Mid-term Outcomes of Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE) in Acute Type B Aortic Dissection.

OBJECTIVES: This article reports mid-term results of 41 patients treated by the stent assisted balloon induced intimal disruption and relamination (STABILISE) technique for acute type B aortic dissection. METHODS: Between November 2011 and November 2017, 41 patients (10 male; median age 50 years) underwent proximal descending aortic stent grafting plus stent assisted balloon induced intimal disruption of the thoraco-abdominal aorta for acute type B aortic dissection. Serial computed tomography angiography was used to assess aortic remodelling. RESULTS: There were no intra-procedural complications. Fifteen branch arteries supplied by the false lumen were stented (9% of the visceral branch arteries). The thirty day incidence of death, stroke, and paralysis/visceral ischaemia was 2% (n = 1), 0%, 5% (n = 2), and 2% (n = 1) respectively. During a median follow up of 12 months (range 1-168) eight patients (20%) required re-intervention. Primary visceral stent patency was 93% (n = 14). No aortic related deaths occurred. On the most recent computed tomography angiogram, complete false lumen obliteration and aortic remodelling was obtained in all patients at the thoraco-abdominal level, and in 39% (n = 16) at the unstented infrarenal aorto-iliac level. The maximum aortic diameter increased in only two patients (5%) at the unstented infrarenal level. CONCLUSION: To obtain immediate and durable thoraco-abdominal aortic remodelling in acute type B dissections, the STABILISE technique is safe and reproducible while not compromising the patency of collateral branches.

Predictive factors for limb occlusions after endovascular aneurysm repair.

OBJECTIVE: Greater flexibility and smaller sizes for introducer sheaths in the newest stent grafts increase the feasibility of endovascular aneurysm repair but raise concerns about long-term limb patency. The aim of the study was to determine the incidence of and predictive factors for limb occlusion after use of the Endurant stent graft (Medtronic Inc, Minneapolis, Minn) for abdominal aortic aneurysm. METHODS: The Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) prospectively included 1143 patients treated with bifurcated devices who were observed for up to 2 years. Limb occlusions were evidenced by computed tomography, angiography, or ultrasound. To predict stent graft limb occlusion, a two-step model-building technique was applied. We first identified predictors from a total of 47 covariates obtained at baseline and in the periprocedural period. Subsequently, we reduced the set of potential predictors to key factors that are clinically meaningful. To handle large numbers of covariates, we used the Classification And Regression Tree (CART) method. RESULTS: Forty-two stent graft limbs occluded in 39 patients (3.4% of the patients). At 2 years, the rate of freedom from stent graft limb occlusion calculated by Kaplan-Meier plot was 97.9% (standard error [SE], 0.33%). Of the 42 occlusions, 13 (31%) were observed within 30 days and 30 (71%) within 6 months. The strongest independent predictors were distal landing zone on the external iliac artery, external iliac artery diameter ≤10 mm, and kinking. High-risk vs low-risk patients were identified according to a decision tree based on the strongest predictors. Freedom from stent graft limb occlusion was 96.1% (SE, 0.64%) in high-risk patients vs 99.6% (SE, 0.19%) in low-risk patients. CONCLUSIONS: After Endurant stent grafting, the incidence of limb occlusion was low. Classifying patients as high risk vs low risk according to the algorithm used in this study may help define specific strategies to prevent limb occlusion and improve the overall results of endovascular aneurysm repair using the latest generation of stent grafts.

Reintervention after thoracic endovascular aortic repair of complicated aortic dissection.

OBJECTIVE: This study assessed predictive factors for reintervention after thoracic endovascular aortic repair (TEVAR) for complicated aortic dissection (C-AD). METHODS: An institutional review of consecutive TEVAR for C-AD was performed. RESULTS: Between 2000 and 2011, 41 patients underwent TEVAR for a C-AD involving the descending thoracic aorta. Primary indications included aneurysm >55 mm in 24, rapid aneurysmal enlargement or impending rupture in 6, saccular aneurysm >20 mm in 1, malperfusion in 1, intractable chest pain in 3, and rupture in 6. Technical success was achieved in 100%. The 30-day mortality rate was 5% (n = 2). Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing ≥20% (odds ratio [OR], 16; P = .011), bare-spring stent in the proximal landing zone of the stent graft (OR, 12; P = .032), and anticoagulant therapy (OR, 78; P = .03) were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention (P = .002), whereas complete false lumen thrombosis at the stent graft level was protective (P < .05). CONCLUSIONS: This study confirms the feasibility of TEVAR for C-AD, although the rate of reintervention is high. Excessive oversizing, a bare-spring stent graft in the proximal landing zone, large aortic dilatation, and anticoagulant therapy were factors associated with reintervention. Complete false lumen thrombosis at the stent graft level was protective.