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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 75-79

Application of occlusive devices in endovascular repair of Stanford type B aortic dissection with insufficient landing zones


Department of Vascular Surgery, National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China

Date of Submission09-Nov-2021
Date of Decision11-Feb-2022
Date of Acceptance16-Feb-2022
Date of Web Publication10-Nov-2022

Correspondence Address:
Dr. Guangqi Chang
Division of Vascular Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.360873

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  Abstract 


OBJECTIVES: Occlusion of intimal tear with occlusive devices is an alternative or adjuvant method for endovascular repair of Stanford type B aortic dissection (TBAD) with insufficient landing zones. This study aimed to evaluate the efficacy and safety of using occluders in highly selective TBAD patients inappropriate for conventional thoracic endovascular aortic repair (TEVAR).
METHODS: All patients undergoing TEVAR between July 2009 and July 2015 were retrospectively reviewed and patients treated with only or adjuvant occlusive devices were included in the study. Demographic data, clinical characteristics, perioperative data, and follow-up were collected and analyzed.
RESULTS: A total of 10 TBAD patients treated with occluders were included in the study. The mean age was 56.8 ± 12.7 years old and the majority of the patients were male (7/10). Only occluders were applied to seal the proximal tears in seven cases, while occluders combined with other endovascular techniques were used in three cases. No 30-day mortality operative reintervention was required in two cases. Eight patients were followed up for 10.0 ± 4.1 years and two cases were lost to follow-up. Three patients died during the follow-up period; one patient died of stroke, while the other two patients died due to noncardiovascular causes. One reintervention was performed due to endoleak 2 years after the surgery.
CONCLUSIONS: The early and long-term outcomes of the 10 patients show that treating difficult aortic lesions unfit for traditional TEVAR with occluders is effective and safe. The technique may provide a treatment alternative in highly selective TBAD patients unfit for traditional TEVAR.

Keywords: Occlude, occlusive devices, Stanford type B aortic dissection, thoracic endovascular aortic repair


How to cite this article:
Li Z, Wang R, Wang M, Liu C, Wu R, Yao C, Chang G. Application of occlusive devices in endovascular repair of Stanford type B aortic dissection with insufficient landing zones. Vasc Invest Ther 2022;5:75-9

How to cite this URL:
Li Z, Wang R, Wang M, Liu C, Wu R, Yao C, Chang G. Application of occlusive devices in endovascular repair of Stanford type B aortic dissection with insufficient landing zones. Vasc Invest Ther [serial online] 2022 [cited 2022 Dec 9];5:75-9. Available from: https://www.vitonline.org/text.asp?2022/5/3/75/360873




  Introduction Top


Thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for complicated Stanford type B aortic dissection (TBAD). To avoid coverage of vital brachial arteries, conventional TEVAR requires both sufficient proximal and distal landing zones with a diameter <40 mm and a length ≥20 mm.[1],[2] However, it is reported that nearly half of TEVAR procedures require coverage of vital branches such as the left subclavian artery (LSA) to reach healthy proximal aorta.[3] Thus, for aortic lesions involving vital branches, more and more endovascular techniques were reported and applied in the real world to acquire sufficient landing zone while preserving the vital branch vessels. These novel techniques include parallel grafts technique, fenestrated technique, and branched stent grafts. However, these techniques might be technically difficult, unaffordable, or not readily available in some cases. These limitations have led to the use of other devices or techniques that are more accessible in highly selected cases with specific certain anatomy.

The atrial septal defect (ASD) and ventricular septal defect (VSD) were the most common congenital cardiac abnormalities which can be treated by transcatheter occlusion with ASD or VSD occluder.[4] Recently, the versatility of occluder has been demonstrated in publications of its application in TBAD with insufficient landing zones.[5] Our center reported the first case of using a VSD occluder to treat a TBAD patient with a proximal entry tear 5 mm distal to LSA[6] in 2010. In 2013, we reported using an ASD occluder combined with a chimney stent to treat a 41-year-old male patient with traumatic pseudoaneurysm in the aortic arch.[7] Primary outcomes of these two patients demonstrated that the application of occluder in treating TBAD with insufficient landing zone was effective and safe. Hence, we further applied this technique in some highly selected TBAD patients unfit for conventional TEVAR in our center. In this study, clinical experiences of ASD or VSD occluder in treating TBAD with insufficient landing zone were analyzed and reported.


  Methods Top


Patients

All patients underwent total endovascular treatment for TBAD between July 2009 and July 2015 were retrospectively reviewed and 10 patients treated with occlusive devices were included in the study. Proximal and distal tears, anatomy of dissection of all patients were evaluated by preoperative computed tomographic angiography (CTA).

Procedure techniques and postoperative management

All procedures were performed under general or local anesthesia in hybrid operating room. The operation plan was individually designed according to the anatomical characteristics of each patient. Occluders were applied alone to exclude intimal tears or combined with other endovascular techniques as an adjuvant treatment. In brief, the occluder was implanted as follows. After anesthesia, patients were accessed percutaneously through common femoral artery. Location of tears and the anatomic relation between intimal tears and vital arterial branches were further confirmed by angiography at the beginning of operation. After angiography, device delivery sheath was introduced, although the tear into the false lumen, followed by release of the disc on the front end. Then, the delivery sheath was gently pulled back; as the front disc was stuck at the tear, the disc on the rear end was released, which leads the connecting waist stuck in the middle of the tear. In some cases, to attain a better sealing, a bare-metal stent was implanted to achieve an optimal attachment between the occluder and the intimal flap.

Follow-up

All 10 patients were followed with CTA at 1, 6, and 12 months and yearly thereafter after discharge.

Statistical analysis

The continuous values in clinical data are expressed as mean ± standard deviation, while categorical variables are expressed as frequencies and percentages. The analyses were performed using SPSS version 24.0 (IBM SPSS, Chicago, Illinois, USA).


  Results Top


Patients characteristics

A total of 10 patients with a mean age of 56.8 ± 12.7 years underwent implantation of occluders to treat TBAD. The majority of the patients were male (7/10), which was consistent with natural epidemiology of AD.[8] Seven of the 10 patients had hypertension. All of the proximal tears were located in descending aorta distal to LSA or abdominal aorta, and one of the patients had retrograde type A AD. Of these patients, two cases had dissecting aneurysm and one patient had chronic dissection complicated with abdominal aortic aneurysm [Table 1].
Table 1: Characteristics of the study population

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Intraoperative management

Details of the procedures and anatomic characteristics of AD were demonstrated in [Table 2] and [Table 3]. Indications for using occluders were divided into two situations as follows: (1) The proximal tear of AD was too close to vital artery branches (all <20 mm), and the occluders were applied to seal the proximal tear.(2) Occluders were used to seal distal tears after implanting stent grafts to seal the primary tear [Figure 1].
Figure 1: (a) Computed tomographic angiography shows that the proximal tear was near the left subclavian artery. (b) Chimney technique with bare-metal stent was used to reconstruct the left subclavian artery. (c) Angiography showed significant backflow in the false lumen from the distal tear. (d) An occluder was used to seal the distal tear. (e) Postoperative computed tomographic angiography

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Table 2: Characteristics of aortic dissection and surgical methods

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Table 3: Characteristics of occluders

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The average distance between tears and arterial branches was 9.5 ± 5.5 mm, as the mean diameter of tear 9.9 ± 3.1 mm. Except for patient 1, all patients received oversized occluder to achieve full blockage of the tear. The mean surgery time was 3.5 ± 0.7 h, and the estimated blood loss was 71.0 ± 51.5 ml [Table 3]. The technical success rate was 100%, with all adjacent vital branches well preserved.

Perioperative results and follow-up

There was no 30-day mortality, while perioperative reintervention was required in two cases. Stent implantation was performed to solve postoperative endoleak in patient 4, while the second-stage endovascular repair of the abdominal aortic aneurysm was performed 15 days after blockage of the proximal tear with an occlude in patient 5 [Procedure 2 in [Table 2] and [Figure 2]]. Three patients required short-term intensive care unit (ICU) monitoring (one or 2 days) after surgery. The average hospital stay was 29.3 ± 14.5 days (17–67 days). The patient 3 who stayed in the hospital over 60 days was originally administrated with chronic kidney disease and transferred back to the nephrology department for further management after surgery [Table 4].
Figure 2: (a-c) Preoperative computed tomographic angiography and angiography showed that the patient (patient 5 in tables) with abdominal aortic aneurysm was complicated with a chronic dissection, which involved the aneurysmal sac. (d) An occluder was applied to seal the proximal tear, which was near the left renal artery. (e) Planned endovascular aortic repair was performed 15 days after implantation of the occluder. (f) Postoperative computed tomographic angiography

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Table 4: Procedures and perioperative results

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Eight patients were followed up for 10.0 ± 4.1 years and two cases were lost to follow-up. During the follow-up period, three patients died. Of these three patients, patient 7 died of stroke 1 year after surgery, whereas patients 6 and 9 died due to noncardiovascular cause 6 and 10 years postoperatively, respectively. Reintervention to manage endoleak was required in patient 8, 2 years after the surgery.


  Discussion Top


TEVAR has been proven as an effective and less invasive treatment method for TBAD. However, as quite a few primary tears of TBAD are located close to aortic arch branch vessels or visceral arteries, it is unfit for standard TEVAR alone without branch vessel reconstruction to ensure proximal sealing over 20 mm at healthy aorta.[8] The conventional treatment approaches for patients without sufficient landing zone were open or hybrid debranching surgery which were associated with high mortality and perioperative complication rate. With the development of endovascular techniques, total endovascular repair procedures with novel techniques were applied worldwide, including fenestrated TEVAR, chimney or scallop technique (also known as parallel stent technique), and custom-made branched stent graft. Although all of the techniques were proven as effective as the hybrid operation[9],[10] and reported to have similar results comparing with each other,[3],[11],[12] it takes a substantial amount of time and money to make an operative plan and modify stent grafts, so these techniques might not be suitable for all cases, especially for complicated TBAD requiring emergency surgery.

ASD or VSD occluders designed to treat congenital cardiac abnormalities have been used in TBAD treatment since a decade ago. The rationale of occluder for AD was to block the tear with a solid tiny patch instead of the membrane-covered stent graft to avoid coverage of branches. In our center, we firstly applied a ventricular septal defect occluder to treat a 39-year-old male patient with TB-AD, in which the proximal entry tear was only 5 mm distal to the LSA.[6] Later on, we used an atrial septal defect occluder combined with chimney stents to treat a 41-year-old male patient with aortic arch pseudoaneurysm after blunt trauma.[7] As the long-term follow-up of these two patients showed favorable results, we further applied occluders to seal proximal or distal tears of TBAD in another nine cases.

To choose the appropriate size of the occluders, we measured tears diameter by CTA and applied 50% of oversize for occluders to ensure an adequate sealing. As mentioned above, we further applied bare-metal stents in certain cases to ensure better attachment between occluders and intima. Indeed, these strategies eliminated or minimized endoleak in all cases on the completion of angiography.

The short-and long-term follow-up showed that the application of occluder for selective TBAD unfit for standard TEVAR is feasible, effective, and safe. There were no dissection-related deaths during the perioperative period or long-term follow-up. While the incidence of endoleak should be aware of, these endoleaks can be effectively managed with appropriate endovascular interventions.


  Conclusions Top


In conclusion, treating TBAD in highly selected patients with appropriate anatomy by sealing the proximal or distal tear with occluder is technically feasible, safe, and effective at short-to long-term follow-up.

Ethics statement

Informed consent was obtained from all patients. The research reported has adhered to the relevant ethical guidelines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873-926.  Back to cited text no. 1
    
2.
Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr., et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol 2010;55:e27-129.  Back to cited text no. 2
    
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Chassin-Trubert L, Mandelli M, Ozdemir BA, Alric P, Gandet T, Canaud L. Midterm follow-up of fenestrated and scalloped physician-modified endovascular grafts for zone 2 TEVAR. J Endovasc Ther 2020;27:377-84.  Back to cited text no. 3
    
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, et al. 2018 AHA/ACC Guideline for the management of adults with congenital heart disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;139:e698-800.  Back to cited text no. 4
    
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Yuan X, Mitsis A, Semple T, Castro Verdes M, Cambronero-Cortinas E, Tang Y, et al. False lumen intervention to promote remodelling and thrombosis – The FLIRT concept in aortic dissection. Catheter Cardiovasc Interv 2018;92:732-40.  Back to cited text no. 5
    
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Chang G, Wang H, Chen W, Yao C, Li Z, Wang S. Endovascular repair of a type B aortic dissection with a ventricular septal defect occluder. J Vasc Surg 2010;51:1507-9.  Back to cited text no. 6
    
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Chang G, Chen W, Yin H, Li Z, Li X, Wang S. Endovascular repair of an aortic arch pseudoaneurysm by an atrial septal defect occluder combined with a chimney stent. J Vasc Surg 2013;57:1657-60.  Back to cited text no. 7
    
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Bossone E, LaBounty TM, Eagle KA. Acute aortic syndromes: Diagnosis and management, an update. Eur Heart J 2018;39:739-49d.  Back to cited text no. 8
    
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Wang M, Dong D, Yuan H, Wang M, Wu X, Zhang S, et al. Hybrid versus in vitro fenestration for preserving the left subclavian artery in patients undergoing thoracic endovascular aortic repair with unfavorable proximal landing zone. Vascular 2020;28:42-7.  Back to cited text no. 9
    
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Piffaretti G, Pratesi G, Gelpi G, Galli M, Criado FJ, Antonello M, et al. Comparison of two different techniques for isolated left subclavian artery revascularization during thoracic endovascular aortic repair in zone 2. J Endovasc Ther 2018;25:740-9.  Back to cited text no. 10
    
11.
Zhang H, Huang H, Zhang Y, Liu Z, Qiao T, Zhang X, et al. Comparison of chimney technique and single-branched stent graft for treating patients with type B aortic dissections that involved the left subclavian artery. Cardiovasc Intervent Radiol 2019;42:648-56.  Back to cited text no. 11
    
12.
Zhang L, Wu MT, Zhu GL, Feng JX, Song C, Li HY, et al. Off-the-shelf devices for treatment of thoracic aortic diseases: Midterm follow-up of TEVAR with chimneys or physician-made fenestrations. J Endovasc Ther 2020;27:132-42.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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