Custom Made Candy Plug for Distal False Lumen Occlusion in Aortic Dissection: International Experience

OBJECTIVE

To evaluate early and midterm outcomes of the Candy Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection (AD) in a more real world cohort of patients from an international multicentre registry.

METHODS

A multicentre retrospective study was conducted of all consecutive patients from the contributing centres with subacute and chronic AD treated with the CP technique from October 2013 to April 2020 at 18 centres.

RESULTS

A custom made CP was used in 155 patients (92 males, mean age 62 ± 11 years). Fourteen (9%) presented with ruptured false lumen aneurysms. Technical success was achieved in all patients (100%). Clinical success was achieved in 138 patients (89%). The median hospital stay was 7 days (1 - 77). The 30 day mortality rate was 3% (n = 5). Stroke occurred in four patients (3%). Spinal cord ischaemia occurred in three patients (2%). The 30 day computed tomography angiogram (CTA) confirmed successful CP placement at the intended level in all patients. Early complete FL occlusion was achieved in 120 patients (77%). Early (30 day) CP related re-intervention was required in four patients (3%). The early (30 day) stent graft related re-intervention rate was 8% (n = 12). Follow up CTA was available in 142 patients (92%), with a median follow up of 23 months (6 - 87). Aneurysmal regression was achieved in 68 of 142 patients (47%); the aneurysm diameter remained stable in 69 of 142 patients (49%) and increased in five of 142 patients (4%). A higher rate of early FL occlusion was detected in the largest volume centre patients (50 [88%] vs. 70 [71%] from other centres; p = .019). No other differences in outcome were identified regarding volume of cases or learning curve.

CONCLUSION

This international CP technique experience confirmed its feasibility and low mortality and morbidity rates. Aortic remodelling and false lumen thrombosis rates were high and support the concept of distal FL occlusion in AD using the CP technique.

A modified candy-plug technique to occlude false lumen in aortic dissection

PURPOSE

Aim of this technical note article is to introduce a modified, novel way to custom create a candy-plug (CP) device to endovascularly occlude false lumen. The technique is illustrated by a patient case with significant backflow to false lumen (FL). The patient had already undergone surgical repair of the ascending aorta, aortic arch and subsequent TEVAR procedure down to the ostium of the celiac trunk because of type A aortic dissection, but the descending thoracic aorta continued to dilate due to backflow to the FL from an uncovered tear at the level of the renal arteries.

MATERIALS AND METHODS

We modified a Gore Excluder 36-45 mm aortic extender (W. L. Gore & Associates, Inc. Flagstaff, USA) endoprosthesis into a CP device that was subsequently positioned under local anesthesia into the FL of the distal descending thoracic aorta.

RESULTS

In 1 month control the backflow to false lumen had ceased and the aorta had decreased in diameter from 69 to 66 mm, FL from 37 to 34 mm, true lumen (TL) remained the same 32 mm.

CONCLUSION

We describe a modified, effective candy-plug technique to occlude retrograde false lumen filling in aortic dissection.

Aortic remodeling after false lumen occlusion using an atrial septal occluder in chronic DeBakey IIIb aortic dissection

OBJECTIVE

Retrograde false lumen flow through distal entry tears poses a challenge in the treatment of chronic DeBakey IIIb aneurysms. In the present report, we have described the feasibility and outcomes of false lumen occlusion using an atrial septal occluder (ASO) in chronic DeBakey IIIb dissection associated with a descending aneurysm.

METHODS

All the patients who had undergone thoracic endovascular aortic repair for chronic DeBakey IIIb aortic dissection at our institution from January 2014 to November 2020 were retrospectively reviewed. The primary endpoints were technical success and in-hospital postoperative results. The secondary endpoints included the midterm survival status and aortic remodeling outcomes.

RESULTS

A total of 37 patients (age, 56.24 ± 10.47 years) with persistent retrograde false lumen perfusion and aneurysm formation at the thoracic segment were treated using an ASO for false lumen occlusion. We achieved 100% technical success. No spinal cord ischemia or in-hospital death was observed. The median follow-up time was 36 months (interquartile range, 24-51 months). After the procedure, three patients (8.1%) had had an endoleak (type Ia in two patients and type II in one patients), and five patients had required late reintervention. The overall 5-year survival rate was 71%. One aortic-related death (2.7% of the total cohort) occurred during follow-up at 9 months. Complete thrombosis of the false lumen along the treated aortic segment was recorded postoperatively in 34 patients (91.9%) at the final follow-up using computed tomography angiography. In a mixed-effects model, a diameter analysis revealed that the thoracic true lumen diameter had increased and the thoracic false lumen diameter had decreased significantly (0.256 mm/mo, P < .001; and -0.512 mm/mo, P < .001, respectively).

CONCLUSIONS

The combination of standard thoracic endovascular aortic repair and false lumen occlusion using the ASO to promote false lumen thrombosis and remodeling in the treated segments is a technically feasible and effective alternative treatment of chronic DeBakey IIIb dissection with an associated descending aneurysm. This approach yielded satisfactory midterm survival outcomes and a low incidence of aortic-related death in our patients. However, further studies with more subjects and a prospective design should verify our findings before routine clinical implementation of this technique.