Reviews in Cardiovascular Medicine  2020, Vol. 21 Issue (1): 129-137     DOI: 10.31083/j.rcm.2020.01.5105 Complete Entry and Re-entry Neutralization protocol in endovascular treatment of aortic dissection Tomasz Jędrzejczak1, Paweł Rynio2, Rabih Samad2, Anita Rybicka3, Agata Krajewska4, Piotr Gutowski2, Arkadiusz Kazimierczak2, *() 1 Cardiac Surgery Department, Pomeranian Medical University in Szczecin, Powstancow Wielkopolskich 72, Szczecin 72-111, Poland
2 Department of Vascular Surgery, Pomeranian Medical University in Szczecin, Powstancow Wielkopolskich 72, Szczecin 72-111, Poland
3 Department of Nursing, Pomeranian Medical University in Szczecin, Zolnierska 48, Szczecin 71-210, Poland
4 Department of Neurology, Pomeranian Medical University, Unii Lubelskiej 1, Szczecin 71-210, Poland Abstract:

There have been indisputable developments in techniques for stabilizing acute aortic syndromes. However, aneurysmal degeneration following aortic dissection remains a problem to be solved. The currently available treatment options for aortic dissection still fail to take into account the known risk factors for aneurysmal degeneration. This is why we introduced a new approach to treating patients with an aortic dissection, called Complete Entry and Re-entry Neutralization (CERN). This is our initial report on the promising interim results. Material and Methods: 68 patients qualified for endovascular treatment of an acute or chronic aortic dissection. Computed tomography was performed post-operatively to assess aortic remodeling after 1/6/12/24/36 months. Results: the 30-day mortality rate was 4.4%. In 29 cases (43%) unfavorable remodeling was noted in the follow-up. The most important factors leading to unfavorable remodeling were: uncovered re-entry tear including the infra-renal segment, no relining of dissection membranes and insufficient coverage of the descending aorta. We analyzed these factors to develop the CERN protocol. This concept consists of six basic rules: A. cover all entry tears, B. amplify the BMS radial force, C. use the STABILISE technique, D. consider using thrombus plugs, E. avoid stenting the visceral branches, F. spare the intercostal and lumbar side branches. CERN improves the rate of favorable remodeling from 25% to 85% (P = 0.0067). Conclusion: Introduction of the Complete Entry and Re-entry Neutralization protocol improves the rate of favorable remodeling following endovascular treatment of aortic dissection in mid-term follow-up in patients with diffused aortic dissection.

Submitted:  29 December 2019      Accepted:  17 March 2020      Published:  30 March 2020      *Corresponding Author(s):  Arkadiusz Kazimierczak     E-mail:  biker2000@wp.pl Service E-mail this article Add to citation manager E-mail Alert RSS Articles by authors Tomasz Jędrzejczak    Paweł Rynio    Rabih Samad    Anita Rybicka    Agata Krajewska    Piotr Gutowski    Arkadiusz Kazimierczak   

Figure 1.  Study groups and patient selection. The figure shows the selection of treatment options and their compliance with CERN rules. And as a result, the final qualification of patients to the study and control groups together with the final result of treatment.

Table 1.  Risk factors in various surgical interventions non-compliant with the CERN protocol.

Procedures non-compliant with the CERN protocolRisk factorsTEVARPETTICOATSTABILIZEe-PETICOATAEndo-leak type IA0002BBMS inside TEVAR02504CIliac parallel grafts start > 2cm below the RANANA05DTEVAR terminating >10cm above the CT0004EToo little overlap0401FOversizing <5%0601GDistal re-entry tear left uncoveredNA2600HCEFLV > 20 ml02202IInsufficient TL expanding leading to BMS collapseNA700

Table 2.  Discriminant analysis for group epidemiology and type of surgery.

Wilks` Lambda testP-valueStanford type of AD0.4834960.505089Stage of AD (acute/chronic)0.4787310.907974Age0.4787890.891480Gender0.4900040.311117e-Petticoat0.5028220.142628

Figure 2.  Conditions potentially leading to a technical failure. The figure shows examples of all suspicious technical factors that were observed in cases ending in unfavorable remodeling. All presented factors were then subjected to single and multifactor statistical analysis to determine the need for their elimination during endovascular treatment of aortic dissection. These were the following factors. A: Endo-leak type IA (after Cardiac Surgery in type A aortic dissection); B: BMS inside TEVAR (classic deployment); C: Iliac parallel grafts starting > 2 cm below the Renal Arteries; D: TEVAR terminating 10-15 cm above the Celiac Trunk (the lower part of the BMS unsupported- compressed by the FL); E: Too little overlap between devices; F: Oversizing < 5%; G: Iliac re-entry tear left uncovered (lack of e-Petticoat technique in type IIIB AD); H: Contrast Enhanced False Lumen Volume over 20ml; I: Collapsed BMS due to high pressure in FL and insufficient true lumen re-expansion during surgery

Table 3.  Univariate analysis for suspected factors linked to unfavorable remodeling

Suspected technical conditionsnUnfavorable remodelling
(n-29)Favorable remodelling
(n-38)P-valueAEndo-leak type IA (after Cardiac Surgery in TAAD)22 (100%)0 (0%)0.1982BBMS inside TEVAR (classic deployment)2925 (86.2%)4 (13.8%)0.0001CIliac parallel grafts starting > 2 cm below Renal Arteries54 (80%)1 (20%)0.1722DTEVAR terminating > 10 cm over Celiac Trunk (BMS collapse)44 (100%)0 (0%)0.042ETo little overlap between devices53 (60%)2 (40%)0.6498FOversizing < 5%77 (100%)0 (0%)0.0046GDistal re-entry tear in iliac arteries left uncovered2623 (88.5%)3 (11.5%)0.0001HCEFLV > 20 ml2424 (83%)0 (0%)0.00001ICollapsed BMS due to high pressure in FL and insufficient TL re-expansion during surgery75 (71.4%)2 (28.6%)0.2364

Table 4.  Discriminant analysis for all suspected risk factors.

Suspected risk factorsWilks` Lambda testP-valueA) Endo-leak type IA0.1704860.056726B) BMS inside TEVAR0.2518400.000005C) Iliac parallel grafts starting >2 cm below Renal Arteries0.1838860.008157D) TEVAR terminating >10 cm over Celiac Trunk0.1857810.006326E) Too little overlap between devices0.1580730.605945F) Oversizing < 5%0.1718930.045596G) Iliac re-entry tear left uncovered0.1924770.002654H) CEFLV over 20 ml0.2262960.000056I) Insufficient true lumen re-expansion during surgery0.1679580,085040

Figure 3.  CERN rules. The figure summarizes all six conditions for compliance with CERN principles during endovascular treatment of aortic dissection. For an explanation of their significance, see the discussion chapter. A: Cover all entry tears; B: Oversize and amplify BMS radial force; C: Perform True lumen forced ballooning (STABILISE technique); D: Use a thrombus plug; E: Avoid stenting the visceral branches; F: Spare the small branches; TL: true lumen; FL: false lumen

Figure 4.  Examples of favorable remodeling after treatment performed accordingly to the CERN rules (e-Petticoat technique) in type A and B aortic dissection. TAAD - Type A Aortic Dissection; TBAD: Type B Aortic Dissection; A: Initial CTA in TAAD; B: Frame of the Stent-grafts used for e-Petticoat technique (fully comply with CERN rules); C: Favorable remodeling after TAAD (Hybrid arch debranching and e-Petticoat as a Stage procedure); D: Initial CTA in TBAD; E: Frame of the Stent-grafts (e-Petticoat technique performed in compliance with CERN rules); F: Favorable remodeling after TBAD

[1] Akin, I.,Kische, S.,Rehders, T. C.,Ince, H. and Nienaber, C. A. (2010)Acute aortic syndromes.Medicine 38, 450-455. [2] Brunkwall, J.,Lammer, J.,Verhoeven, E. and Taylor, P. (2012)ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.European Journal of Vascular and Endovascular Surgery 44, 31-36. [3] Canaud, L.,Gandet, T.,Sfeir, J.,Ozdemir, B. A.,Solovei, L. and Alric, P. (2019)Risk factors for distal stent graft-induced new entry tear after endovascular repair of thoracic aortic dissection.Journal of Vascular Surgery 69, 1610-1614. [4] Canaud, L.,Ozdemir, B. A.,Patterson, B. O.,Holt, P. J. E.,Loftus, I. M. and Thompson, M. M. (2014)Retrograde aortic dissection after thoracic endovascular aortic repair.Annals of Surgery 260, 389-395. [5] Fanelli, F.,Cannavale, A.,O’Sullivan, G. J.,Gazzetti, M.,Cirelli, C.,Lucatelli, P.,Santoni, M. and Catalano, C. (2016)Endovascular repair of acute and chronic aortic type B dissections: main factors affecting aortic remodeling and clinical outcome.JACC: Cardiovascular Interventions 9, 183-191. [6] Fattori, R.,Cao, P.,De Rango, P.,Czerny, M.,Evangelista, A.,Nienaber, C.,Rousseau, H. and Schepens, M. (2013)Interdisciplinary expert consensus document on management of type B aortic dissection.Journal of the American College of Cardiology 61, 1661-1678. [7] Geisbüsch, S.,Stefanovic, A.,Koruth, J. S.,Lin, H.-M.,Morgello, S.,Weisz, D. J.,Griepp, R. B. and Di Luozzo, G. (2014)Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: an experimental model.The Journal of Thoracic and Cardiovascular Surgery 147, 220-227. [8] Goverde, P.,Grimme, F.,Verbruggen, P. and Reijnen, M. (2013)Covered endovascular reconstruction of aortic bifurcation (CERAB) technique: a new approach in treating extensive aortoiliac occlusive disease.J Cardiovasc Surg (Torino) 54, 383-387. [9] Groot Jebbink, E.,Ter Mors, T. G.,Slump, C. H.,Geelkerken, R. H.,Holewijn, S. and Reijnen, M. M. (2017)In vivo geometry of the kissing stent and covered endovascular reconstruction of the aortic bifurcation configurations in aortoiliac occlusive disease.Vascular 25, 635-641. [10] He, H.,Yao, K.,Nie, W.,Wang, Z.,Liang, Q.,Shu, C. and Dardik, A. (2015)Modified Petticoat technique with pre-placement of a distal bare stent improves early aortic remodeling after complicated acute Stanford type B aortic dissection.European Journal of Vascular and Endovascular Surgery 50, 450-459. [11] Hofferberth, S. C.,Nixon, I. K.,Boston, R. C.,McLachlan, C. S. and Mossop, P. J. (2014)Stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair: the STABILISE concept.The Journal of Thoracic and Cardiovascular Surgery 147, 1240-1245. [12] Hollier, L. H.,Symmonds, J. B.,Pairolero, P. C.,Cherry, K. J.,Hallett, J. W. and Gloviczki, P. (1988)Thoracoabdominal aortic aneurysm repair: analysis of postoperative morbidity.Archives of Surgery 123, 871-875. [13] Hughes, G. C.,Andersen, N. D. and McCann, R. L. (2013)Management of acute type B aortic dissection; ADSORB trial.J Thorac Cardiovasc Surg 149, s158-s162 [14] Jebbink, E. G.,Grimme, F. A.,Goverde, P. C.,van Oostayen, J. A.,Slump, C. H. and Reijnen, M. M. (2015)Geometrical consequences of kissing stents and the Covered Endovascular Reconstruction of the Aortic Bifurcation configuration in an in vitro model for endovascular reconstruction of aortic bifurcation.Journal of Vascular Surgery 61, 1306-1311. [15] Jing-dong, T.,Jun-feng, H.,Ke-qiang, Z.,Wen-zhao, H.,Ming-feng, Y.,Wei-guo, F. and Yu-qi, W. (2011)Emergency endovascular repair of complicated Stanford type B aortic dissections within 24 hours of symptom onset in 30 cases.The Journal of Thoracic and Cardiovascular Surgery 141, 926-931. [16] Kazimierczak, A. and Rynio, P. (2019)Extended Petticoat strategy in type B aortic dissection.European Journal of Vascular and Endovascular Surgery 57, 302. [17] Kazimierczak, A.,Jedrzejczak, T.,Rynio, P. and Waligórski, S. (2018)Favorable remodeling after hybrid arch debranching and modified provisional extension to induce complete attachment technique in type a aortic dissection: A case report.Medicine 97, e12409. [18] Kazimierczak, A.,Rynio, P.,Jędrzejczak, T.,Mokrzycki, K.,Samad, R.,Brykczyński, M.,Rybicka, A.,Zair, L. and Gutowski, P. (2019b)Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection.Journal of Vascular Surgery 70, 1782-1791. [19] Kazimierczak, A.,Rynio, P.,Jędrzejczak, T.,Samad, R.,Rybicka, A. and Gutowski, P. (2019a)Aortic remodeling after extended PETTICOAT technique in acute aortic dissection Type III B.Annals of Vascular Surgery. [20] Kazimierczak, A.,Sledz, M.,Gutowski, P.,Guzicka-Kazimierczak, R.,Cnotliwy, M.,Zeair, S. and Samad, R. (2010)Przydatnosc skali P-POSSUM w prognozowaniu wyników i kosztów leczenia w chirurgii naczyniowej = Efficacy of P-POSSUM calculator in prediction of early results and cost of treatment in vascular surgery.Chirurgia Polska 59-66.(In Polish) [21] Kölbel, T.,Carpenter, S. W.,Lohrenz, C.,Tsilimparis, N.,Larena-Avellaneda, A. and Debus, E. S. (2014)Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique.Journal of Endovascular Therapy 21, 117-122. [22] Kölbel, T.,Lohrenz, C.,Kieback, A.,Diener, H.,Debus, E. S. and Larena-Avellaneda, A. (2013)Distal false lumen occlusion in aortic dissection with a homemade extra-large vascular plug: the candy-plug technique.Journal of Endovascular Therapy 20, 484-489. [23] Kornafel, O.,Baran, B.,Pawlikowska, I.,Laszczyński, P.,Guziński, M. and Sąsiadek, M. (2010)Analysis of anatomical variations of the main arteries branching from the abdominal aorta, with 64-detector computed tomography.Polish journal of radiology 75, 38. [24] Lombardi, J. V.,Cambria, R. P.,Nienaber, C. A.,Chiesa, R.,Mossop, P.,Haulon, S.,Zhou, Q. and Jia, F. (2014)Aortic remodeling after endovascular treatment of complicated type B aortic dissection with the use of a composite device design.Journal of Vascular Surgery 59, 1544-1554. [25] Melissano, G.,Bertoglio, L.,Rinaldi, E.,Mascia, D.,Kahlberg, A.,Loschi, D.,De Luca, M.,Monaco, F. and Chiesa, R. (2018)Satisfactory short-term outcomes of the STABILISE technique for type B aortic dissection.Journal of Vascular Surgery 68, 966-975. [26] Midulla, M.,Renaud, A.,Martinelli, T.,Koussa, M.,Mounier-Vehier, C.,Prat, A. and Beregi, J.-P. (2011)Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up.The Journal of Thoracic and Cardiovascular Surgery 142, 66-72. [27] Molinari, A. C.,Leo, E.,Ferraresi, M.,Ferrari, S. A.,Terzi, A.,Sommaruga, S. and Rossi, G. (2019)Distal extended endovascular aortic repair PETTICOAT: a modified technique to improve false lumen remodeling in acute type B aortic dissection.Annals of Vascular Surgery 59, 300-305. [28] Mossop, P. J.,McLachlan, C. S.,Amukotuwa, S. A. and Nixon, I. K. (2005)Staged endovascular treatment for complicated type B aortic dissection.Nature clinical practice Cardiovascular medicine 2, 316-321. [29] Nienaber, C. A.,Kische, S.,Rousseau, H.,Eggebrecht, H.,Rehders, T. C.,Kundt, G.,Glass, A.,Scheinert, D.,Czerny, M.,Kleinfeldt, T.,Zipfel, B.,Labrousse, L.,Fattori, R. and Ince, H. (2013)Endovascular repair of type B aortic dissection.Circulation: Cardiovascular Interventions 6, 407-416. [30] Rynio, P.,Kazimierczak, A.,Gutowski, P. and Cnotliwy, M. (2017)An unusual case of aortic rupture after deployment of a bare stent in the treatment of aortic dissection in a patient with giant-cell arteritis.Videosurgery and Other Miniinvasive Techniques 12, 194. [31] Sailer, A. M.,Van Kuijk, S. M.,Nelemans, P. J.,Chin, A. S.,Kino, A.,Huininga, M.,Schmidt, J.,Mistelbauer, G.,Bäumler, K. and Chiu, P. (2017)Computed tomography imaging features in acute uncomplicated Stanford type-B aortic dissection predict late adverse events.Circulation: Cardiovascular Imaging 10, e005709. [32] Scali, S. T.,Feezor, R. J.,Chang, C. K.,Stone, D. H.,Hess, P. J.,Martin, T. D.,Huber, T. S. and Beck, A. W. (2013)Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration.Journal of Vascular Surgery 58, 10-17.e11. [33] Sobocinski, J.,Dias, N. V.,Clough, R. and HAULON, S. (2014)Exploring the use of bare stents in the treatment of type B dissection.Suppl Endovasc Today Eur 4, 17-21. [34] Sobocinski, J.,Lombardi, J. V.,Dias, N. V.,Berger, L.,Zhou, Q.,Jia, F.,Resch, T. and Haulon, S. (2016)Volume analysis of true and false lumens in acute complicated type B aortic dissections after thoracic endovascular aortic repair with stent grafts alone or with a composite device design.Journal of Vascular Surgery 63, 1216-1224. [35] Spear, R.,Hertault, A.,Van Calster, K.,Settembre, N.,Delloye, M.,Azzaoui, R.,Sobocinski, J.,Fabre, D.,Tyrrell, M. and Haulon, S. (2018)Complex endovascular repair of postdissection arch and thoracoabdominal aneurysms.Journal of Vascular Surgery 67, 685-693. [36] Van Bogerijen, G. H.,Tolenaar, J. L.,Rampoldi, V.,Moll, F. L.,Van Herwaarden, J. A.,Jonker, F. H.,Eagle, K. A. and Trimarchi, S. (2014)Predictors of aortic growth in uncomplicated type B aortic dissection.Journal of Vascular Surgery 59, 1134-1143. [37] Verhoeven, E. L. (2019)Extended petticoat strategy in aortic dissection: when is it too much, or not enough?European Journal of Vascular and Endovascular Surgery 57, 303. [38] VIRTUE Registry Investigators(2014)Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE registry.European Journal of Vascular and Endovascular Surgery 48, 363-371. No Suggested Reading articles found! Viewed Full text


Abstract

Cited

  Shared      Discussed