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Grandi A, D'Oria M, Panuccio G, Rohlffs F, Eleshra A, Torrealba J, Nana P, Lepidi S, Melloni A, Bertoglio L, Kölbel T. Design, evolution, and experience with the candy plug device for endovascular false lumen occlusion of chronic aortic dissections. Expert Rev Med Devices 2024:1-4. [PMID: 38803133 DOI: 10.1080/17434440.2024.2360987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION The management of the false lumen (FL) when dealing with aortic dissection is a crucial aspect since inducing its thrombosis is necessary in order to achieve aortic remodeling. One of the pitfalls of endovascular treatment of aortic dissection (AD) is retrograde distal FL perfusion and pressurization, which prevents FL thrombosis and thus aortic remodeling, while being associated with aneurysmal degeneration of the FL and poor long-term outcomes. AREAS COVERED Currently, there is no CE/FDA approved device for FL closure, however different techniques and devices have been proposed to overcome this challenge, the most known of which is the Candy Plug (CP). This review aims to describe the CP device, its implantation technique, and the available data in the literature (PubMed, Cochrane, and EMBASE databases; last queried, December 31, 2023). EXPERT OPINIONS While the treatment of AD remains technically challenging, the use of the CP technique to close any distal FL reperfusion proved to be feasible and safe with excellent rates of both technical and clinical success. Furthermore, recent studies have shown a quick learning curve with this technique.
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Affiliation(s)
- Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Ahmed Eleshra
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Jose Torrealba
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Department of Clinical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Medical Center Eppendorf, Hamburg, Germany
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Melloni A, D’Oria M, Dioni P, Ongaro D, Badalamenti G, Lepidi S, Bonardelli S, Bertoglio L. Plug-Based Embolization Techniques of Aortic Side Branches during Standard and Complex Endovascular Aortic Repair. J Clin Med 2024; 13:2084. [PMID: 38610847 PMCID: PMC11012954 DOI: 10.3390/jcm13072084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.
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Affiliation(s)
- Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiothoracovascular Department, University Hospital of Trieste ASUGI, 34139 Trieste, Italy; (M.D.); (G.B.); (S.L.)
| | - Pietro Dioni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Deborah Ongaro
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Giovanni Badalamenti
- Division of Vascular and Endovascular Surgery, Cardiothoracovascular Department, University Hospital of Trieste ASUGI, 34139 Trieste, Italy; (M.D.); (G.B.); (S.L.)
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiothoracovascular Department, University Hospital of Trieste ASUGI, 34139 Trieste, Italy; (M.D.); (G.B.); (S.L.)
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University and ASST Spedali Civili Hospital of Brescia, 25123 Brescia, Italy; (P.D.); (D.O.); (S.B.); (L.B.)
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Baghbani-Oskouei A, Savadi S, Mesnard T, Sulzer T, Mirza AK, Baig S, Timaran CH, Oderich GS. Transcatheter electrosurgical septotomy technique for chronic postdissection aortic aneurysms. J Vasc Surg Cases Innov Tech 2024; 10:101402. [PMID: 38304296 PMCID: PMC10830870 DOI: 10.1016/j.jvscit.2023.101402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms.
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Affiliation(s)
- Aidin Baghbani-Oskouei
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Titia Sulzer
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aleem K. Mirza
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Shadman Baig
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H. Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Gustavo S. Oderich
- Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
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Bastianon M, Di Gregorio S, Melani C, Mena Vera JM, Mozzetta G, Grimaldi F, Pallini C, Pratesi G. Visceral Aorta Electrocautery Septotomy to Allow Branched Endovascular Aortic Repair in Ruptured Chronic Post-Dissection Thoraco-Abdominal Aneurysm. J Endovasc Ther 2024:15266028241240900. [PMID: 38533777 DOI: 10.1177/15266028241240900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
PURPOSE Endovascular repair of chronic post-dissection thoraco-abdominal aortic aneurysms (PD-TAAA) presents specific technical challenges due to the presence of chronic septum. Small true lumen diameter and false lumen visceral vessel origin can make branched endograft prohibitive. Septotomy may allow to overcome these challenges in cases of high complex anatomy. TECHNIQUE We describe the application of electrocautery septotomy to the visceral aorta segment to deploy an off-the-shelf branched endograft in a chronic PD-TAAA rupture with true lumen collapse. CONCLUSIONS Electrocautery septotomy can be an effective adjunctive technique to facilitate branched endograft, overcoming technical challenges associated with the endovascular treatment of chronic PD-TAAA. CLINICAL IMPACT Electrocautery septotomy is an adjunctive technique that can facilitate endovascular treatment of post-dissection thoraco-abdominal aneurysm. By creating a common lumen, this technique might reduce the number of re-interventions associated with PD-TAAA endovascular exclusion.
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Affiliation(s)
- Martina Bastianon
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy
| | - Sara Di Gregorio
- Clinic of Vascular and Endovascular Surgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Caterina Melani
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy
| | - Jorge Miguel Mena Vera
- Clinic of Vascular and Endovascular Surgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Gaddiel Mozzetta
- Clinic of Vascular and Endovascular Surgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Grimaldi
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy
| | - Cristina Pallini
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy
| | - Giovanni Pratesi
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Genoa, Italy
- Clinic of Vascular and Endovascular Surgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Loschi D, Santoro A, Rinaldi E, Anselmi C, Grignani C, Chiesa R, Melissano G. Open and endovascular reinterventions after Candy Plug false lumen embolization of type B aortic dissection. J Vasc Surg 2023; 78:1409-1417. [PMID: 37572890 DOI: 10.1016/j.jvs.2023.07.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE In the majority of patients with chronic type B aortic dissection, there is persistent retrograde flow in the false lumen (FL) through distal re-entry tears. Among several endovascular techniques proposed for FL management, the "Candy Plug" (CP) technique has gained acceptance with good early results. The aim of this study is to report the types and outcomes of open and endovascular reinterventions and identify mechanisms of procedure failure as well as other causes for reinterventions. METHODS All patients with type B aortic dissection submitted to thoracic endovascular aneurysm repair and CP implantation for FL embolization from January 2016 to December 2022 at our institution were included in this study. The preoperative, intraoperative, and postoperative data of the primary intervention and secondary reinterventions, when performed, were prospectively collected and retrospectively analyzed. Preoperative and postoperative computed tomography angiography were also analyzed. RESULTS During the study period, 33 patients were submitted to thoracic endovascular aneurysm repair and CP implantation. Twenty-three patients (69.7%) showed thoracic FL complete thrombosis with aortic stability or positive remodeling at a mean follow-up of 45 ± 23.1 months. Ten patients (30.3%) underwent aortic reinterventions (male, n = 9; mean age, 60.5 ± 7.6 years). Of these 10 patients, in four patients, complete thrombosis of the FL was never achieved, leading to ongoing perfusion of the FL, defined as "primary failure." The other six patients underwent reinterventions for different causes: two patients, after initial sealing, showed a progressive enlargement of the abdominal FL leading to distal degeneration. One patient showed proximal degeneration, two patients showed a type II thoracoabdominal aortic aneurysm and CP implantation was used as a planned procedure to reduce the extent of the surgical procedure, and one patient had recurrent, intractable back pain despite complete thrombosis of the FL. Reinterventions were open in five cases and endovascular in five. One in-hospital death (postoperative day 27) after a type II thoracoabdominal aortic aneurysm open repair was recorded. In addition, two cases of delayed spinal cord ischemia after open reintervention were recorded: one resulting in permanent paraplegia and one transitory with complete recovery. CONCLUSIONS The CP technique was safe and effective; however, a significant rate of aortic-related reintervention was observed. Several mechanisms led to reinterventions either in terms of "primary failure" of the CP or subsequent aneurysmal degeneration. Complex reinterventions were often necessary, with a high rate of major complications in case of open repair. Life-long and closer surveillance might be required in these patients.
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Affiliation(s)
- Diletta Loschi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy.
| | - Annarita Santoro
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Enrico Rinaldi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Claudia Anselmi
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Camilla Grignani
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Roberto Chiesa
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
| | - Germano Melissano
- "Vita-Salute" University, Scientific Institute H. San Raffaele, Milan, Italy
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Wang Q, Wei H, He C, Liu Y. Atrial septal defect occluder combined with stent graft for the management of post-dissection aortic aneurysm previously treated with unsuccessful coils: a case report. CVIR Endovasc 2023; 6:58. [PMID: 38019332 PMCID: PMC10686903 DOI: 10.1186/s42155-023-00405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Although the candy-plug technique has been reported to be useful for the treatment of post-dissection aortic aneurysm, the stent graft needs be to customized to accommodate the size of vascular occluders. CASE PRESENTATION We present a case of a persistent false lumen successfully treated with endovascular stent-graft and atrial septal defect occluder in a patient with Stanford Type B dissection. A covered stent graft was implanted into the false cavity through a distal rupture, and an atrial septal defect occluder was inserted into the covered stent to seal of the false cavity. Decreased aneurysmal diameter and false lumen thrombosis were noted by CT scan at 6-month follow-up. CONCLUSIONS Our case showed that combined use of a stent graft and atrial septal defect occluder is safe, technically feasible and effective in sealing of the false lumen in post-dissection aortic aneurysm patients with previously failed false lumen thrombosis.
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Affiliation(s)
- Qiqi Wang
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Haijun Wei
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Chunshui He
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yang Liu
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
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Takagi H. Air aortogram. J Vasc Surg 2023:S0741-5214(23)02205-X. [PMID: 37952780 DOI: 10.1016/j.jvs.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
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Palmier M, Mougin J, Bendavid J, Fabre D, Kölbel T, Haulon S. Evaluation of false lumen occluders implanted in the abdominal aorta false lumen. J Vasc Surg 2023; 78:1146-1152. [PMID: 37406944 DOI: 10.1016/j.jvs.2023.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Management of postdissection thoracoabdominal aneurysms with a fenestrated and/or branched endograft (F/BEVAR) is associated with favorable outcomes. Treatment should include both true lumen endografting and false lumen occlusion (FLO). Favorable results have recently been reported for FLO in the false lumen of the thoracic aorta. The purpose of this study is to analyze the results of FLO of the abdominal aorta in patients treated for post dissection thoracoabdominal aneurysm. METHODS A multicenter retrospective analysis of prospective data of consecutive patients managed for post dissection thoracoabdominal aortic aneurysm from April 2019 to December 2022 with F/BEVAR associated with FLO in the abdominal false lumen was conducted. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) was followed. Baseline demographics, operative details, and early outcomes (mortality, length of stay) were recorded. Primary endpoints were technical and clinical success. FLO technical success was defined as complete occlusion of false lumen backflow above the FLO on completion angiogram. RESULTS During the 3-year study, 23 patients were treated for post dissection thoracoabdominal aneurysm with F/BEVAR and the use of abdominal FLO. Twenty-one patients (91.3%) had received prior endovascular treatment. The technical and clinical success was 95.7%. The abdominal FLO had a technical success rate of 78.3%. The median diameter of the FLO was 34 mm. No patient died during the perioperative period, and one patient had spinal cord ischemia (4.3%) with partial recovery. Six patients (26.1%) required early reintervention. The median duration of hospitalization in the intensive care unit and overall was 1 day (interquartile range, 0-3 days) and 7.5 days (interquartile range, 2-22 days), respectively. During the mean follow-up of 9.9 ± 9.0 months, no patient died. False lumen occlusion was complete or partial in nine (39.1%) and nine (39.1%) patients, respectively. No aortic rupture occurred during follow-up. Maximum aortic diameter decreased in 48% and remained stable in 39% of cases. CONCLUSIONS Abdominal aorta FLO during endovascular treatment of post dissection thoracic abdominal aortic aneurysm is associated with favorable outcomes. It offers an additional staging therapeutic option before extensive aorto-bi-iliac coverage, associated with low spinal cord ischemia rates. FLO also provides high rates of false lumen occlusion and false lumen remodeling during follow-up. Longer follow-up and larger cohorts are required to confirm these very promising early findings.
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Affiliation(s)
- Mickael Palmier
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis Robinson, France
| | - Justine Mougin
- Service de Chirurgie Vasculaire, Hôpital G&R Laënnec, CHU Nantes, Nantes, France
| | - Jeremy Bendavid
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis Robinson, France
| | - Dominique Fabre
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis Robinson, France
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Eppendorf, Hamburg, Germany
| | - Stéphan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Université Paris Saclay, Le Plessis Robinson, France.
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Shehab M, Mani K. Trick or Treat with the Candy Plug. Eur J Vasc Endovasc Surg 2023; 66:57. [PMID: 37075923 DOI: 10.1016/j.ejvs.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Affiliation(s)
- Maysam Shehab
- Department of surgical sciences, Uppsala university, Uppsala, Sweden
| | - Kevin Mani
- Department of surgical sciences, Uppsala university, Uppsala, Sweden.
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