Stent Graft-induced New Entry Research Articles

Predictors of Return to Work After Thoracic Endovascular Aortic Repair in Patients With Type B Aortic Dissection.

Type B aortic dissection (TBAD) is a life-threatening condition, and it takes heavy burden to family and society. Return to work (RTW) not only means patients' physical health but also demonstrates their mental well-being. Thoracic endovascular aortic repair (TEVAR) has been successful in treatment of TBAD patients. However, less studies have addressed on the social functional recovery of TBAD after TEVAR, especially for RTW. From January 1, 2017 to January 1, 2021, TBAD patients who underwent TEVAR and completed a 12-month follow-up were retrospectively enrolled. Primary outcome was RTW. Patients' demographic, sociological, and clinical characteristics, and so on were recorded to analyze and demonstrate independent risk factors for RTW. Four hundred thirty-two TBAD patients (388 males) were enrolled with a mean age of 48.3±8.9 years (ranged from 19 to 60 years). The 12-month cumulative RTW rate was 62.7% (95% confidence interval [CI]: 57.2%-67.8%). Age <50 years (odds ratio [OR]=3.675, 95% CI: 1.436-9.405) was identified as independent protective factors for RTW, while preoperative job as manual workers (OR=0.101, 95% CI: 0.029-0.353), average annual income, <30 000 Chinese Yuan (CNY) [<4400 US dollar], (OR=0.186, 95% CI: 0.054-0.637), complicated TBAD (malperfusion) (OR=0.246, 95% CI: 0.092-0.659), and distal stent graft-induced new entry (SINE) (OR=0.218, 95% CI: 0.083-0.575, p=0.002) were identified as independent risk factors. Approximately 64% of our patients were able to RTW in the 12 months post-TEVAR for TBAD. Younger patients, patients with less physically demanding jobs, and patients with less complex surgeries were more likely to RTW. Based on these results, more can be done to facilitate the patient's ability and willingness to RTW after TEVAR. Type B aortic dissection (TBAD) is a life-threatening condition that poses significant burden on both individuals and society. The ability to return to work (RTW) not only reflects the patient's physical health but also indicates their mental well-being. Therefore, identifying risk factors for RTW and promoting the reintegration of TBAD patients into the workforce is crucial in clinical practice.To our knowledge, this study is the first to elucidate and predict the RTW outcomes of TBAD patients who underwent thoracic endovascular aortic repair (TEVAR).

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

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

Procedure and Aortic Remodeling Effects of Entry Closure with Stentgraft for Type B Aortic Dissection: Comparison between the Patients with Narrow True Lumen and Those with Aneurysmal Dilated False Lumen.

Objectives: Appropriateness of device selection, procedure protocol and aortic remodeling effects of entry closure (TEVAR) with stent-graft (SG) for patent false lumen type B aortic dissection (TBAD) were compared between the patients with narrow true lumen (narrow group) and those with aneurysmal dilated false lumen (aneurysmal group).Methods: Twenty-six patients with narrow true lumen (narrow group) and 20 patients with aneurysmal false lumen (aneurysmal group) were included in this study. In narrow group, straight SG was implanted from Zone 3 regardless the distance between the left subclavian artery and entry. In aneurysmal group, straight or taped SG was implanted with proximal landing zone length 20 mm or more. Thoracic aortic anatomy was evaluated by CT and aortic remodeling was defined as true lumen diameter ≥50% of the aortic diameter and occlusion of false lumen. Aorta related death, retrograde type A aortic dissection (RTAD), stentgraft induced new entry (SINE) and aortic maximum diameter enlargement 5 mm or more (aortic expansion) were included in the aortic event.Results: There was no procedure related complication in narrow group and 1 patient died due to aortic rupture in aneurysmal group, Type Ia endoleak by enhanced CT 7 days after TEVAR was detected in one patient in each group. Achievement of aortic remodeling was significantly better in narrow group. Aortic event occurred in only one patient in narrow group, in whom aortic expansion was observed. In aneurysmal group, aortic event occurred 12 patients (60%) and 2 RTAD, 5 SINE, and 8 aorta expansion were observed. Aortic event free rate was significantly better in narrow group.Conclusion: TEVAR procedure for the TBAD patients with narrow true lumen seemed to be appropriate, however, different TEVAR procedure or additional procedures would be required for those with aneurysmal dilated false lumen to obtain favorable outcomes. (This is secondary publication from Jpn J Vasc Surg 2021; 30: 347–357.)

The PETTICOAT-Snowshoe Technique Prevents Distal Stent Graft-Induced New Entry in Patients with Aortic Dissection

Distal stent graft-induced new entry (SINE) is a serious complication of thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD). The PETTICOAT-snowshoe technique was developed to prevent distal SINE for double-barrel TBAD. Initially, a proximal stent-graft (SG) is deployed, followed by the extension of a bare stent above the celiac artery and deployment of a second SG within the bare stent. This study examined whether the PETTICOAT-snowshoe technique prevents distal SINE. This was a single-center, retrospective study comparing 2 groups that underwent conventional standard TEVAR between January 2013 and September 2018 and TEVAR using the PETTICOAT-snowshoe technique after October 2018 for double-barrel TBAD. Twenty-seven patients (74% male) underwent standard TEVAR (group A), while another 27 (78% male) underwent the PETTICOAT-snowshoe technique (group B). TEVAR was performed in the chronic phase on 15 patients (55.6%) in group A and on 16 (59.2%) in group B. Aorta-related mortality occurred in 1 patient in group A (3.7%). Oversizing ratios at the distal edge of the SG diameter to the major axis of the true lumen were 25% ± 26% and 25% ± 21% in groups A and B, respectively. During the follow-up period, 5 patients (18.5%) in group A and none in group B (P=0.02) developed distal SINE. 3 of 5 patients with distal SINE in group A were treated with additional TEVAR, one with thoracoabdominal aortic replacement, and one with conservative observation. The freedom from distal SINE rate was significantly higher in group B than in group A (P=0.04). The PETTICOAT-snowshoe technique significantly prevented distal SINE during the mid-term period even with the same distal SG oversizing as conventional standard TEVAR.

One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft-induced new entry (SINE) tear

Video 1 One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft induced new entry (SINE) tear.

One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft induced new entry (SINE) tear

One stage ascending and descending aorta replacement through the posterior pericardium to treat aortic rupture due to stent graft induced new entry (SINE) tear

Patient-Specific Virtual Stent-Graft Deployment for Type B Aortic Dissection: A Pilot Study of the Impact of Stent-Graft Length.

Thoracic endovascular aortic repair (TEVAR) has been accepted as a standard treatment option for complicated type B aortic dissection. Distal stent-graft-induced new entry (SINE) is recognised as one of the main post-TEVAR complications, which can lead to fatal prognosis. Previous retrospective cohort studies suggested that short stent-graft (SG) length (<165 mm) might correlate with increased risk of distal SINE. However, the influence of SG length on changes in local biomechanical conditions before and after TEVAR is unknown. In this paper, we aim to address this issue using a virtual SG deployment simulation model developed for application in type B aortic dissection. Our model incorporates detailed SG design and hyperelastic behaviour of the aortic wall. By making use of patient-specific geometry reconstructed from pre-TEVAR computed tomography angiography (CTA) scan, our model can predict post-TEVAR SG configuration and wall stress. Virtual SG deployment simulations were performed on a patient who underwent TEVAR with a short SG (158 mm in length), mimicking the actual clinical procedure. Further simulations were carried out on the same patient geometry but with different SG lengths (183 mm and 208 mm) in order to evaluate the effect of SG length on changes in local stress in the treated aorta. Comparisons of simulation results for different SG lengths showed the location of maximum stress varied with the SG length. With the short SG (deployed in the patient), the maximum von Mises stress of 238.9 kPa was found on the intimal flap at the distal landing zone where SINE was identified at 3-month follow-up. Increasing the SG length caused the maximum von Mises stress to move away from the distal landing zone where stress values were reduced by approximately 17% with the medium-length SG and by 60% with the long SG. This pilot study demonstrates the potential of using the virtual SG deployment model as a pre-surgical planning tool to help select the most appropriate SG length for individual patients.

Clinical Outcomes of Distal Tapered Restrictive Covered Stent Applied in Endovascular Treatment of Aortic Dissection Involving Zone 0

The safety and efficacy of a distal tapered restrictive covered stent (RCS) applied in the endovascular treatment of aortic dissection involving Zone 0 was evaluated. This study retrospectively analysed 43 patients with acute aortic dissection involving Zone 0 who received in situ laser fenestrated thoracic endovascular aortic repair with distal tapered RCS from January 2015 to February 2019. The indication for the distal tapered RCS procedure was an inappropriate distal size of the main stent graft. Technical success, aortic remodelling, and clinical outcomes were evaluated. Technical success was achieved in all patients. The 30 day post-operative mortality rate was 0%. All patients had complete false lumen thrombosis in the stent coverage segment. True lumen volume increased significantly (p<.001) with an average change of 87.0%±34.3%, while false lumen volume decreased significantly (p<.001) with an average change of-71.0%±13.5% between baseline and 12 months. During the follow up period (mean 28.7 months, range 12-63 months), no distal stent graft induced new entry (SINE) was observed. The average distance between the distal end of the RCS and the coeliac trunk was 57.5mm. Two (4.7%) patients had spinal cord ischaemia (SCI) and recovered without permanent paraplegia after undergoing conservative treatment. The distal tapered RCS applied in the endovascular treatment of aortic dissection involving Zone 0 is considered to be a feasible and effective approach along with satisfactory aortic remodelling, a low risk of SINE, and SCI. The favourable results are partly explained by selection. No patients had an entry tear near the coronary artery, nor were the coronary arteries, pericardium, or aortic valve involved at the time of repair.

Local and Not Crucial Issue Needs To Interest the Global Community?

Potential endovascular therapy for acute aortic dissection presenting with the proximal entry tear in the distal ascending aorta or aortic arch is a matter for debate. Besides the treatment modality, this is usually such a critical condition and necessitates prompt, life saving management. In the paper by Liu et al., entitled “Clinical outcomes of distal tapered restrictive covered stent applied in endovascular treatment of aortic dissection involving Zone 0”,1 the authors primarily looked at mid term outcome of the distal aorta regarding the potential occurrence of SINE (stent graft induced new entry), for which a restricted covered stent was inserted for prevention.

Re-TEVAR in treatment of stent graft-induced new entry between two non-overlapping stent-grafts: a case report

BackgroundProgress of the aortic disease after the stent graft treatment of aortic dissection implicates the potential risks of stent graft-induced new entry (SINE). Although rarely reported, it should be vigilant in patients who might incur serious complication in early period after the thoracic endovascular aortic repair (TEVAR). Thus, the development of aortic disease-specific stent grafts would assist in achieving positive patient outcomes when suffering SINE. However, it is an extremely rare for SINE between two non-overlapping stent-grafts.Case presentationWe here reported a 59-year-old male patient with sudden onset of chest pain for 4 h. Multi-detector computed tomography (MDCT) revealed a huge SINE formed between two non-overlapping stent-grafts. The re-TEVAR surgery was performed and the patient experienced a good recovery.ConclusionThe SINE between two non-overlapping stent-grafts treated by re-TEVAR operation was alternative and feasible. The short-term and medium-term follow-up results were satisfactory.

Relevance of Aortic Dissection Chronicity to the Development of Stent Graft–induced New Entry

The relevance of aortic dissection chronicity to the development of stent graft-induced new entry (SINE) is unknown. This study enrolled 69 patients who underwent thoracic endovascular aortic repair (TEVAR) for chronic aortic dissection from January 2006 to December 2017 and were followed up for ≥6 months. Their medical records were reviewed retrospectively. Patients were stratified according to TEVAR timing into an early group (≤6 months from the onset of aortic dissection) and a late group (>6 months after the onset). The incidence of SINE as well as the interval between TEVAR and the development of SINE was compared between these groups. During the follow-up period, SINE occurred in 12% (3/26) and 35% (15/43) of patients in the early and late groups, respectively (P= .029). The interval between TEVAR and SINE development was significantly longer in the late group than the early group (median, 92 days vs 1144 days, respectively; P= .002). According to the multivariate analysis results, the late group (hazard ratio, 3.667; 95% confidence interval, 1.037-12.968; P= .044) and the distal oversizing ratio (hazard ratio, 1.492; 95% confidence interval, 1.071-2.080; P= .018) were the independent predictors for SINE development. TEVAR should be performed in the early period of the chronic phase to prevent SINE. Close and lifelong follow-up is mandatory for patients who undergo TEVAR >6 months after onset because SINE can develop several years after TEVAR in those patients.

3:54 PM Abstract No. 97 The relationship between the timing of thoracic endovascular aortic repair and the development of stent graft–induced new entry in chronic aortic dissection

To investigate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) and the development of stent graft–induced new entry (SINE) in chronic aortic dissection (CAD). This study enrolled 69 patients who underwent TEVAR for CAD since January 2006 through December 2017 and were followed up for at least 6 months. Their medical records were retrospectively reviewed. The patients were stratified by the timing of TEVAR into the early group (within 6 months from the onset of aortic dissection) and the late one (more than 6 months after the onset). The incidence of SINE and the interval between TEVAR and the development of SINE were compared between these groups. During the follow-up period, SINE occurred in 12% (3/26) in the early group, while 35% (15/43) in the late group (P = 0.029). The interval between TEVAR and the development of SINE was significantly longer in the late group than the early one (P = 0.002). According to the multivariate analysis, the late group (hazard ratio, 3.667; 95% confidence interval, 1.037–12.968, P = 0.044) and the distal oversizing ratio (hazard ratio, 1.492; 95% confidence interval, 1.071–2.080, P = 0.018) were the independent predictors of the development of SINE. SINE is not a rare complication following TEVAR for CAD. TEVAR should be performed in the early period to prevent SINE. Close and lifetime follow-up is mandatory for patients who undergo TEVAR more than 6 months after the onset.

Association Between Targeted Aortic Segment Tortuosity and Stent-Graft-Induced New Entry After Thoracic Endovascular Aortic Repair for Aortic Dissection or Intramural Hematoma.

OBJECTIVE. The aim of this study was to investigate the association between the tortuosity of the targeted aortic segment (TAS) for stent-graft implantation and distal stent-graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) for aortic dissection or intramural hematoma. MATERIALS AND METHODS. We retrospectively analyzed data from 70 patients who underwent TEVAR using a single stent-graft between 2006 and 2016, and the tortuosity index of the TAS was measured. The patients were divided into high and low TAS tortuosity groups according to the median value of the tortuosity index. The incidence of distal SINE was compared between the two groups. RESULTS. The cumulative incidence of distal SINE at 2 years after TEVAR was 39% in patients in the high TAS tortuosity group and 7% in patients in the low TAS tortuosity group. The incidence of distal SINE was higher in patients in the high TAS tortuosity group than in those in the low TAS tortuosity group (p < 0.01, log-rank test). Multivariate Cox regression showed a higher risk of distal SINE in the high TAS tortuosity group (adjusted hazard ratio, 4.56 [95% CI, 1.40-14.86]; p = 0.01). CONCLUSION. Patients with high TAS tortuosity have a higher incidence of distal SINE after TEVAR. More caution must be exercised during follow-up of patients with high TAS tortuosity after TEVAR.

A Case of Recurrent Acute Inferior Limb Arterial Occlusion Seemingly Caused by Antegrade False Lumen Blood Flow due to Stent Graft-Induced New Entry (SINE)

症例は，53歳女性．急性大動脈解離A型に対して，上行弓部置換（J-graft 24 mm，Open Stent Graft併用），CABG（SVG-RCA）を施行した．術後，退院にむけてリハビリテーションを励行中（術後33，38日目）に右下肢急性動脈閉塞を発症し，血栓除去を行った．どちらも右総大腿動脈閉塞で器質化血栓を認めた．周術期不整脈はなく，CTで明らかな左心内血栓も認めなかったため，器質化血栓飛散の原因検索目的に血管造影検査を施行したところ，遠位弓部大動脈に位置したOpen Stent Graftの先端にentryを認め，同部から偽腔内の順行性血流を認めた．Re-entryを介した偽腔内血栓飛散による塞栓症と考え，術後48日目にTEVAR（cTAG）を施行し，以後塞栓症をきたすことなく，リハビリテーション病院へ転院の運びとなった．

Finite Element Analysis for Type B Aortic Dissection Treated with Two Types of Stent Grafts

Retrograde type A dissection (RTAD) and stent graft-induced new entry (SINE) is one of the most common post-TEVAR complications, and is defined as a new tear caused by the stent-graft itself (Dong Z.H. et al., 2009). Presumably, the mechanical action and potential damage of stent-graft to the aorta is related to the stent-graft and the anchoring position, mainly from two aspects: (1) The metal skeleton functions to fix the whole support to the wall of the aorta because it is self-inflating and strong in radial force. (2) After implantation, the stent-graft is bent into the arch like a bent spring, with a tendency to be straight. This may result in elastic recoil force to the aortic wall. This study investigated the occurring reasons of new lesions from the biomechanical and mechanobiological view when stent-grafts were implanted into the true lumen to treat an aortic dissection.

Distal Stent Graft-Induced New Entry After TEVAR of Type B Aortic Dissection: Experience in 15 Years

Experience is limited with distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of type B dissection (TBAD). We report the management strategy and outcomes in such patients. Clinical data were analyzed for 95 patients (age, 53.2 ± 10.9 years; 82 men) who presented with distal SINE after TEVAR for TBAD. Follow-up was 100% for 7.2 ± 3 years after primary TEVAR. Distal SINE occurred at a mean of 2.7±2.4 years. Re-TEVAR was performed for 78, with routine stent grafts in 64 and a more tapered graft in 14. Three patients were managed surgically and 14 medically. Two patients died after re-TEVAR. During follow-up at 5.8 ± 2.9 years, late death occurred in 19 patients, 7 with medical therapy and 12 with re-TEVAR. Distal SINErecurred in 11 at 3.5 ± 1.7 years after re-TEVAR. Reintervention significantly improved survival up to 8years compared with medical therapy (88.3% vs 63.5%, p= 0.001). In 64 patients with routine stent grafts, mortality was 24%, distal SINE recurred in 20%, and recurrence-free survival was 56% at 6 years. Neither death nor recurrence of SINE occurred in 14 patients with a more tapered stent graft. Predictors for distal SINE after primary TEVAR were stent graft length (hazard ratio, 0.984; p= 0.037) and chronic phase (hazard ratio, 1.725; p= 0.049). In TBAD patients with distal SINE after TEVAR, reintervention with re-TEVAR could improve long-term survival significantly. Recurrence of distal SINE was high after re-TEVAR using routine stent grafts. More tapered stent grafts may be helpful in preventing the recurrence of distal SINE.

Stent-graft induced new entry tears after type B aortic dissection: how to treat and how to prevent?

Progress of aortic disease after stent-graft treatment of aortic dissection includes the risk of stent graft-induced new entry (SINE). In this paper we review the incidence and mechanisms thought to be responsible for retrograde ascending and distal SINE after thoracic endovascular aortic repair (TEVAR) for type B dissection, and examine potential techniques for treatment and prevention. Although the risk of proximal SINE is low, the fatality of this complication requires vigilance in patients who develop new onset symptoms in the early period after TEVAR treatment. Careful technique, minimal oversizing, and use of disease specific stent grafts may reduce the risk for proximal SINE. Distally, SINE is more frequently seen during follow-up in patients treated for chronic dissection. The most important risk factor is oversizing of the stent-graft compared to the true lumen distal landing zone. Development of new disease specific stent grafts with reduced distal radial force may reduce the risk for distal SINE.

Comparative Study of the Effect of Structural Parameters on the Flexibility of Endovascular Stent Grafts

The complication of stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) may be caused by the spring-back force of both ends of the stent grafts. Spring-back force, which is exerted by the curvature and ends of stent grafts on the greater wall of the aorta, suggests poor flexibility. Research on stent graft flexibility via design optimization has been widely disregarded. Thus, this study investigates the relationship between stent graft structure and flexibility by measuring bending and spring-back forces. Stent spacing (5, 10, and 15 mm), apex angle (30° and 45°), and strut configuration (Z- and M-stented) were considered for the structural parameters. The overall tendency of spring-back and bending forces was similar. The stent graft with 15 mm spacing attained the lowest force level. The force difference between samples with 30° and 45° apex angles became prominent as the curving angle increased. The sample with 45° stent apex attained low force value. The Z-stented graft obtained a lower force than the M-stented graft with the same number of struts per hoop. Consequently, optimal flexibility was obtained when the structural design was characterized by long stent spacing, big stent apex angle, and Z-type strut configuration.

The Impact of Distal Stent Graft–Induced New Entry on Aortic Remodeling of Chronic Type B Dissection

In chronic type B aortic dissection, late distal stent graft-induced new entry (SINE) has a possible negative role in long-term aortic remodeling. This study aimed to investigate the impact of SINE occurrence on survival by evaluating true and false lumen remodeling in thoracic and abdominal segments at midterm surveillance. This study enrolled 65 patients with chronic type B aortic dissection (DeBakey type IIIb), who had received hybrid thoracic endovascular aortic repair (TEVAR) and had completed surveillance for at least 3 years. The 3-year survival rate was 84.7%. The patients were classified into non-SINE (n= 47) and SINE (n= 18) groups. Serial computed tomography scans were used to analyze volumetric change, true and false lumens, and thrombus volume from arch to aortic bifurcation level. The SINE event occurred at a median of 22.5 months. In the SINE group, there was a significant interruption of the abdominal true lumen expansion in the second year (median 0.01 [interquartile range (IQR), -0.03 to 0.12] in the non-SINE group versus median -0.04 [IQR, -0.12 to 0.04] in the SINE group; p= 0.014). There was a significantly worse thoracic false lumen remodeling in the SINE group compared with the non-SINE group in the third year after the SINE event occurred (median 0 [IQR, -0.09 to 0.05] in the non-SINE group versus median 0.06 [IQR, 0 to 0.13] in the SINE group; p= 0.038). For chronic aortic dissection, late occurrence of distal SINE could influence abdominal true lumen expansion and thoracic false lumen shrinkage. Early reintervention for distal SINE could improve aortic remodeling in chronic aortic dissection.

Endovascular surgery in Marfan syndrome: CON.

The frequency of endovascular stent grafting procedures to treat various conditions of the thoracic aorta has increased dramatically over the past three decades. Stent grafting has been applied on a limited basis in patients with Marfan syndrome and other connective tissue disorders, despite recommendations from current guidelines and expert consensus statements against its use in this setting. A review of publications reporting outcomes after stent grafting of the descending thoracic aorta in Marfan patients with acute or chronic aortic dissection indicates that these procedures can be accomplished with rates of early mortality, stroke and spinal cord ischemic injury that are comparable to those observed in patients who do not have Marfan syndrome. However, the rates of primary treatment failure (principally endoleak), secondary treatment failure, need for open repair and late death among the Marfan patients are substantially higher than those observed in patients without this condition. In addition, the rates of retrograde aortic dissection and development of stent-graft induced new entry (SINE), are also greater among patients with Marfan syndrome. All of these findings argue strongly against the routine use of endovascular grafts in Marfan patients with type B or residual type A dissection. Few data are available to assess the role of endografting in Marfan patients with aneurysmal disease, but the progressive aortic dilatation noted in these patients argues strongly against its use in this setting as well. At present, the available data indicate that there is no justification for elective stent grafting in Marfan patients with aortic dissection or aneurysm. The only reasonable indications for primary aortic stent grafting are in the setting of acute aortic dissection or rupture, where the intervention is considered life-saving and rarely, considering the relatively young age of these patients, where the risk of open operation is considered to be prohibitive.