Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection Zhihui Dong, MD, Weiguo Fu, MD, Yuqi Wang, MD, Chunsheng.

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Presentation transcript:

Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection Zhihui Dong, MD, Weiguo Fu, MD, Yuqi Wang, MD, Chunsheng Wang, MD, Zhiping Yan, MD, Daqiao Guo, MD, Xin Xu, MD, Bin Chen, MD Journal of Vascular Surgery Volume 52, Issue 6, Pages 1450-1457 (December 2010) DOI: 10.1016/j.jvs.2010.05.121 Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 1 A, When passively bent at the arch, the self-expanding stent graft, like a spring, has the inherent tendency to spring back to its initial straight status, especially in the presence of the longitudinal connecting bar (red). Such spring-back strength could yield stress on the greater curve, particularly at two ends of the graft. B, In patient 3, computed tomography angiography (CTA) at 28 months detected an asymptomatic distal stent graft-induced new entry (SINE; arrow). C, CTA at 29 months showed a proximal SINE (long arrow) and resultant retrograde type A dissection, and the distal SINE (short arrow) remained stable. D, At 12 months after the graft replacement of the ascending thoracic aorta and partial arch, the distal SINE expanded (arrow). E and F, By 27 months after the open surgery, the distal SINE progressively enlarged, leading to contained rupture. G and H, At 3 months after an urgent secondary thoracic endovascular aortic repair, CTA evidenced complete seal of the distal SINE (arrow) and entire absorption of the pleural effusion. Journal of Vascular Surgery 2010 52, 1450-1457DOI: (10.1016/j.jvs.2010.05.121) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 2 A, The stent graft is frequently placed across the aortic arch in type B dissection patients, and the proximal end (dot a) of the endograft (green shade) is usually much closer to the curving point (dot b) than the distal one (dot c); that is to say that segment ab is shorter than segment bc, probably making the stress more concentrated on its proximal tip and causing the proximal stent graft-induced new entry (SINE). B, As occurred in patient 13, the proximal SINE developed 1 week after thoracic endovascular aortic repair (TEVAR). C, During the surgical conversion, it was evidenced that the proximal bare spring (arrow) created a new entry and protruded into the false lumen. D, Twelve months after the David procedure and semiarch replacement, computed tomography angiography showed a stable arch and expanded distal true lumen. E, If segment ab were longer than segment bc, the new entry would probably develop at the distal end. F, As occurred in patient 19, the distal SINE occurred 15 months after TEVAR. G, The angiogram during the secondary TEVAR clearly revealed the distal SINE (arrow). H, An additional stent graft was implanted with distal overlapping with the original one, which, however, might change the distribution of the stress and transfer its concentration from the distal to the proximal end of the endograft, possibly causing the subsequent proximal SINE and resultant retrograde type A dissection, which was suspected to be responsible for his sudden death 1 month later. Journal of Vascular Surgery 2010 52, 1450-1457DOI: (10.1016/j.jvs.2010.05.121) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 3 A to D, Preoperative computed tomography angiography (CTA) in patient 17 demonstrated the maximum aortic diameter of 50 mm and the evident gap of diameter between the proximal landing area (30 mm) and the distal true lumen (10 mm), at which level there was no entry thus far. E to H, The patient had chest pain 1 day after thoracic endovascular aortic repair with ZTEG-2P (34 × 15, Zenith TX2, Cook). CTA revealed a remarkable thrombosis of the false lumen, expansion of the distal true lumen up to 20 mm, and still no entry at that level where the stent graft distally fixed. I to L, CTA at 3 months showed that the maximum aortic diameter had shrunk to 45 mm, that the distal true lumen significantly expanded up to 36 mm, and that a distal stent graft-induced new entry (SINE) occurred (short arrow). The new false lumen was noted to be independent of the original false lumen (long arrow). M to P, CTA at 12 months evidenced that the maximum aortic diameter further decreased to 40 mm, and the distal SINE (arrow) had caused aortic enlargement from 36 to 40 mm. Journal of Vascular Surgery 2010 52, 1450-1457DOI: (10.1016/j.jvs.2010.05.121) Copyright © 2010 Society for Vascular Surgery Terms and Conditions

Fig 4 More attention needs to be given to an optimal compliance of the stent graft with the aorta in addition to its fixation distance. A, From the standpoint of the minimal requirement of the 15-mm proximal landing distance, it would have been enough to place the endograft right proximal to the left subclavian artery (blue line) in this case. However, it would achieve better compliance if the endoprosthesis could be deployed immediately distal to the left common artery (red line). B, So we ultimately fixed the endograft proximally at the red line, achieving an optimal compliance. C, Otherwise, as in this case, the proximal end of the stent graft would probably spring up and be angulated, with the greater curve (arrow) increasing the risk of wall injury. D, The proximal bare spring needs to be prevented from protruding into either origin of the three main branches. Such as in this case, the proximal bare spring went into the left common carotid artery, and its tip was almost perpendicularly pointed against the arterial wall (arrow), substantially increasing the risk of injury. E to G, In patient 21, computed tomography angiography (CTA) at 33 months demonstrated satisfactory proximal false lumen thrombosis but unsatisfactory compliance of the distal portion of the stent graft with the descending thoracic aorta and the distal stent graft-induced new entry (SINE; arrow). The distal SINE was located at the dissected flap and did not communicate with the original false lumen. H to J, In patient 20, CTA at 12 months revealed complete false lumen thrombosis at the proximal segment. However, the endograft distally stopped at the tortuous segment of the descending thoracic aorta and created a distal SINE (arrow), which was also at the dissected flap and independent of the primary false lumen. It would have been better in patients 21 and 20 to use a longer endograft that could extend more distally down to the relatively straight portion of the aorta and acquire better compliance. Journal of Vascular Surgery 2010 52, 1450-1457DOI: (10.1016/j.jvs.2010.05.121) Copyright © 2010 Society for Vascular Surgery Terms and Conditions