Thoracic Endovascular Aortic Repair for Chronic DeBakey IIIb Aortic Dissection

Abstract

Background Thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb dissection with associated descending aneurysm remains controversial. This study examines long-term results of TEVAR for this disorder including examination of anatomic features associated with TEVAR outcomes. Methods Between July 2005 and January 2013, 32 patients underwent TEVAR for chronic (>30 days) DeBakey IIIb dissection involving the descending thoracic aorta at a single institution and constituted the study cohort. Results The mean interval from dissection to TEVAR was 32 ± 44 months (range, 1 to 146 months). There were no 30-day or in-hospital deaths, strokes, or paraplegia. During a 54-month median follow-up, there were no aortic-related deaths. Significant thoracic aneurysm sac regression (>1 cm) in the intervened segment was observed in 89%. Thoracic remodeling was not correlated with the number of visceral vessels arising from the true lumen or the number or size of residual distal fenestrations; failure of thoracic remodeling was associated with fenestrations distal to the endograft(s) in the descending thoracic aorta, most often stent graft-induced new entry tears. Complete resolution of the thoracic and abdominal false lumen after TEVAR was observed in 15.6% (n = 5). All patients in this group had all visceral vessels arising from the true lumen and fewer than three residual distal fenestrations. Conclusions Thoracic endovascular aortic repair is effective for chronic DeBakey IIIb dissection with associated descending aneurysm, with excellent 30-day and long-term outcomes and significant aortic remodeling in the vast majority of patients. Thoracic remodeling does not appear dependent on distal anatomic characteristics of the true and false lumens, although care should be taken to cover all thoracic fenestrations and avoid creation of stent graft-induced new entry tears to ensure clinical success. Complete aortic remodeling was observed only in the setting of all visceral vessels off the true lumen with fewer than three residual distal fenestrations, and this would appear the ideal anatomy for TEVAR in this scenario.

Predicting Distal Aortic Remodeling After Endovascular Repair for Chronic DeBakey III Aortic Dissection

“…Similarly, patients with more than two visceral vessels originating from the false lumen were less likely to regress. This has been shown by other groups in the past and our findings confirm the same [7]. With previous operative strategy that involved covering the proximal descending thoracic aorta, we have noticed that most patients do not undergo regression.…”

Effects of False Lumen Procedures on Aorta Remodeling of Chronic DeBakey IIIb Aneurysm

“…Postoperative CT scans were performed with arterial phase and delayed contrast imaging to assess the presence of endovascular leak and the patency of the FL before discharge. Furthermore, CT scans were performed at 1, 6, and 12 months after the procedure, and then yearly thereafter [7,10,11].…”

“…In the case of CDIIIb aneurysms, both the presence of a stiff dissection flap and the inability to seal off the false lumen (FL) distally have been suggested as factors that may cause failure in TEVAR procedures. Indeed, TEVAR for CDIIIb aneurysms has previously exhibited unfavorable complete thrombosis rates (30% to 60%) [7][8][9]. Furthermore, we have previously used aggressive TEVAR while ensuring the sufficiency of the proximal landing zone and extending the stent graft to the level of the celiac trunk, but observed a complete thrombosis rate of only 65% for CDIIIb aneurysms [1].…”

Open aortic surgery after thoracic endovascular aortic repair

“…& Joseph S. Coselli jcoselli@bcm.edu degenerative aneurysms [4][5][6], 16 to 24 % when used for chronic type B aortic dissections [4][5][6][7][8], and 21 to 32 % when used for acute type B dissections [5,6,9,10]. In addition, a lack of operator experience likely plays a role in the development of postoperative complications after TEVAR.…”