New endovascular techniques for false lumen thrombosis in aortic dissection after thoracic endovascular aortic repair

Abstract

Over the past decades, both open surgery and endovascular treatment of aortic dissection have made great progress with good clinical outcomes. However, despite this progress, the presence of distal re-entry tears can sustain perfusion of false lumen (FL) and induce aneurysm formation or growth. In particular, about 20% of patients undergoing thoracic endovascular aortic repair (TEVAR) for aortic dissection require reintervention because of incomplete FL thrombosis promoting aortic wall degeneration, post-dissection aortic aneurysm, and rupture. Endovascular techniques to promote FL thrombosis after TEVAR show good early results together with minimal invasiveness, offering different alternatives depending on the case and the level of urgency. Endovascular techniques include FL embolization (with coils, vascular plugs, etc.), candy-plug techniques, parallel stent graft, and branched and fenestrated aortic endoprosthesis. Each of these solutions has advantages and disadvantages. We herein describe the available endovascular options.

Keywords

Aortic dissection / false lumen thrombosis / endovascular repair / thoracic endovascular aortic repair / TEVAR

References

[1] Fattori R,Myrmel T.Complicated acute type B dissection: is surgery still the best option?.JACC Cardiovasc Interv2008;1:395-402

[2] Zeeshan A,Bavaria JE.Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy.J Thorac Cardiovasc Surg2010;140:S109-15; discussion S142

[3] Jonker FH,Upchurch GR.Acute type B aortic dissection complicated by visceral ischemia.J Thorac Cardiovasc Surg2015;149:1081-6.e1

[4] Nienaber CA.Influence and critique of the INSTEAD Trial (TEVAR versus medical treatment for uncomplicated type B aortic dissection).Semin Vasc Surg2011;24:167-71

[5] Brunkwall J,Verhoeven E.ADSORB TrialistsEndovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.Eur J Vasc Endovasc Surg2014;48:285-91

[6] Mani K,Lyons OT.Predictors of outcome after endovascular repair for chronic type B dissection.Eur J Vasc Endovasc Surg2012;43:386-91

[7] Thrumurthy SG,Patterson BO.A systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection.Eur J Vasc Endovasc Surg2011;42:632-47

[8] Zhang S,Zhang Y.Should the distal tears of aortic dissection be treated?.Int J Cardiol2018;261:162-6

[9] Song SW,Lim SH,Yoo KJ.Prognostic factors for aorta remodeling after thoracic endovascular aortic repair of complicated chronic DeBakey IIIb aneurysms.J Thorac Cardiovasc Surg2014;148:925-32, 933.e1; discussion 932

[10] Evangelista A,Ribera A.Long-term outcome of aorticdissection with patent false lumen: predictive role of entrytear size and location.Circulation2012; 125:3133-41

[11] Akutsu K,Kiuchi K.Effects of the patent false lumen on the long-term outcome of type B acute aortic dissection.Eur J Cardiothorac Surg2004;26:359-66

[12] Yuan X,Semple T.False lumen intervention to promote remodelling and thrombosis-The FLIRT concept in aortic dissection.Catheter Cardiovasc Interv2018;92:732-40

[13] Miletic KG,Hodges KE.Impact of endovascular false lumen embolization on thoracic aortic remodeling in chronic dissection.Ann Thorac Surg2021;111:495-501

[14] Kölbel T,Kieback A,Debus ES.Distal false lumen occlusion in aortic dissection with a homemade extra-large vascular plug: the candy-plug technique.J Endovasc Ther2013;20:484-9

[15] Rohlffs F,Tsilimparis N,Kölbel T.Techniques and outcomes of false lumen embolization in chronic type B aortic dissection.J Cardiovasc Surg (Torino)2018;59:784-8

[16] Ogawa Y,Chiba K.Clinical utility of the candy-plug technique using an excluder aortic extender.Ann Vasc Dis2021;14:139-45 PMCID:PMC8241552

[17] Eleshra A,Tsilimparis N.Candy-plug generation II for false lumen occlusion in chronic aortic dissection: feasibility and early results.J Endovasc Ther2019;26:782-6

[18] Rohlffs F,Fiorucci B.The candy-plug technique: technical aspects and early results of a new endovascular method for falselumen occlusion in chronic aortic dissection.J Endovasc Ther2017;24:549-555

[19] Verhoeven EL,Bekkema F.Editor’s choice - ten-year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients.Eur J Vasc Endovasc Surg2015;49:524-31

[20] Zeng Z,Wu M.Endovascular strategies for post-dissection aortic aneurysm (PDAA).J Cardiothorac Surg2020;15:287 PMCID:PMC7528487

[21] Schepens MAAM.Type B aortic dissection: new perspectives.J Vis Surg2018;4:75 PMCID:PMC5945851

[22] Donas KP,Lachat M,Veith FJ.PERICLES investigatorsCollected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry.Ann Surg2015;262:546-53; discussion 552

[23] Moulakakis KG,Dalainas I.The chimney-graft technique for preserving supra-aortic branches: a review.Ann Cardiothorac Surg2013;2:339-46 PMCID:PMC3741865

[24] Liu J,Feng J.Total endovascular repair with parallel stent-grafts for postdissection thoracoabdominal aneurysm after prior proximal repair.J Endovasc Ther2019;26:668-75

[25] Li D,He Y.False lumen status in patients with acute aortic dissection: a systematic review and meta-analysis.J Am Heart Assoc2016;5:e003172 PMCID:PMC4889188

[26] Faure EM,Sutter W.Stent-assisted balloon-induced intimal disruption and relamination of distal remaining aortic dissection after acute DeBakey type I repair.J Thorac Cardiovasc Surg2019;157:2159-65

[27] Kölbel T,Lohrenz C,Larena-Avellaneda A.Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique.J Endovasc Ther2014;21:117-22