technique were collected in a prospectively maintained database and follow-up computed tomography scan were retrospectively analyzed. Study endpoints included short- and long-term clinical success (absence of need for reintervention) and any major adverse event. The volumes of thoracic and abdominal aorta at long-term follow-up were also analyzed. Results: Twenty-eight patients received a TEVAR + PETTICOAT and were followed up (median follow-up 85 months). Primary 30-day clinical success rate was 82% with an adverse event rate of 31%; 4 type I endoleak and 1 retrograde dissection were recorded. Secondary mid-term clinical success was 96% while the long-term clinical success rate was 79%. Six cases (21%) received either an open repair or an endovascular repair for a significant distal aortic enlargement at follow-up. With regards to volumetric analysis, an increase of overall (thoracic and abdominal) aortic volume was observed in 8 cases mainly related to an increase (mean: +31%) of the abdominal volume that was observed in 11 cases. Conclusions: PETTICOAT technique does not protect from long-term significant aneurysmal degeneration that may require aortic open or endovascular reinterventions. Aortic growth occurs mainly in the bare-stented aorta and thus, life-long surveillance is advisable in these patients.

The provisional extension to induce complete attachment technique is associated with abdominal aortic remodeling and reduces aorta-related adverse events after aortic dissection

ObjectiveThis study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique. MethodsIn this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively. ResultsForty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64). ConclusionsThis study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.

Full PETTICOAT in acute type B aortic dissection with patent false lumen may offer positive remodeling for the distal aorta.

The provisional extension to induce complete attachment (PETTICOAT) technique is a unique thoracic endovascular aortic repair (TEVAR) for aortic dissection, which consists of proximal descending aortic endografting plus distal bare-metal stenting. This study aimed to investigate the efficacy of the PETTICOAT technique in patients with acute-sub-acute complicated type B aortic dissections. In particular, we compared the remodeling effect of full PETTICOAT covering down to the abdominal aorta with that of simple entry closure. In this retrospective pre-post study, we compared the clinical course of consecutive patients undergoing TEVAR with the PETTICOAT technique in which proximal entry tear was excluded with a covered stent, and extension bare stents were placed down to the abdominal segment for acute-sub-acute complicated type B aortic dissections, between 2015 and 2017, with a control group treated with TEVAR with entry closure between 2011 and 2015. Outcomes included the aortic remodeling rate and the aortic diameter up to 1year after surgery. Subjects consisted of 47 patients (21 in full PETTICOAT group, 26 in the simple entry closure group). The remodeling rate of the abdominal aorta in the full PETTICOAT group was significantly higher than in the simple entry closure group (p < 0.05), while that of the thoracic aorta was comparable between the two groups. This study suggests that the full PETTICOAT technique achieves better aortic remodeling compared to entry closure alone, and might lead to less reintervention.

Effects of PETTICOAT Technique in Acute and Chronic DeBakey Type III Aortic Dissection

Our objective was to examine the role of the provisional extension to induce complete attachment (PETTICOAT) technique in aortic remodeling of acute and chronic DeBakey type III aortic dissection. We also seek the proper timing of this technique to promote false lumen reduction.

Combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair for complicated type B aortic dissections.

Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but life-threatening condition. The incidence of aortic dissection is 3 to 6 per 10,000 per year in the Western population, and can be up to 43 per 10,000 per year in the Eastern population. Over 20% of people with an aortic dissection do not reach a hospital alive. After admission, the mortality rates for people with an aortic dissection are between 10% and 20% for those who received endovascular treatment, and between 20% and 30% for those who had open surgery. Thoracic endovascular aortic repair (TEVAR) is the standard endovascular method to treat complicated type B aortic dissection (aortic dissections without involvement of the ascending aorta). Although TEVAR is less invasive than open surgery and has a better long-term aortic remodeling effect than conservative medical treatment, favourable aortic remodelling is usually limited to the thoracic aortic segment. TEVAR cannot be extended into the abdominal aorta because it could cover the ostia of the reno-visceral arteries. Thus, the abdominal aorta is still at risk of progressive aneurysmal degeneration. The PETTICOAT (provisional extension to induce complete attachment) technique, with proximal endograft and distal bare metal stent, was proposed in 2006 to address this issue. The concept of this technique was to implant a distal bare metal stent into the aortic true lumen, distal to the proximal endograft, to stabilize the distal collapsed intimal flap, while allowing blood flow to reno-visceral arteries. Therefore, the PETTICOAT technique was considered to be related to a more extensive aortic remodelling for people with type B aortic dissection, especially in the area of the abdominal aorta. However, it is still unclear whether the PETTICOAT technique is superior to standard TEVAR. To assess the effects of combined proximal descending aortic endografting plus distal bare metal stenting versus conventional proximal descending aortic stent graft repair for treating complicated type B aortic dissections. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2018. We also undertook reference checking and citation searching to identify additional studies. We considered all randomised controlled trials which compared the outcome of complicated type B aortic dissection, when treated by combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair. Two independent review authors assessed all references identified by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We found no trials that met the inclusion criteria for this review. We identified no randomised controlled trials and therefore cannot draw any definite conclusion on this topic. Evidence from non-randomised studies appears to be favourable in the short-term, for combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) to solve the problem of unfavourable distal aortic remodeling. Randomised controlled trials are warranted to provide solid evidence on this topic. Evidence from cohort studies with large sample sizes would also be helpful in guiding clinical practice.

Distal Extended Endovascular Aortic Repair PETTICOAT: A Modified Technique to Improve False Lumen Remodeling in Acute Type B Aortic Dissection

Data from the literature suggest that in patients with acute, complicated type B aortic dissection (cTBAD), initial successful treatment with thoracic endovascular aneurysm repair (TEVAR) is not necessarily associated with favorable remodeling of the dissected aorta during follow-up, and long-term results indicate that TEVAR failed to completely suppress false lumen patency. Sealing of all relevant distal reentries, infrarenal and/or iliac, seems to be the key issue to induce total false lumen thrombosis in abdominal aorta as well as the iliac arteries, especially in complicated patients presenting with malperfusion or complete true lumen collapse. Of the 34 consecutive patients diagnosed with cTBAD at our hospital from January 2015 to April 2018, 30 had complicated dissections receiving endovascular treatment according to the standard Provisional ExTension To Induce COmplete ATtachment (PETTICOAT) technique and were excluded from this study, whereas 4 patients with radiologic evidence of multiple reentry tears at detached lumbar arteries and iliac bifurcation with complete true lumen collapse and clinical evidence of malperfusion were treated with a modified PETTICOAT technique with distal extension of the aortic stent, balloon expansion of the stented true lumen, and use of the AFX bifurcated endograft system to preserve the natural aortic bifurcation and provide complete distal sealing of reentry tears. Primary technical success was achieved in all patients. No postoperative deaths were observed, but 1 patient experienced an hemorrhagic shock on the second postoperative day. No patient suffered postoperative stroke, paraplegia, paraparesis, or acute renal failure. Using an abdominal aortic bifurcated endograft with PETTICOAT to treat acute cTBAD seems to be a feasible approach in high-risk patients to improve aortic remodeling. The AFX bifurcated endograft system meets the requirements of anatomical fixation and sealing of distal tears.

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.

Early Results of the PETTICOAT Technique for the Management of Acute Type A Aortic Dissection.

Conventional surgical techniques for acute Type A aortic dissection (ATAAD) generally fail to address residual dissection in the descending aorta. The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting. Hybrid aortic arch repair techniques may improve perioperative and long-term mortality by expanding the true lumen and obliterating the false lumen. However, there is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia. In Type B dissection, the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique, which entails stent graft coverage of the primary intimal tear followed by bare metal stent placement distally, may improve true lumen caliber and promote false lumen thrombosis without increasing the risk of spinal cord ischemia, as intercostal branches remain perfused through the bare metal stents. The technique of hybrid arch with surgical creation of a Dacron landing zone covering a stent graft in the proximal descending aorta and bare metal stents in the thoraco-abdominal aorta is a promising concept in the treatment of ATAAD.

The PETTICOAT Technique for Complicated Acute Stanford Type B Aortic Dissection Using a Tapered Self-Expanding Nitinol Device as Distal Uncovered Stent

Provisional Extension To Induce Complete Attachment (PETTICOAT) technique has shown good results in the treatment of acute type B aortic dissections (ABAD). Usually, uncovered tubular stainless steel stents are used to promote distal true lumen reattachment. We describe the Petticoat technique using a conic self-expanding nitinol device as distal uncovered stent in five cases of complicated ABAD. We used as distal uncovered stent the single-flared E-XL (Jotec-GmbH). In one case, renal arteries were successfully stented throughthe large cells of the E-XL. No perioperative complications were reported. During follow-up (18-24months), positive remodeling of the entire aorta occurred in 3 cases; in 1 case with associated thoracoabdominal aneurysm, false lumen thrombosis at the thoracic level with true lumen expansion at the visceral aorta was detected at the 18-month CT angiogram, and in 1 patient with Marfan syndrome, open surgical conversion with the E-XL explantation was performed after 24months due to aneurysmal evolution at the visceral level. The E-XL can be successfully used in ABAD. It adapts to different aortic diameters, and its major radial force promotes successful positive remodeling. The open cell structure allows visceral arteries stenting, and it can be removed without complications during open conversion.

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.

Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection

The PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) technique may be employed during endovascular treatment of type B aortic dissection (TBD) using self-expandable bare stents distal to the covered stent graft placed over the proximal entry tear. The aim of this study is to evaluate the volume changes of the true (TL) and false lumen (FL) on computed tomography (CT) scans. Since 2005, 25 selected patients received endovascular treatment for complicated TBD with the PETTICOAT technique employing the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark). Indications to the use of the PETTICOAT technique were the evidence of clinical manifest dynamic malperfusion in five cases (20%) and/or radiologic evidence of TL collapse in 20 cases (80%). Five patients were treated within 2 weeks from onset, 13 patients between 2 weeks and 3 months, and seven patients over 3 months after the initial acute event. The volumetric analysis of the changes of TL and FL obtained from CT scan performed before endovascular treatment of TBD, postoperatively and yearly thereafter were analyzed using the OsiriX software v 3.9 (Pixmeo sarl, Bernex, Switzerland). Initial clinical (30 days) and midterm clinical success was observed in 21 cases (84%) and in 23 cases (92%), respectively. The volumes of the aortic TL and FL were evaluated at 30 days and midterm follow-up (mean, 38 ± 17 months). The following TL volumes were recorded: baseline 84 ± 29 cm(3), postoperative 167 ± 31 cm(3) (+98%), 1 year 193 ± 46 cm(3) (+131%), and 2 years 216 ± 54 cm(3) (+140%). The following FL volumes were recorded: baseline 332 ± 86 cm(3), postoperative 286 ± 85 cm(3) (-14%), 1 year 233 ± 81 cm(3) (-30%), and 2 years 248 ± 112 cm(3) (-32%). Progressive remodeling of the TL was recorded over time in both thoracic and abdominal segments with shrinkage of the FL mainly in the thoracic segment. These data provide insight into potential therapeutic benefit of the PETTICOAT technique. A significant immediate increase in TL could be achieved with resolution of all cases of dynamic malperfusion and TL collapse. A different behavior of volumes in the thoracic and abdominal segments was observed.