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

Burdess, Anne; Mani, Kevin; Tegler, Gustaf; Wanhainen, Anders

doi:10.23736/s0021-9509.18.10570-2

Cited by 26 publications

(25 citation statements)

References 30 publications

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“…Nonetheless, stent-graft–induced new entry tears following TEVAR could lead to distal degeneration of the aortic wall, resulting in late development of new dissections and, potentially, aneurysms. 35 , 36 One should keep in mind that TEVAR for TBAD is prone to retrograde type A aortic dissection, which is known to have disastrous outcomes. This is especially true when using proximal bare metal stents, proximal balloon dilation, or noncompliant, rigid devices.…”

Section: Discussionmentioning

confidence: 99%

One-Year Single-Center Results of the Multilayer Flow Modulator Stents for the Treatment of Type B Aortic Dissection

et al. 2020

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Purpose To report a single-center series of patients with type B aortic dissection treated with the Multilayer Flow Modulator (MFM). Materials and Methods Over a 36-month period, 23 patients (median age 53 years; 20 men) with complicated type B aortic dissections (2 acute, 5 subacute, and 16 chronic) were treated with the MFM. Primary endpoints of rupture or dissection-related death, overall mortality, and reintervention were evaluated using the Kaplan-Meier method; estimates for freedom from the endpoints are reported with the 95% confidence interval (CI). Secondary outcomes included technical success, adverse events, and aortic remodeling. Clinical and imaging data were collected preoperatively, directly postoperatively, and annually to 36 months for analysis using computational fluid dynamics (CFD). Results Initial technical success was 91.3%. The estimates of the endpoints at 12 months were 100% for freedom from rupture or aortic-related death, 95.7% for freedom from overall mortality, and 91.3% for freedom from reintervention. No device-related neurological or systemic complications occurred, and no additional reinterventions were needed during follow-up. A total of 144 branches overstented by the MFM remained patent. Morphologic analysis of the aortic dissection showed progressive true lumen volume increase (75.9%, p<0.001) with concomitant false lumen volume decrease (42.8%, p<0.001); the CFD analyses showed increased laminar flow. Conclusion In the current series, the MFM provided a safe and feasible treatment option for complicated acute, subacute, and chronic type B aortic dissections, with high technical success, low mortality, and active aortic remodeling. Further studies should elucidate the long-term safety of the MFM and its effectiveness in a larger patient cohort.

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Section: Discussionmentioning

confidence: 99%

One-Year Single-Center Results of the Multilayer Flow Modulator Stents for the Treatment of Type B Aortic Dissection

et al. 2020

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“…52 Over-sizing carries the risk of damage to a relatively fragile aortic wall which may cause stentgraft induced new entry tear or retrograde type A aortic dissection. 52,53 Aortic diameter at the landing zone that exceeds the recommended width for largest available stent-grafts by more than 10% is a contraindication to TEVAR. 7 Distal sizing is also important as the true lumen is usually smaller in the distal landing zone.…”

Section: Technical Considerations and Prevention Of Complicationsmentioning

confidence: 99%

“…54 Over-sizing at the distal landing zone is a risk for distal stent-graft induced new entry tear and/or propagation of dissection. 52 If a single stent-graft is to be used then commercially available options do not taper enough, so a number of strategies have been suggested: (i) the use of a restrictive bare metal stent in the distal landing zone; (ii) overlapping two or more relatively short tapered stent-grafts; or (iii) the further development of a dissection-specific stent-graft which is conformable, lacks proximal bare stents or barbs and has a greater distal taper. 52 In addition to conventional fluoroscopy, accurate stent-graft placement can be assisted by TOE, and intravascular ultrasound in patients with involvement of the visceral segment and anatomical complexity.…”

Section: Technical Considerations and Prevention Of Complicationsmentioning

confidence: 99%

“…The importance of sizing and measuring the landing zone are in achieving adequate fixation of the stent‐graft. As the aortic diameter can change by more than 10% during the cardiac cycle, even after scaffolding with a stent‐graft, 51 over‐sizing by up to 10% is recommended 52 . Over‐sizing carries the risk of damage to a relatively fragile aortic wall which may cause stent‐graft induced new entry tear or retrograde type A aortic dissection 52,53 .…”

Section: Surgical Interventionmentioning

confidence: 99%

“…As the aortic diameter can change by more than 10% during the cardiac cycle, even after scaffolding with a stent‐graft, 51 over‐sizing by up to 10% is recommended 52 . Over‐sizing carries the risk of damage to a relatively fragile aortic wall which may cause stent‐graft induced new entry tear or retrograde type A aortic dissection 52,53 . Aortic diameter at the landing zone that exceeds the recommended width for largest available stent‐grafts by more than 10% is a contraindication to TEVAR 7 …”

Section: Surgical Interventionmentioning

confidence: 99%

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Management of acute type B aortic dissection

Munshi

Ritter

Doyle

et al. 2020

ANZ Journal of Surgery

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Background: The best management of acute uncomplicated type B aortic dissection is currently a controversial area. Recent advances in endovascular intervention have begun to establish pre-emptive thoracic endovascular aortic repair as a potential strategy. A review about the management for type B aortic dissection has been conducted. Methods: A narrative review consisting of 157 original articles, meta-analyses and guidelines was conducted. The findings were synthesized and summarized using 70 articles. Results: There are clear guidelines directing surgical management of acute complicated type B aortic dissection. However, the best management of acute uncomplicated disease is more ambiguous, which is especially concerning in a condition which is associated with significant morbidity and mortality. Medical management alone is generally favoured. Endovascular intervention is now being considered by some surgeons, but it can be technically difficult, while exposing the patient to potential surgical risks. Conclusions: Clinical and anatomical risk factors have been identified to help vascular surgeons make decisions about treatment in acute uncomplicated type B aortic dissection. New endovascular strategies are being developed to reduce surgical risk and address technical challenges. Registry data should be used to support future best management.

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