Provisional Extension To Induce Complete Attachment Research Articles

The Rate of Postoperative Complications in Complicated Acute, and Subacute Type B Aortic Dissections after TEVAR vs. PETTICOAT Procedures: Systematic Review and Meta-Analysis.

Background and Objectives: Provisional extension to induce complete attachment (PETTICOAT) is suggested as being associated with a lower incidence of aorta-related events and fewer reinterventions compared to thoracic endovascular aortic repair (TEVAR) in patients with complicated acute, and subacute type B aortic dissections. Materials and Methods: This article is a systematic review and meta-analysis following the PRISMA guidelines. The Medline, PubMed, Embase, and Cochrane databases were searched, starting on 21 February 2022 and ending on 22 June 2022, to identify studies that investigated the rate of postoperative complications in patients treated with the PETTICOAT compared to the TEVAR. A random effects meta-analysis was performed. Of 2350 studies, 5 studies involving 360 patients were included: 143 patients after the PETTICOAT procedure and 217 after the TEVAR. Results: The meta-analysis of all studies showed that the rate of secondary endovascular reinterventions was smaller in patients treated with the PETTICOAT (n = 3 studies; OR, 0.30; 95% CI, 0.10 to 0.94; p = 0.04). The results of other postoperative complications (30-day mortality, mortality during follow-up, paraplegia, stroke, and occurrence of endoleak) were lower in the PETTICOAT group but were not statistically significant. The rate of postoperative renal failure was lower in patients treated with the TEVAR (n = 4; OR, 1.08; 95% CI, 0.46 to 2.51; p = 0.86). Conclusion: This meta-analysis suggests that the PETTICOAT procedure is related to the lower rate of secondary endovascular reinterventions for complicated acute, and subacute type B aortic dissections.

The false lumen problem.

The false lumen problem.

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.

Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection: Pre- and Postprocedural Imaging.

Aortic dissection is a chronic disease that requires lifelong clinical and imaging surveillance, long after the acute event. Imaging has an important role in prognosis, timing of repair, device sizing, and monitoring for complications, especially in the endovascular therapy era. Important anatomic features at preprocedural imaging include the location of the primary intimal tear and aortic zonal and branch vessel involvement, which influence the treatment strategy. Challenges of repair in the chronic phase include a small true lumen in conjunction with a stiff intimal flap, complex anatomy, and retrograde perfusion from distal reentry tears. The role of thoracic endovascular aortic repair (TEVAR) remains controversial for treatment of chronic aortic dissection. Standard TEVAR is aimed at excluding the primary intimal tear to decrease false lumen perfusion, induce false lumen thrombosis, promote aortic remodeling, and prevent aortic growth. In addition to covering the primary intimal tear with an endograft, several adjunctive techniques have been developed to mitigate retrograde false lumen perfusion. These techniques are broadly categorized into false lumen obliteration and landing zone optimization strategies, such as the provisional extension to induce complete attachment (PETTICOAT), false lumen embolization, cheese-wire fenestration, and knickerbocker techniques. Familiarity with these techniques is important to recognize expected changes and complications at postintervention imaging. The authors detail imaging options, provide examples of simple and complex endovascular repairs of aortic dissections, and highlight complications that can be associated with various techniques. Online supplemental material is available for this article. ©RSNA, 2022.

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.

The STABILISE technique to address malperfusion on acute-subacute type B aortic dissections.

Endovascular treatment is the current standard of care for complicated acute and subacute type B aortic dissection. Closure of the primary entry tear with thoracic endovascular aneurysm repair (TEVAR) is often insufficient to induce complete false lumen thrombosis and a positive aortic remodeling. Moreover, TEVAR does not solve all the cases of malperfusion. The Provisional ExTension to Induce COmplete ATtachment (PETTICOAT) technique (deploying self-expandable bare metal stents in the true lumen in addition to TEVAR) can re-expand the true lumen, stabilize the lamella and promote aortic remodeling, but it does not recreate a single-lumen aorta and long-term aneurysmal degeneration of the aorta is frequent. Endovascular treatment by means of TEVAR + PETTICOAT does not recreate a single-lumen aorta so long-term aneurysmal degeneration of the aorta is frequent. The stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) technique may help to this purpose disrupting the intimal lamella and creating a relaminated uni-luminal aorta.

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.

Complex Regional Pain Syndrome with Aortic Distress after Thoracic Endovascular Aortic Repair and False Lumen Exclusion with "Candy Plug" Technique.

A 41-year-old male presented for pain treated with oxycodone. A zone-2 thoracic endovascular aortic repair with distal PETTICOAT (provisional extension to induce complete attachment) for complicated Type-IIIB aortic dissection was performed 18 months before. Repeated hospitalizations did not show any issues to justify the recurrent pain. The aortic nature of the pain was suspected considering the plug as a pain trigger. Through a left thoracoabdominal incision in the eighth intercostal space, the candy plug was removed. Pain diminished after thoracoabdominal surgery steadily.

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.

Endovascular Repair of the Thoracic or Thoracoabdominal Aorta Following the Frozen Elephant Trunk Procedure

This study evaluated the outcomes of endovascular repair of the thoracoabdominal aorta following the frozen elephant trunk (fET) procedure. Between October 2014 and July 2018, 249 patients underwent thoracic or thoracoabdominal endovascular aortic repair in our institution. Of these, 10 patients (50% male) underwent second-stage endovascular repair after previous fET implantation. Feasibility and outcomes were evaluated. The mean interval between fET implantation and the second-stage endovascular repair was 136 days (range, 14-282 days). Indications for second-stage endovascular repair were thoracoabdominal aortic aneurysm Crawford type I (n= 3) or Crawford type II (n= 4) and complicated residual aortic dissection after fET (n= 3). We implanted 4 branched custom-made devices and 4 off-the-shelf thoracic stent grafts. Two patients were treated using the provisional extension to induce complete attachment (PETTICOAT) technique through a percutaneous access. The median intensive care unit stay was 1 day (range, 0-3 days), and median hospital stay was 7 days (range, 5-12 days). Spinal cord preconditioning was performed in 70% of our patients with zero paraplegia at 30 days. Computed tomographic scans at 8.5 ± 11.4 months of follow-up showed complete false lumen thrombosis of all type B aortic dissections and 1 type III endoleak with constant aneurysm diameter. Branch patency was 100%. Second-stage endovascular repair after a previous fET is feasible with good midterm results. This staged hybrid procedure is extremely effective in patients whose aneurysms are confined both to the arch and thoracoabdominal aorta, leading to an excellent functional result. In case of favorable anatomy, endovascular repair in residual type B aortic dissection led to complete false lumen thrombosis.

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.

Aortic remodeling after hybrid provisional extension to induce complete attachment aortic repair of chronic residual type I aortic dissection

ObjectivesOur objective was to examine the role of the provisional extension to induce complete attachment (PETTICOAT) aortic dissection repair technique with bare metal stents (BMSs) in abdominal remodeling of residual DeBakey type I aortic dissection. MethodsWe retrospectively reviewed the records of patients with chronic aneurysm formation and residual DeBakey type I aortic dissection (ie, original acute aortic dissection DeBakey type I after primary surgical open repair) who underwent arch reoperation with frozen elephant trunk replacement or endovascular debranching with or without an abdominal BMS between December 2006 and December 2016. We analyzed diameters and volumes in 3 dimensions for the true and false lumens of the thoracic and abdominal aorta as well as the thrombosis percentage of the false lumen between the non-BMS (non-PETTICOAT) and BMS (PETTICOAT) groups. ResultsForty-seven patients who had completed at least 1 year of follow-up were included. The non-BMS (without abdominal BMS) and BMS groups had significant differences in abdominal true lumen diameter and volumetric change at the first postoperative examination and at the examination 1 year after surgery (26.8 mL, median [19.4-34.1 mL, interquartile range (IQR)]) in non-BMS vs 42.5 mL, median [31.1-57.9 mL, IQR]) in BMS (postoperative survey [F test, 33.775; P = .000]) and (30.1 mL, median [20.5-34.1 mL, IQR] in non-BMS vs 46.6 mL, median [31.3-57.4 mL, IQR]) in BMS (12-month survey [F test, 14.001; P = .001]). The abdominal false lumen thrombosis percentage was higher in the BMS group than in the non-BMS group (25.6%, median [16.4%-58.9%, IQR] in non-BMS vs 54.0%, median [36.7%-65.3%, IQR] in the BMS group (F test, 6.318; P = .016). ConclusionsFollowing reintervention for chronic residual DeBakey type I aortic dissection, PETTICOAT abdominal dissection BMS effectively expanded the thoracic and abdominal true lumen and augmented false lumen thrombosis percentage during the first postoperative year.

Techniques and outcomes of secondary endovascular repair for postdissection TAA/TAAA.

Postdissection aortic aneurysms (PDAA) affect 20-40% of patients with aortic dissection. Open repair remains the first line therapy of PDAA, but is still associated with high mortality and morbidity rates. Endovascular repair is increasingly being used as a less invasive treatment option. Thoracic endovascular aneurysm repair (TEVAR) covering only the proximal entry tear has proven to be insufficient in most patients with chronic PDAA and has a limited role only for PDAA with distal sealing zone in the thoracic aorta. In PDAA extending to the thoracoabdominal aorta, a more complex repair is needed to achieve aneurysm exclusion. Fenestrated and branched stent-grafts have been used lately in some expert centres to treat PDAA of the thoracoabdominal aorta with good preliminary results despite the technical difficulties in these patients (narrow true lumen, stiff chronic dissection flap, target vessels that originate from the false lumen [FL]). A subset of patients with aneurysmal degeneration mainly in the descending thoracic aorta, can be treated with TEVAR landing proximal to the celiac artery along with adjuvant techniques such as coils, plugs, glue or "Candy-Plug" and "Knickerbocker" concepts to occlude the FL, preventing retrograde flow and reducing the pressure in the aneurysm. Other options that have been used in limited numbers of patients with PDAA include the PETTICOAT (provisional extension to induce complete attachment) and STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) techniques. This article aims to review the outcomes of different endovascular techniques and strategies available for the repair of PDAA.

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.