The Efficacy of Second-Stage Endovascular Repair Strategy for Acute Type A Aortic Dissection

PURPOSE

To evaluate the usefulness of a hybrid treatment strategy for acute type A aortic dissection (AAAD).

METHODS

We retrospectively evaluated the outcomes of 39 partial arch replacements (PAR; 26 male/13 female, mean age=67.9 years) in 62 patients with AAAD operated at our hospital from January 2019 to January 2023. The technique included PAR with graft-designed landing length and translocated the brachiocephalic artery inflow site during the initial surgery to minimize the invasiveness of the surgery. Thereafter, second-stage thoracic endovascular aortic repair (second TEVAR) for distal aortic events in the chronic phase was performed.

RESULTS

There was 1 case of 30-day mortality (2.6%) and 2 cases of postprocedural cerebral infarction (5.1%). The cumulative survival rates were 97.4%/1 year and 97.4%/3 years. The cumulative freedom from aorta-related second-stage procedure for the distal aortic event after initial PAR, which was performed in 13 patients (33.3%), was 63.9%/1 year and 59.7%/3 years. All patients requiring re-intervention after initial PAR underwent a second TEVAR with a 100% success rate and no postoperative complications.

CONCLUSION

Initial PAR for AAAD in anticipation of the second TEVAR is a valuable strategy for enabling minimally invasive additional treatment of aorta-related re-intervention for distal aortic events in the chronic phase.

CLINICAL IMPACT

This study provides detailed information on the hybrid aortic repair strategy of the initial open partial arch repair and second staged endovascular repair for the acute type A aortic dissection. Based on this study, distal aortic re-intervention after initial open partial arch repair was necessary only in about 30% of cases, and no cases of SCI were observed in the initial treatment or in the second-stage endovascular repair and no cases of distal SINE were observed after the second staged endovascular repair. Overall, the results suggest that limiting the initial open partial arch repair can achieve good perioperative and early outcomes of initial surgery, and that second staged endovascular re-intervention for distal aortic events can be performed reliably, safely, and with minimal invasiveness.

Distal Stent Graft-Induced New Entry After Frozen Elephant Trunk Procedure for Aortic Dissection

BACKGROUND

The purpose of this study was to evaluate the risk factors of distal stent graft-induced new entry (dSINE) after frozen elephant trunk (FET) procedure for aortic dissection (AD) and to consider strategies to prevent this complication.

METHODS

This retrospective review included 52 patients who had undergone aortic arch repair for AD with the FET procedure using J Graft FROZENIX from 2014 to 2020 at a single center. Baseline characteristics, aortic characteristics and mid-term outcomes were compared between patients with and without dSINE. The extent of unfolding of the device and movement of the distal edge of the device were analyzed by multidetector computed tomography. The primary endpoints were survival and freedom from reintervention.

RESULTS

dSINE was the most prevalent complication after FET procedure, with an incidence of 23%. Eleven of 12 patients with dSINE underwent secondary interventions. dSINE was common in chronic aortic dissection (P = 0.001) and was associated with the residual false lumen area (P < 0.001) and movement distance of the distal edge of the device in the cranial direction (P < 0.001).

CONCLUSIONS

The distal edge of the FET is more likely to move in the cranial direction, and this movement may cause dSINE.

Clinical Outcomes of Distal Tapered Restrictive Covered Stent Applied in Endovascular Treatment of Aortic Dissection Involving Zone 0

OBJECTIVE

The safety and efficacy of a distal tapered restrictive covered stent (RCS) applied in the endovascular treatment of aortic dissection involving Zone 0 was evaluated.

METHODS

This study retrospectively analysed 43 patients with acute aortic dissection involving Zone 0 who received in situ laser fenestrated thoracic endovascular aortic repair with distal tapered RCS from January 2015 to February 2019. The indication for the distal tapered RCS procedure was an inappropriate distal size of the main stent graft. Technical success, aortic remodelling, and clinical outcomes were evaluated.

RESULTS

Technical success was achieved in all patients. The 30 day post-operative mortality rate was 0%. All patients had complete false lumen thrombosis in the stent coverage segment. True lumen volume increased significantly (p < .001) with an average change of 87.0% ± 34.3%, while false lumen volume decreased significantly (p < .001) with an average change of -71.0% ± 13.5% between baseline and 12 months. During the follow up period (mean 28.7 months, range 12-63 months), no distal stent graft induced new entry (SINE) was observed. The average distance between the distal end of the RCS and the coeliac trunk was 57.5 mm. Two (4.7%) patients had spinal cord ischaemia (SCI) and recovered without permanent paraplegia after undergoing conservative treatment.

CONCLUSION

The distal tapered RCS applied in the endovascular treatment of aortic dissection involving Zone 0 is considered to be a feasible and effective approach along with satisfactory aortic remodelling, a low risk of SINE, and SCI. The favourable results are partly explained by selection. No patients had an entry tear near the coronary artery, nor were the coronary arteries, pericardium, or aortic valve involved at the time of repair.