Challenges of Total Endovascular Repair of Chronic Type B Aortic Dissection
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COMMENTARY
COMMENTARY
Challenges of Total Endovascular Repair of Chronic Type B Aortic Dissection Mohamad Hamady1,2
•
Colin Bicknell2,3
Received: 9 July 2020 / Accepted: 8 August 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Chronic post-dissection thoracoabdominal aortic aneurysm (pD-TAAA) is a significant challenge to manage for open, hybrid or endovascular approaches. The main potential anatomical challenges confronting total endovascular approach include: short proximal landing zone, severe aortic angulation, tight compression of true lumen with or without thrombosed false lumen, target vessel take-off from false lumen, hostile take-off angle of target vessel and extension of dissection flap deeply into target vessel or iliac arteries. Early and contemporary experience including ours at Imperial College reports technical and clinical outcome success for total endovascular intervention [1]. Verzini et al. in the CVIR issue published online in June 2020 [2] have demonstrated their multicentre experience with custom-made f/brEVAR stent grafts using one manufacturer (Cook Medical, Brisbane, Australia) in 21 patients with pdTAAA. We congratulate Verzini’s team for this excellent work, with a well-described technical description. Especially important is the authors’ sage advice that careful and comprehensive planning together with cohesive teamwork is mandatory. Anatomical challenges are of paramount importance. The compression of true lumen remains one of the biggest
& Mohamad Hamady [email protected] 1
Department of Interventional Radiology, St Mary’s Hospital, Praed Street, Paddington, London W2 1NY, UK
2
Department of Surgery and Cancer, Imperial CollegeLondon, London W2 1NY, UK
3
Regional Vascular Unit, St Mary’s Hospital, Praed Street, Paddington, London W2 1NY, UK
reasons for concern during planning stage. Three options are available including pre-stenting of the thoracic aorta, penetration of the flap using the sharp end of the wire, reentry device or TIPPS needle, or visceral hybrid revascularisation. We have experience with all these options. The issue with TEVAR pre-stenting is no accurate prediction of diameter expansion of the compressed true lumen. It is conceivable that the intimo-medial flap becomes thicker and more rigid in chronic phase of dissection [3]. Puncturing intimo-medial flap with the sharp end of wire is not really a controlled manoeuvre. We find the use of a re-entry device is a safe, successful and better controlled approach. In young patients and/or those with connective tissue disease, in particular with awkward anatomy, visceral hybrid revascularisation appears the most technically successful and durable strategy [4]. There are, however, significant morbidity and mortality and needs excellent open surgical skills. The development of inner branch stent graft (TAMBE, Gore & Associates, Flagstaff, Arizona) (E-nside, JOTEC, Cryolife, Germany) is a promising techn
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