Distal re-entry closure with neobranching technique after thoracic endovascular aortic repair of Type B aortic dissection

Distal re-entry closure with neobranching technique after thoracic endovascular aortic repair of... Abstract Retrograde false-lumen flow after thoracic endovascular aortic repair of Type B aortic dissection occurs occasionally and may have a negative impact on aortic remodelling and even prevent the decompression of the false lumen. A 67-year-old man with a Type B aortic dissection underwent thoracic endovascular aortic repair for severe compression of the true lumen and visceral malperfusion 7 weeks after the onset. Intraoperative angiography revealed proximal entry tear closure, but the false-lumen flow increased because of retrograde flow through the re-entry tear. Additional intervention including re-entry tear closure was performed with a neobranching technique with covered stent placement in the visceral artery from the aortic true lumen through the distal re-entry tear. We report a case of Type B aortic dissection and discuss the surgical techniques used. Aortic dissection, Thoracic endovascular aortic repair, Neobranching technique INTRODUCTION Thoracic endovascular aortic repair (TEVAR) of Type B aortic dissection had excellent outcomes in preventing aortic rupture and malperfusion syndrome [1]. We report a case of increased false-lumen (FL) flow after proximal entry tear closure using TEVAR where additional intervention to seal the distal re-entry tear by covered stent placement in the visceral branch from the true lumen (TL) through the re-entry tear was required. CASE REPORT A 67-year-old man with a history of abdominal aortic replacement presented with Type B aortic dissection. Computed tomography revealed a proximal entry tear in the thoracic aorta distal to the left subclavian artery and extending above the bifurcate graft (Fig. 1A). The right renal artery (rRA) was filled up by the FL without stenosis or malperfusion, although the other visceral branches were the TLs (Fig. 1B). The thoraco-abdominal aorta was 34 mm in diameter. Therefore, he underwent initial optimal medical therapy. Figure 1: View largeDownload slide Computed tomography images. (A) An aortic dissection with an entry tear (arrowhead). (B) A re-entry tear (arrow) near the rRA. (C) Postoperative image showing a covered stent in the abdominal aorta and rRA. The FL is thrombosed. FL: false lumen; lRA: left renal artery; rRA: right renal artery; TL: true lumen. Figure 1: View largeDownload slide Computed tomography images. (A) An aortic dissection with an entry tear (arrowhead). (B) A re-entry tear (arrow) near the rRA. (C) Postoperative image showing a covered stent in the abdominal aorta and rRA. The FL is thrombosed. FL: false lumen; lRA: left renal artery; rRA: right renal artery; TL: true lumen. Seven weeks after optimal medical therapy, computed tomography revealed severe TL compression in thoraco-abdominal aorta, with visceral malperfusion. He underwent TEVAR for entry tear closure with Zenith TX2 (ZTEG-2PT-42-158-PF, ZTEG-2P-28-120-PF, Cook Medical, Bloomington, IN, USA) from Zone 2 to the level of the 7th vertebra. Post-dilatation was not performed to avoid aortic injury. Angiography ensured full expansion of the stent graft and sealing of the proximal entry tear despite residual FL flow caused by retrograde flow through the distal re-entry tear. Pre-TEVAR transoesophageal echocardiography (TOE) revealed blood flow from the FL to the TL via the re-entry tear near the rRA (Fig. 2A, Video 1). The re-entry tear flow was reversed from the TL to the FL after the TEVAR (Fig. 2B). Additional intervention was performed by bridging both TL between the aorta and the rRA by crossing the retear with a covered stent (FLUENCY, BARD Peripheral Vascular, Inc., Tempe, AZ, USA). TOE confirmed elimination of blood flow and thrombosis of the FL (Fig. 2C). Postoperative computed tomography revealed thrombosis of the FL and patency of the rRA (Fig. 1C, Video 2). Figure 2: View largeDownload slide Transoesophageal echocardiography images showing (A) the thoraco-abdominal aorta re-entry tear and flow (arrow) from the FL into the TL. (B) After proximal entry tear closure, retrograde flow is shown at the re-entry tear from the TL to the FL (arrow). (C) Covered stent placement in the right renal artery, and the stent crossing the re-entry tear (arrow). FL: false lumen; TL: true lumen. Figure 2: View largeDownload slide Transoesophageal echocardiography images showing (A) the thoraco-abdominal aorta re-entry tear and flow (arrow) from the FL into the TL. (B) After proximal entry tear closure, retrograde flow is shown at the re-entry tear from the TL to the FL (arrow). (C) Covered stent placement in the right renal artery, and the stent crossing the re-entry tear (arrow). FL: false lumen; TL: true lumen. Video 1 Echocardiography images. Video 1 Echocardiography images. Close Video 2 Computed tomography images. Video 2 Computed tomography images. Close DISCUSSION Long-term results of INSTEAD-XL led to consensus on the treatment of Type B aortic dissection [1]. Despite entry closure by TEVAR, some patients experience residual FL flow after the procedure. One of the causes may be insufficient depressurization of the FL because of the persistent re-entry tear. The PETTICOAT technique was useful for stabilizing the intimal flap and relieving malperfusion [2]. Meanwhile, the covered stent placement could also prevent visceral arterial flow and close the re-entry tear. This stenting technique is included in the ‘neobranching technique’ proposed by Vandormael et al. [3]. The neobranching technique should be considered if the re-entry tear is located in the aorta near visceral arteries. Large tears often occur after circumferential detachment with an inner cylinder intussusception of visceral arteries, such as in Type C (Neri’s classification) [4]. An intraoperative TOE is useful to find the re-entry tear because the large intima cylinder is near the visceral artery ostium. The neobranching technique minimizes the endovascular approach, because aortic stent graft is not required. As our institution has a little experience with the neobranching technique, data collection is required to prove the efficacy of the technique. CONCLUSION In conclusion, we report a case of increased FL flow after proximal entry tear closure with TEVAR. Neobranch placement sealed the retear and bridged the TL and visceral artery. Conflict of interest: none declared. REFERENCES 1 Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G et al.   Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv  2013; 6: 407– 16. Google Scholar CrossRef Search ADS PubMed  2 Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Y, Kahlberg A et al.   Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection. J Vasc Surg  2012; 55: 641– 51. Google Scholar CrossRef Search ADS PubMed  3 Vandormael IL, Salmasi MY, Yeh JS, Nienaber CA. Endovascular “neobranching” to manage acute aortic syndrome. Catheter Cardiovasc Intervent  2017; 90: 298– 302. Google Scholar CrossRef Search ADS   4 Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G et al.   Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg  2001; 121: 552– 60. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Distal re-entry closure with neobranching technique after thoracic endovascular aortic repair of Type B aortic dissection

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Oxford University Press
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1010-7940
eISSN
1873-734X
D.O.I.
10.1093/ejcts/ezx384
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Abstract

Abstract Retrograde false-lumen flow after thoracic endovascular aortic repair of Type B aortic dissection occurs occasionally and may have a negative impact on aortic remodelling and even prevent the decompression of the false lumen. A 67-year-old man with a Type B aortic dissection underwent thoracic endovascular aortic repair for severe compression of the true lumen and visceral malperfusion 7 weeks after the onset. Intraoperative angiography revealed proximal entry tear closure, but the false-lumen flow increased because of retrograde flow through the re-entry tear. Additional intervention including re-entry tear closure was performed with a neobranching technique with covered stent placement in the visceral artery from the aortic true lumen through the distal re-entry tear. We report a case of Type B aortic dissection and discuss the surgical techniques used. Aortic dissection, Thoracic endovascular aortic repair, Neobranching technique INTRODUCTION Thoracic endovascular aortic repair (TEVAR) of Type B aortic dissection had excellent outcomes in preventing aortic rupture and malperfusion syndrome [1]. We report a case of increased false-lumen (FL) flow after proximal entry tear closure using TEVAR where additional intervention to seal the distal re-entry tear by covered stent placement in the visceral branch from the true lumen (TL) through the re-entry tear was required. CASE REPORT A 67-year-old man with a history of abdominal aortic replacement presented with Type B aortic dissection. Computed tomography revealed a proximal entry tear in the thoracic aorta distal to the left subclavian artery and extending above the bifurcate graft (Fig. 1A). The right renal artery (rRA) was filled up by the FL without stenosis or malperfusion, although the other visceral branches were the TLs (Fig. 1B). The thoraco-abdominal aorta was 34 mm in diameter. Therefore, he underwent initial optimal medical therapy. Figure 1: View largeDownload slide Computed tomography images. (A) An aortic dissection with an entry tear (arrowhead). (B) A re-entry tear (arrow) near the rRA. (C) Postoperative image showing a covered stent in the abdominal aorta and rRA. The FL is thrombosed. FL: false lumen; lRA: left renal artery; rRA: right renal artery; TL: true lumen. Figure 1: View largeDownload slide Computed tomography images. (A) An aortic dissection with an entry tear (arrowhead). (B) A re-entry tear (arrow) near the rRA. (C) Postoperative image showing a covered stent in the abdominal aorta and rRA. The FL is thrombosed. FL: false lumen; lRA: left renal artery; rRA: right renal artery; TL: true lumen. Seven weeks after optimal medical therapy, computed tomography revealed severe TL compression in thoraco-abdominal aorta, with visceral malperfusion. He underwent TEVAR for entry tear closure with Zenith TX2 (ZTEG-2PT-42-158-PF, ZTEG-2P-28-120-PF, Cook Medical, Bloomington, IN, USA) from Zone 2 to the level of the 7th vertebra. Post-dilatation was not performed to avoid aortic injury. Angiography ensured full expansion of the stent graft and sealing of the proximal entry tear despite residual FL flow caused by retrograde flow through the distal re-entry tear. Pre-TEVAR transoesophageal echocardiography (TOE) revealed blood flow from the FL to the TL via the re-entry tear near the rRA (Fig. 2A, Video 1). The re-entry tear flow was reversed from the TL to the FL after the TEVAR (Fig. 2B). Additional intervention was performed by bridging both TL between the aorta and the rRA by crossing the retear with a covered stent (FLUENCY, BARD Peripheral Vascular, Inc., Tempe, AZ, USA). TOE confirmed elimination of blood flow and thrombosis of the FL (Fig. 2C). Postoperative computed tomography revealed thrombosis of the FL and patency of the rRA (Fig. 1C, Video 2). Figure 2: View largeDownload slide Transoesophageal echocardiography images showing (A) the thoraco-abdominal aorta re-entry tear and flow (arrow) from the FL into the TL. (B) After proximal entry tear closure, retrograde flow is shown at the re-entry tear from the TL to the FL (arrow). (C) Covered stent placement in the right renal artery, and the stent crossing the re-entry tear (arrow). FL: false lumen; TL: true lumen. Figure 2: View largeDownload slide Transoesophageal echocardiography images showing (A) the thoraco-abdominal aorta re-entry tear and flow (arrow) from the FL into the TL. (B) After proximal entry tear closure, retrograde flow is shown at the re-entry tear from the TL to the FL (arrow). (C) Covered stent placement in the right renal artery, and the stent crossing the re-entry tear (arrow). FL: false lumen; TL: true lumen. Video 1 Echocardiography images. Video 1 Echocardiography images. Close Video 2 Computed tomography images. Video 2 Computed tomography images. Close DISCUSSION Long-term results of INSTEAD-XL led to consensus on the treatment of Type B aortic dissection [1]. Despite entry closure by TEVAR, some patients experience residual FL flow after the procedure. One of the causes may be insufficient depressurization of the FL because of the persistent re-entry tear. The PETTICOAT technique was useful for stabilizing the intimal flap and relieving malperfusion [2]. Meanwhile, the covered stent placement could also prevent visceral arterial flow and close the re-entry tear. This stenting technique is included in the ‘neobranching technique’ proposed by Vandormael et al. [3]. The neobranching technique should be considered if the re-entry tear is located in the aorta near visceral arteries. Large tears often occur after circumferential detachment with an inner cylinder intussusception of visceral arteries, such as in Type C (Neri’s classification) [4]. An intraoperative TOE is useful to find the re-entry tear because the large intima cylinder is near the visceral artery ostium. The neobranching technique minimizes the endovascular approach, because aortic stent graft is not required. As our institution has a little experience with the neobranching technique, data collection is required to prove the efficacy of the technique. CONCLUSION In conclusion, we report a case of increased FL flow after proximal entry tear closure with TEVAR. Neobranch placement sealed the retear and bridged the TL and visceral artery. Conflict of interest: none declared. REFERENCES 1 Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G et al.   Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv  2013; 6: 407– 16. Google Scholar CrossRef Search ADS PubMed  2 Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Y, Kahlberg A et al.   Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection. J Vasc Surg  2012; 55: 641– 51. Google Scholar CrossRef Search ADS PubMed  3 Vandormael IL, Salmasi MY, Yeh JS, Nienaber CA. Endovascular “neobranching” to manage acute aortic syndrome. Catheter Cardiovasc Intervent  2017; 90: 298– 302. Google Scholar CrossRef Search ADS   4 Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G et al.   Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg  2001; 121: 552– 60. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 1, 2018

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