In this issue, Kabbani et al. describe a novel technique of “electrocautery-wire” septotomy.[1Loay S. Kabbani LS, et al. Novel Technique to Fenestrate an Aortic Dissection Flap using Electrocautery. J Vasc Surg Cases Innov Tech. 20XX, 1(1), XX-XX. doi: XXXX.Google Scholar] The false lumen is one of the most vexing problems in the endovascular management of chronic type B aortic dissections (cTBAD). For years, conventional principles of endograft fixation and seal for degenerative aneurysms have been applied to dissections only to result in suboptimal late outcomes and need for multiple secondary interventions. Except for some rare instances where the dissection spares a segment of the distal aortoiliac anatomy, the false lumen extends the entirety of the thoracoabdominal aorta and beyond into the iliac arteries. The septum and the false lumen of cTBAD pose certain unique problems that atherosclerotic aneurysms do not. First, the true lumen is often severely tapered making endograft sizing difficult. Second, the obligatory extreme oversizing at the distal end of the endograft can lead to a late SINE (stent induced new entry) tear and acute reperfusion of a previously excluded or partially depressurized false lumen.[2Dong Z. Fu W. Wang Y. Wang C. Yan Z. Guo D. Xu X. Chen B. Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection.J Vasc Surg. 2010; 52: 1450-1457Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar] Third, there are multiple dispensable (intercostal, lumbar, and inferior mesenteric arteries) and indispensable (visceral, renal) vessels that arise from the false lumen that can lead to ongoing type II FLP (false lumen perfusion) with late aortic dilation, and/or need for adjunctive techniques to gain access to the false lumen and preserve a vital target vessel. And fourth, there are often one or more distal re-entry tears in the perivisceral aorta and near the hypogastric arteries that, if left untreated, can lead to a type R FLP and may require closure. To date, these “false lumen problems” have been largely managed using a luminal approach, either from the true or false side. In the former instance, using a combination of self-expanding proximal covered and distal bare stents operators would balloon dilate and segmentally rupture the septum during the subacute period of a cTBAD. This so-called PETTICOAT (Provisional Extension To Induce Complete Attachment) technique attempts to recreate a single lumen in the dilated thoracic aorta proximally, re-attach the separated intimal/medial layer to the outer wall, and obliterate the false lumen.[3Nienaber C.A. Kische S. Zeller T. Rehders T.C. Schneider H. Lorenzen B. et al.Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept.Endovasc Ther. 2006; 13: 738-746Crossref PubMed Scopus (210) Google Scholar] In an opposite approach the goal of treatment is thrombosis and exclusion of the false lumen. In this technique the false lumen itself is directly filled with a variety of embolic devices such as coils and glue to treat a type II and a “candy-plug” to treat a type R FLP.[4Kolbel T. Lohrenz C. Kieback A. Diener H. Debus E.S. Larena-Avellaneda A. Distal false lumen occlusion in aortic dissection with a homemade extra-large vascular plug: the candy-plug technique.J Endovasc Ther. 2013; 20: 484-489Crossref PubMed Scopus (117) Google Scholar] Recognizing that these problems and the limitations of applying conventional endovascular techniques are fundamentally due to the ubiquitous presence of a thickened, fibrotic septum that is unique to cTBAD,[5Troncone M. Dagenais F. Commentary: Is aortic septotomy the "Holy Grail" for thoracic endovascular aortic repair management of chronic type B dissection?.J Thorac Cardiovasc Surg. 2021; S0022-5223 (0): 01229Google Scholar] techniques to address this have been previously described.[6Fukuhara S. Khaja M.S. Williams D.M. Marko X. Yang B. Patel H.J. et al.Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection.J Thorac Cardiovasc Surg. 2021; S0022-5223 (0): 01246Google Scholar] Anecdotally, J. Parodi had described an “endovascular scissor” to create a long linear septotomy and convert the dissection into a single lumen. The techniques of “cheese cutter” and laser-septotomy have been used with variable outcomes and occasional serious complications. Although experience is clearly limited, the use of the electrocautery to enable a more controlled septotomy represents an interesting enhancement of an existing technique in the management of this most vexing problem. Novel Technique to Fenestrate an Aortic Dissection Flap using ElectrocauteryJournal of Vascular Surgery Cases, Innovations and TechniquesPreviewChronic distal thoracic dissections treated with thoracic endovascular repair are prone to type 1b false lumen perfusion. When the supra-celiac aorta is of normal caliber, fenestration of the dissection flap proximal to the visceral vessels creates a seal zone for the thoracic stent graft and eliminates the type 1b false lumen perfusion. We describe a novel way of crossing the septum using electrocautery delivered through a wire tip then fenestrating the septum using electrocautery delivered over a 1-mm area of uninsulated wire to cut the septum. Full-Text PDF Open Access