Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection


In recent guidelines of international societies, the most frequent indication for treatment after chronic type B aortic dissection (cTBAD) is aneurysmal dilatation. Endovascular repair is recommended in patients with moderate to high surgical risk or with contraindications to open repair. During the last decade, many advances have been made in the field of endovascular techniques and devices. The aim of this article is to address the current status of endoluminal techniques for the management of cTBAD including standard thoracic endovascular repair, new devices, fenestrated and branched abdominal aortic devices and false lumen occlusion techniques.

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  1. 1.

    Riambau V, Böckler D, Brunkwall J, et al. Editor's choice-management of descending thoracic aorta diseases: clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53:4–52.

    CAS  Article  Google Scholar 

  2. 2.

    Hiratzka LF, Bakris GL, Beckman JA, et al. 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. Circulation. 2010;121:266–369.

    Google Scholar 

  3. 3.

    Hughes GC. Management of acute type B aortic dissection. ADSORB Trial J Thorac Cardiovasc Surg. 2015;149:S158–S162162.

    Article  Google Scholar 

  4. 4.

    Luebke T, Brunkwall J. Type B aortic dissection: a review of prognostic factors and meta-analysis of treatment options. Aorta. 2014;2:265–78.

    Article  Google Scholar 

  5. 5.

    Nienaber CA, Kische S, Rousseau H, et al. INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6:407–16.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Kamman AV, de Beaufort HW, van Bogerijen GH, et al. Contemporary management strategies for chronic type B aortic dissections: a systematic review. PLoS ONE. 2016;11(5):e0154930.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Thrumurthy SG, Karthikesalingam A, Patterson BO, et al. A systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection. Eur J Vasc Endovasc Surg. 2011;42:632–47.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Chou HW, Chan CY, Chang CH, et al. Comparisons of aortic remodelling and outcomes after endovascular repair of acute and chronic complicated Type B aortic dissections. Interact Cardiovasc Thorac Surg. 2018;27:733–41.

    Article  PubMed  Google Scholar 

  9. 9.

    Nienaber CA, Fattori R, Lund G, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement. New Engl J Med. 1999;340:1539–45.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Capoccia L, Riambau V. Current evidence for thoracic aorta type B dissection management. Vascular. 2014;22:439–47.

    Article  PubMed  Google Scholar 

  11. 11.

    Kaji S. Update on the therapeutic strategy of type B aortic dissection. J Atheroscler Thromb. 2018;25:203–12.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Matsushita A, Tabata M, Mihara W, et al. Risk score system for late aortic events in patients with uncomplicated type B aortic dissection. J Thorac Cardiovasc Surg. 2019;S0022–5223(19):31276.

    Google Scholar 

  13. 13.

    Erbel R, Aboyans V, Boileau C, et al. 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.

    Article  Google Scholar 

  14. 14.

    JCS Joint Working Group. Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection (JCS 2011): digest version. Circ J. 2013;77:789–828 .

    Article  Google Scholar 

  15. 15.

    Appoo JJ, Bozinovski J, Chu MW, et al. Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery Joint Position Statement on Open and Endovascular Surgery for ThoracicAortic Disease. Can J Cardiol. 2016;32:703–13.

    Article  PubMed  Google Scholar 

  16. 16.

    Wang GJ, Cambria RP, Lombardi JV, et al. Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project. J Vasc Surg. 2019;69(3):680–91.

    Article  PubMed  Google Scholar 

  17. 17.

    Canaud L, Ozdemir BA, Patterson BO, et al. Retrograde aortic dissection after thoracic endovascular aortic repair. Ann Surg. 2014;260:389–95.

    Article  PubMed  Google Scholar 

  18. 18.

    VIRTUE Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE registry. Eur J Vasc Endovasc Surg. 2014;48:363–71.

    Article  Google Scholar 

  19. 19.

    Zipfel B, Zaefferer P, Riambau V, et al. Worldwide results from the RESTORE II on elective endografting of thoracic aneurysms and dissections. J Vasc Surg. 2016;63:1466–75.

    Article  PubMed  Google Scholar 

  20. 20.

    Zipfel B, Czerny M, Funovics M, et al. RESTORE Investigators. endovascular treatment of patients with types A and B thoracic aortic dissection using relay thoracic stent-grafts: results from the restore patient registry. J Endovasc Ther. 2011;18:131–43.

    Article  Google Scholar 

  21. 21.

    Spanos K, Kölbel T. Device profile of the Zenith dissection endovascular system for aortic dissection. Expert Rev Med Devices. 2019;16:541–8.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Cambria RP, Crawford RS, Cho JS, et al. GORE TAG Investigators. a multicenter clinical trial of endovascular stent graft repair of acute catastrophes of the descending thoracic aorta. J Vasc Surg. 2009;50(1255–64):e1–4.

    Article  Google Scholar 

  23. 23.

    Rousseau H, Revel-Mouroz P, Saint Lebes B, et al. Single aortic branch device: the Mona LSA experience. J Cardiovasc Surg (Torino). 2019;60:81–90.

    Article  Google Scholar 

  24. 24.

    Patel HJ, Dake MD, Bavaria JE, et al. Branched endovascular therapy of the distal aortic arch: preliminary results of the feasibility multicenter trial of the Gore thoracic branch endoprosthesis. Ann Thorac Surg. 2016;102:1190–8.

    Article  Google Scholar 

  25. 25.

    Alsafi A, Bicknell CD, Rudarakanchana N, et al. Endovascular treatment of thoracic aortic aneurysms with a short proximal landing zone using scalloped endografts. J Vasc Surg. 2014;60:1499–506.

    Article  PubMed  Google Scholar 

  26. 26.

    Chassin-Trubert L, Mandelli M, Ozdemir BA, et al. Midterm follow-up of fenestrated and scalloped physician-modified endovascular grafts for zone 2 TEVAR. J Endovasc Ther. 2019;24:1526602819881128.

    Article  Google Scholar 

  27. 27.

  28. 28.

    Czerny M, Schmidli J, Adler S, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg. 2019;55:133–62.

    Article  PubMed  Google Scholar 

  29. 29.

    Bosiers MJ, Donas KP, Mangialardi N, et al. European multicenter registry for the performance of the chimney/snorkel technique in the treatment of aortic arch-pathologic conditions. Ann Thorac Surg. 2016;101:2224–30.

    Article  Google Scholar 

  30. 30.

    Mangialardi N, Serrao E, Kasemi H, et al. Chimney technique for aortic arch pathologies: an 11-year singlecenter experience. J Endovasc Ther. 2014;21:312–23.

    Article  Google Scholar 

  31. 31.

    Liu F, Ge YY, Guo W, et al. Preoperative thoracic false lumen branches are predictors of aortic enlargement after stent grafting for DeBakey IIIb aortic dissection. J Thorac Cardiovasc Surg. 2018;155(21–9):e3.

    Article  Google Scholar 

  32. 32.

    Watanabe Y, Shimamura K, Yoshida T, et al. Aortic remodeling as a prognostic factor for late aortic events after thoracic endovascular aortic repair in type B aortic dissection with patent false lumen. J Endovasc Ther. 2014;21:517–25.

    Article  PubMed  Google Scholar 

  33. 33.

    Hughes GC. Stent graft-induced new entry tear (SINE): Intentional and NOT. J Thorac Cardiovasc Surg. 2019;157(1):101–106.e3.

    Article  PubMed  Google Scholar 

  34. 34.

    Kitagawa A, Greenberg RK, Eagleton MJ, et al. Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg. 2013;58:625–34.

    Article  PubMed  Google Scholar 

  35. 35.

    Oikonomou K, Kasprzak P, Katsargyris A, et al. Mid-term results of fenestrated/branched stent grafting to treat post-dissection thoraco-abdominal aneurysms. Eur J Vasc Endovasc Surg. 2019;57:102–9.

    Article  PubMed  Google Scholar 

  36. 36.

    Law Y, Tsilimparis N, Rohlffs F, et al. Fenestrated or branched endovascular aortic repair for postdissection thoracoabdominal aortic aneurysm. J Vasc Surg. 2019;70:404–12.

    Article  PubMed  Google Scholar 

  37. 37.

    Bertoglio L, Rinaldi E, Melissano G, Chiesa R. The PETTICOAT concept for endovascular treatment of type B aortic dissection. J Cardiovasc Surg (Torino). 2019;60:91–9.

    Article  Google Scholar 

  38. 38.

    Lombardi JV, Gleason TG, Panneton JM, et al. STABLE II clinical trial on endovascular treatment of acute, complicated type B aortic dissection with a composite device design. J Vasc Surg. 2020;71(1077–87):e2.

    Article  Google Scholar 

  39. 39.

    Lombardi JV, Cambria RP, Nienaber CA, et al. Aortic remodeling after endovascular treatment of complicated type B aortic dissection with the use of a composite device design. J Vasc Surg. 2014;59:1544–54.

    Article  PubMed  Google Scholar 

  40. 40.

    Kazimierczak A, Rynio P, Jędrzejczak T, et al. Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection. J Vasc Surg. 2019;S0741–5214(19):30343.

    Article  Google Scholar 

  41. 41.

    Ibrahim W, Spanos K, Gussmann A, et al. Early and midterm outcome of multilayer flow modulator stent for complex aortic aneurysm treatment in Germany. J Vasc Surg. 2018;68:956–64.

    Article  PubMed  Google Scholar 

  42. 42.

    Sultan S, Kavanagh EP, Stefanov F, et al. Global MFM Collaborators. endovascular management of chronic symptomatic aortic dissection with the streamliner multilayer flow modulator: twelve-month outcomes from the global registry. J Vasc Surg. 2017;65:940–50.

    Article  PubMed  Google Scholar 

  43. 43.

    Kamman AV, Jonker FHW, Sechtem U, et al. IRAD investigators. predictors of stable aortic dimensions in medically managed acute aortic syndromes. Ann Vasc Surg. 2017;42:143–9.

    Article  Google Scholar 

  44. 44.

    Li D, Ye L, He Y, et al. False lumen status in patients with acute aortic dissection: a systematic review and meta-analysis. J Am Heart Assoc. 2016;10:5.

    Google Scholar 

  45. 45.

    Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med. 2007;357:349–59.

    CAS  Article  Google Scholar 

  46. 46.

    Loubert MC, van der Hulst VP, De Vries C, et al. How to exclude the dilated false lumen in patients after a type B aortic dissection? The cork in the bottleneck. J Endovasc Ther. 2003;10:244–8.

    Article  PubMed  Google Scholar 

  47. 47.

    Spanos K, Kölbel T, Rohlffs F, et al. Intentional targeted false lumen occlusion after aortic dissection: a systematic review of the literature. Ann Vasc Surg. 2019;56:317–29.

    Article  PubMed  Google Scholar 

  48. 48.

    Kölbel T, Lohrenz C, Kieback A, et al. Distal false lumen occlusion in aortic dissection with a homemade extra-large vascular plug: the candy-plug technique. J Endovasc Ther. 2013;20:484–9.

    Article  PubMed  Google Scholar 

  49. 49.

    Kölbel T, Carpenter SW, Lohrenz C, et al. Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique. J Endovasc Ther. 2014;21:117–22.

    Article  PubMed  Google Scholar 

  50. 50.

    Rohlffs F, Tsilimparis N, Fiorucci B, et al. The candy-plug technique: technical aspects and early results of a new endovascular method for false lumen occlusion in chronic aortic dissection. J Endovasc Ther. 2017;24:549–55.

    Article  PubMed  Google Scholar 

  51. 51.

    Eleshra A, Kölbel T, Tsilimparis N, et al. Candy-plug generation ii for false lumen occlusion in chronic aortic dissection: feasibility and early results. J Endovasc Ther. 2019;3:1526602819871613.

    Article  Google Scholar 

  52. 52.

    Pellenc Q, Roussel A, De Blic R, et al. False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up. J Vasc Surg. 2019;70:710–7.

    Article  PubMed  Google Scholar 

  53. 53.

    Crawford ES. The diagnosis and management of aortic dissection. JAMA. 1990;264:2537–41.

    CAS  Article  Google Scholar 

  54. 54.

    Fiorucci B, Kölbel T, Rohlffs F, et al. The role of thoracic endovascular repair in elective, symptomatic and ruptured thoracic aortic diseases. Eur J Cardiothorac Surg. 2019;56:197–203.

    Article  PubMed  Google Scholar 

  55. 55.

    Nakamura K, Uchida T, Sho R, et al. Analysis of risk factors for aortic enlargement in patients with chronic type B aortic dissection. Ann Vasc Dis. 2018;11:490–5.

    Article  PubMed  PubMed Central  Google Scholar 

  56. 56.

    Sze DY, van den Bosch MA, Dake MD, et al. Factors portending endoleak formation after thoracic aortic stent-graft repair of complicated aortic dissection. Circ Cardiovasc Interv. 2009;2:105–12.

    Article  Google Scholar 

  57. 57.

    Sharafuddin MJ, Reece TB, Papia G, et al. Proposed classification of endoleaks after endovascular treatment of stanford type-B aortic dissections. Vascular. 2019;8:1708538119847394.

    Article  Google Scholar 

  58. 58.

    Waterford SD, Chou D, Bombien R, et al. Left subclavian arterial coverage and stroke during thoracic aortic endografting: a systematic review. Ann Thorac Surg. 2016;101:381–9.

    Article  PubMed  Google Scholar 

  59. 59.

    Chen X, Wang J, Premaratne S, et al. Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair. J Vasc Surg. 2019;70:1330–40.

    Article  PubMed  Google Scholar 

  60. 60.

    Konstantinou N, Debus ES, Vermeulen CFW, et al. Cervical debranching in the endovascular era: a single centre experience. Eur J Vasc Endovasc Surg. 2019;58:34–40.

    Article  PubMed  Google Scholar 

  61. 61.

    Kölbel T, Rohlffs F, Wipper S, et al. Carbon dioxide flushing technique to prevent cerebral arterial air embolism and stroke during TEVAR. J Endovasc Ther. 2016;23:393–5.

    Article  PubMed  Google Scholar 

  62. 62.

    Rohlffs F, Trepte C, Ivancev K, et al. Air embolism during TEVAR: liquid perfluorocarbon absorbs carbon dioxide in a combined flushing technique and decreases the amount of gas released from thoracic stent-grafts during deployment in an experimental setting. J Endovasc Ther. 2019;26:76–80.

    Article  PubMed  Google Scholar 

  63. 63.

    Li HL, Wu S, Chan YC, et al. Early and mid-term mortality and morbidity of contemporary international endovascular treatment for type B aortic dissection—a systematic review and meta-analysis. Int J Cardiol. 2020;301:56–61.

    Article  PubMed  Google Scholar 

  64. 64.

    Xue Y, Ge Y, Ge X, et al. Association between extent of stent-graft coverage and thoracic aortic remodeling after endovascular repair of type B aortic dissection. J Endovasc Ther. 2020;27:211–20.

    Article  Google Scholar 

  65. 65.

    Canaud L, Gandet T, Sfeir J, et al. Risk factors for distal stent graft induced new entry tear after endovascular repair of thoracicaortic dissection. J Vasc Surg. 2019;69:1610–4.

    Article  PubMed  Google Scholar 

  66. 66.

    D'cruz RT, Syn N, Wee I, et al. Singapore vascular surgical collaborative (SingVaSC). risk factors for distal stent graft-induced new entry in type B aortic dissections: systematic review and meta-analysis. J Vasc Surg. 2019;70:1682–93.

    Article  Google Scholar 

  67. 67.

    Lortz J, Leinburger F, Tsagakis K, et al. Distal stent graft induced new entry: risk factors in acute and chronic type B aortic dissections. Eur J Vasc Endovasc Surg. 2019;S1078–5884(19):30292–8.

    Article  Google Scholar 

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Correspondence to Konstantinos Spanos.

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Tilo Kölbel has intellectual property with Cook Medical.

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Spanos, K., Kölbel, T. Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection. Cardiovasc Intervent Radiol (2020).

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  • Chronic type B dissection
  • Endovascular repair
  • Inner branch device
  • Remodeling