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“Cheese Wire” Fenestration of Dissection Intimal Flap to Facilitate Thoracic Endovascular Aortic Repair in Chronic Dissection
BRIEF REPORT
“Cheese Wire” Fenestration of Dissection Intimal Flap to Facilitate Thoracic Endovascular Aortic Repair in Chronic Dissection Shinichi Iwakoshi, MD, Claire A. Watkins, MD, Yukihisa Ogawa, MD, Michael Fischbein, MD, Anson Lee, MD, Jason T. Lee, MD, William Hiesinger, MD, and Michael D. Dake, MD
ABSTRACT Thoracic endovascular aortic repair (TEVAR) for aneurysmal chronic dissection is often complicated by retrograde filling of the false lumen and dissected distal landing zone. A “cheese wire”-style fenestration of the dissection intimal flap can create a landing zone facilitating TEVAR. This technique successfully aided TEVAR in 3 patients with an average age of 57.3 years. Complications included type III endoleak requiring relining and renal artery occlusion requiring stent placement. Average duration of clinical follow-up was 19 ± 4 months. Imaging follow-up was 8 ± 10 months. All patients have survived for more than 1 year without aneurysm enlargement.
ABBREVIATION TEVAR ¼ thoracic endovascular aortic repair
Over the past 20 years, thoracic endovascular aortic repair (TEVAR) for complicated Stanford type B aortic dissection (1) has proven to be an effective therapy for a morbid disease. TEVAR for aneurysmal chronic dissection is often complicated by retrograde filling of the false lumen, eliminating a landing zone of normal aorta. Longitudinal septectomy in chronic, abdominal aortic dissection to facilitate endovascular aneurysm repair has been previously reported (2). This technique was applied to the thoracic aorta to
create a suitable, single-lumen landing zone in 3 cases. This report describes the technique and possible complications.
MATERIAL AND METHODS Procedural and research consents were obtained. This retrospective chart review was approved by the institutional review board.
Technique From the Departments of Cardiothoracic Surgery (S.I., C.A.W., Y.O., M.F., A.L., W.H.) and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94035; and Departments of Medical Imaging, Surgery, and Medicine (M.D.D.), University of Arizona, Tucson, Arizona. Received March 15, 2019; final revision received June 7, 2019; accepted June 8, 2019. Address correspondence to S.I.; E-mail: [email protected] None of the authors have identified a conflict of interest. Figures E1 and E2 can be found by accessing the online version of this article on www.jvir.org and clicking on the Supplemental Material tab. © SIR, 2019. Published by Elsevier, Inc. All rights reserved. J Vasc Interv Radiol 2019; ▪:1–5 https://doi.org/10.1016/j.jvir.2019.06.004
Vascular access was obtained in both common femoral arteries: one percutaneously for angiographic assistance, the other by surgical exposure. Simultaneous aortogram was performed through pigtail catheters in both the aortic true and false lumen (Fig 1a). Subsequently, a 21-gauge, 61-cmlong Chiba needle and a stainless-steel, curved TIPS cannula (Rosch-Uchida TIPS set; Cook Medical, Bloomington, Indiana) were coaxially introduced. In a projection parallel to the dissection intimal flap, the cannula was directed from the true lumen, through the intimal flap, into the false lumen (Fig E1a [available online on the article’s Supplemental Material page at www.jvir.org]). An 0.014-inch guidewire (BMW; Abbott Vascular, Santa Clara, California) and
2 ▪ “Cheese Wire” Fenestration in Distal Thoracic Aorta
Iwakoshi et al ▪ JVIR
Figure 1. Aortography of the aortic true lumen before (a) and after (b) longitudinal fenestration of the dissection intimal flap.
catheter were then advanced across the fenestration. An angiogram confirmed catheter presence in the false lumen. The newly created fenestration was dilated using a 4-mm angioplasty balloon. Subsequently, a trilobed snare was used to capture the BMW wire from the false lumen (Fig E1b [available online on the article’s Supplemental Material page at www.jvir.org]). This established throughand-through access from each femoral artery across the intimal flap. The fenestration was again dilated using a 10mm angioplasty balloon (Fig E1c [available online on the article’s Supplemental Material page at www.jvir.org]). An angiogram from the true lumen opacified the true lumen exclusively (Fig E1d [available online on the article’s Supplemental Material page at www.jvir.org]). Under tension applied at both ends of the guidewire, a back-and-forth see-sawing motion of the wire created a longitudinal septectomy starting 5 cm above the celiac trunk and extending to the level of the celiac artery (in 1 case to the superior mesenteric artery) (Fig E1e–g [available online on the article’s Supplemental Material page at www.jvir.org]). Aortography from the true lumen demonstrated a generous septectomy and good communication between true and false lumens, with simultaneous contrast opacification (Fig 1b, Fig E1h [available online on the article’s Supplemental Material page at www.jvir.org]). Then, standard TEVAR was performed using the single-lumen, supraceliac segment as a distal landing zone.
CTAG endograft (W. L .Gore and Associates, Flagstaff, Arizona). She had recently undergone bowel resection, complicated by prolonged supplemental tube feeding and total parenteral nutrition. She was not a surgical candidate due to poor nutrition and functional status. “Cheese wire” fenestration and TEVAR were successfully performed as described above. The aortic diameter 2 cm above the celiac trunk was 52 mm; therefore, extension of the distal landing zone to the level of the superior mesenteric artery was necessary. Consequently, the celiac artery was embolized, and multiple stent grafts (TX alpha, 28 x 109 mm, 36 x 113 mm, and 46 x 125 mm; Cook Medical) were placed. The distal stent graft was deployed just proximal to the superior mesenteric artery. Completion aortography demonstrated a type Ib endoleak. Fluoroscopy time was 38 minutes. The patient had an uneventful postoperative course. Postoperative computed tomography (CT) revealed a type Ib endoleak (Fig 2, Fig E2a [available online on the article’s Supplemental Material page at www.jvir.org]), which resolved spontaneously by 6-month follow-up (Fig E2b [available online on the article’s Supplemental Material page at www.jvir.org]). This patient progressed to have abdominal aorta repair at 18 months and was alive with demonstrated shrinking of her thoracic aneurysm at 24 months.
Case 2 RESULTS Case 1 A 47-year-old woman with Loeys-Dietz syndrome, aortic arch aneurysm, and chronic Stanford type B aortic dissection presented with expansion of her distal descending thoracic aorta to 6.7 cm. She had previously undergone total arch repair with frozen elephant trunk, using a 21 x100 mm
A 75-year-old man with a history of type A aortic dissection repair presented with aneurysmal degeneration of residual dissection in his descending aorta. Contrast-enhanced CT showed a 7.4-cm proximal descending thoracic aorta and marked true lumen collapse. Comorbidities included chronic lung disease, coronary artery disease, atrial fibrillation, and hypertension. The patient was unfit for open surgery due to frailty and comorbidities.
Volume ▪ ▪ Number ▪ ▪ Month ▪ 2019
3
lumen compression was seen through the thoracoabdominal aorta (Fig 3a), and his left renal artery was supplied by the aortic false lumen (Fig 3b). Having refused open surgery, the patient was offered endovascular repair. Cheese wire fenestration was performed as described above. A 31 x 100 mm CTAG thoracic endoprosthesis (W. L. Gore) was deployed just distal to the left subclavian artery within the surgical elephant trunk. Subsequent endografts—34 x 150 mm and 40 x 200 mm—were implanted to the level of the celiac artery with generous overlapping. Completion aortography demonstrated aneurysmal exclusion without endoleak. Fluoroscopy time was 45 minutes. This patient’s hospital course was complicated by left renal artery occlusion revealed on CT angiography on postoperative day 4 (Fig 3c, d). After TEVAR, shrinking and compression of the distal false lumen impinged on the original of the left renal artery. This was treated with an 8 x 20 mm Everflex (Medtronic, Inc, Plymouth, Minnesota) and a 7 x 29 mm Gore VBX stent, from the mid renal artery into the aortic true lumen. Pre-discharge CT angiography demonstrated a patent left renal artery and no aortic complications (Fig 4). At 1-month follow-up, CT angiography demonstrated a stable descending aortic aneurysm with no endoleak. The patient was alive at 16 months; however, imaging is unavailable.
DISCUSSION
Figure 2. Postoperative CT of Case 1 showing a type 1b endoleak (white arrow) that did not communicate with the aneurysm (white arrowhead).
Cheese wire fenestration was successfully performed as described above. A 45 x 200 mm CTAG thoracic endoprosthesis (W. L. Gore) was deployed in aortic zone 3. Two subsequent stent grafts—45 x 200 mm and 45 x 100 mm—were placed. The distal extent of TEVAR was just above the celiac trunk. Completion aortography demonstrated a good stent graft positioning and no endoleak. Fluoroscopy time was 79 minutes. Postoperative CT scan demonstrated a type III endoleak, which was successfully relined. The patient’s hospital course was otherwise unremarkable. CT angiography after TEAVR relining, and at 1 month, demonstrated good stent graft expansion, a stable descending aortic aneurysm, and no endoleak. Although the patient was alive at 24 months, no surveillance imaging beyond 1 month was available.
Case 3 A 49-year-old man with a history of ascending and aortic arch replacement with elephant trunk for type A aortic dissection presented with a new onset of shortness of breath. He was found to have aneurysmal degeneration of residual dissection in his descending thoracic aorta with a diameter of 6.2 cm, as well as a persistent intimal tear in the distal aortic arch. True
TEVAR for chronic aortic dissection is often hampered by a thick and organized intimal flap restricting stent graft expansion. This can allow retrograde perfusion of the descending thoracic aortic false lumen and type Ib endoleak. To control blood flow in the false lumen, devices such as the Knickerbocker stent (3) or Candy Plug (4,5) have been used. Balloon septal rupture has also been described to create a landing zone within the full diameter of the distal thoracic aorta (6). Cheese wire fenestration is an alternative technique to manage a thickened intimal flap and prevent retrograde false lumen filling. Case reports applying this technique to the infrarenal (2,7,8) and thoracoabdominal aorta (9) have described successful endografting in chronic dissection with aneurysm formation. An advantage of this technique is the reliance on standard off-the-shelf products. Other techniques using the Knickerbocker stent or Candy Plug require custom-designed or custom-made specialty devices. Additionally, the cheese wire technique may offer a decreased risk for rupture or stent graft-induced new entry compared to balloon angioplasty rupture of the dissection septum. The notable complications related to this technique include distal embolization, free flap migration, and prolapsing intimal flap tissue. A previous report also described these potential hazards (9). A possible cause of renal occlusion in the third case was distal embolization of intima. The more likely cause was static obstruction caused by an abrupt change in the hemodynamic balance of the true and false lumen, therefore narrowing the origin of the left renal
4 ▪ “Cheese Wire” Fenestration in Distal Thoracic Aorta
Iwakoshi et al ▪ JVIR
Figure 3. CT images of Case 3. (a) Preoperative: dilated aortic false lumen at the celiac artery. (b) Preoperative: left renal artery supplied by the aortic false lumen. (c) Postoperative: expansion of aortic true lumen and compression of aortic false lumen at the celiac artery. (d) Postoperative: left renal artery occlusion.
Figure 4. CT image after renal artery stenting in Case 3.
artery. Supporting this hypothesis is the “cul de sac” shape of the left renal artery and its origin from the false lumen. Renal artery stenting resolved the static obstruction and
successfully treated this complication. Endovascular surgeons should remain aware of the possibility for embolization or migration of septal tissue and resultant malperfusion with this technique. The characterization of post-procedure “type Ib” endoleak should be carefully considered in TEVAR for chronic dissection. Although some retrograde filling of the false lumen was recognized in Case 1, it was distal to an area of good stent graft seal without filling of the false lumen at the level of the aneurysm. This has been observed in association with the controlled balloon septal rupture technique as well. Technical considerations should include the compliance of the intimal flap and comparative size of the true and false lumen. The fenestrations in this report were performed from true to false lumen. It is unknown if the reverse direction would be better. In anatomy with true lumen compression and a large false lumen, directing the fenestration needle toward the larger false lumen may be safer. In these chronic dissection cases, the membrane was relatively immobile and did not require a fixation. However, fixation maybe necessary with more compliant dissection flaps. This consideration likely limits the use of this technique to chronic, rather than acute or subacute, dissections. The absence of an adequate distal landing zone in a degenerated, chronic type B dissection often limits the possibility for, or quality of, TEVAR. Cheese wire fenestration
Volume ▪ ▪ Number ▪ ▪ Month ▪ 2019
offers a technical solution to this common problem, provided the total aortic diameter of the distal landing zone is appropriate for TEVAR with standard endografts. In 3 patients, good anatomic results with manageable complications were obtained. These 3 cases demonstrate that an adequate distal seal can be achieved in TEVAR for chronic type B dissection, using the total aortic diameter after septal fenestration. In conclusion, cheese wire fenestration can be used to create a distal landing zone for TEVAR in challenging chronic aortic dissection. Further experience to elucidate possible indications, complications, and durability is necessary.
REFERENCES 1. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aoritc dissection. N Engl J Med 1999; 340: 1546–1552. 2. Gissler MC, Ogawa Y, Lee JT, et al. Percutaneous septectomy in chronic dissection with abdominal aortic aneurysm creates uniluminal neck for EVAR. Cardiovasc Inter Rad 2017; 40:1522–1528.
5
3. Kolbel T, Carpenter SW, Lohrenz C, et al. Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique. J Endovasc Ther 2014; 21:117–122. 4. Kolbel 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; 20:484–489. 5. Ogawa Y, Nishimaki H, Chiba K, et al. Candy-Plug technique using an excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection. J Endovasc Ther 2016; 23: 483–486. 6. Faure EM, El Batti S, Abou Rjeili M, et al. Mid-term outcomes of stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) in acute type B aortic dissection. Eur J Vasc Endovasc 2018; 56:209–215. 7. Tashiro J, Baqai A, Goldstein LJ, et al. “Cheese wire” fenestration of a chronic aortic dissection flap for endovascular repair of a contained aneurysm rupture. J Vasc Surg 2014; 60:497–499. 8. Kos S, Gurke L, Jacob AL. A novel fenestration technique for abdominal aortic dissection membranes using a combination of a needle re-entry catheter and the “cheese-wire” technique. Cardiovasc Inter Rad 2011; 34:1296–1302. 9. Barshes NR, Gravereaux EC, Semel M, et al. Endovascular longitudinal fenestration and stent graft placement for treatment of aneurysms developing after chronic type B aortic dissection. J Vasc Surg 2015; 61: 1366–1369.
5.e1 ▪ “Cheese Wire” Fenestration in Distal Thoracic Aorta
Iwakoshi et al ▪ JVIR
Figure E1. Fenestration of intimal flap. (a) Needle (white arrow) crossing septum at the level of the diaphragm. (b) Snaring of the 0.014inch guidewire (white arrow) by a tri-lobe snare in the false lumen. (c) Fenestration dilation with a 10-mm angioplasty balloon. (d–g) Longitudinal wire fenestration. (h) Post-fenestration aortography demonstrating a single aortic lumen excl.
Volume ▪ ▪ Number ▪ ▪ Month ▪ 2019
Figure E1. (continued).
Figure E2. Postoperative CT of Case 1 at 1 (a) and 6 (b) months, demonstrating resolution of the type Ib endoleak.
5.e2
“Cheese Wire” Fenestration of Dissection Intimal Flap to Facilitate Thoracic Endovascular Aortic Repair in Chronic Dissection Shinichi Iwakoshi, MD, Claire A. Watkins, MD, Yukihisa Ogawa, MD, Michael Fischbein, MD, Anson Lee, MD, Jason T. Lee, MD, William Hiesinger, MD, and Michael D. Dake, MD
ABSTRACT Thoracic endovascular aortic repair (TEVAR) for aneurysmal chronic dissection is often complicated by retrograde filling of the false lumen and dissected distal landing zone. A “cheese wire”-style fenestration of the dissection intimal flap can create a landing zone facilitating TEVAR. This technique successfully aided TEVAR in 3 patients with an average age of 57.3 years. Complications included type III endoleak requiring relining and renal artery occlusion requiring stent placement. Average duration of clinical follow-up was 19 ± 4 months. Imaging follow-up was 8 ± 10 months. All patients have survived for more than 1 year without aneurysm enlargement.
ABBREVIATION TEVAR ¼ thoracic endovascular aortic repair
Over the past 20 years, thoracic endovascular aortic repair (TEVAR) for complicated Stanford type B aortic dissection (1) has proven to be an effective therapy for a morbid disease. TEVAR for aneurysmal chronic dissection is often complicated by retrograde filling of the false lumen, eliminating a landing zone of normal aorta. Longitudinal septectomy in chronic, abdominal aortic dissection to facilitate endovascular aneurysm repair has been previously reported (2). This technique was applied to the thoracic aorta to
create a suitable, single-lumen landing zone in 3 cases. This report describes the technique and possible complications.
MATERIAL AND METHODS Procedural and research consents were obtained. This retrospective chart review was approved by the institutional review board.
Technique From the Departments of Cardiothoracic Surgery (S.I., C.A.W., Y.O., M.F., A.L., W.H.) and Vascular Surgery (J.T.L.), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94035; and Departments of Medical Imaging, Surgery, and Medicine (M.D.D.), University of Arizona, Tucson, Arizona. Received March 15, 2019; final revision received June 7, 2019; accepted June 8, 2019. Address correspondence to S.I.; E-mail: [email protected] None of the authors have identified a conflict of interest. Figures E1 and E2 can be found by accessing the online version of this article on www.jvir.org and clicking on the Supplemental Material tab. © SIR, 2019. Published by Elsevier, Inc. All rights reserved. J Vasc Interv Radiol 2019; ▪:1–5 https://doi.org/10.1016/j.jvir.2019.06.004
Vascular access was obtained in both common femoral arteries: one percutaneously for angiographic assistance, the other by surgical exposure. Simultaneous aortogram was performed through pigtail catheters in both the aortic true and false lumen (Fig 1a). Subsequently, a 21-gauge, 61-cmlong Chiba needle and a stainless-steel, curved TIPS cannula (Rosch-Uchida TIPS set; Cook Medical, Bloomington, Indiana) were coaxially introduced. In a projection parallel to the dissection intimal flap, the cannula was directed from the true lumen, through the intimal flap, into the false lumen (Fig E1a [available online on the article’s Supplemental Material page at www.jvir.org]). An 0.014-inch guidewire (BMW; Abbott Vascular, Santa Clara, California) and
2 ▪ “Cheese Wire” Fenestration in Distal Thoracic Aorta
Iwakoshi et al ▪ JVIR
Figure 1. Aortography of the aortic true lumen before (a) and after (b) longitudinal fenestration of the dissection intimal flap.
catheter were then advanced across the fenestration. An angiogram confirmed catheter presence in the false lumen. The newly created fenestration was dilated using a 4-mm angioplasty balloon. Subsequently, a trilobed snare was used to capture the BMW wire from the false lumen (Fig E1b [available online on the article’s Supplemental Material page at www.jvir.org]). This established throughand-through access from each femoral artery across the intimal flap. The fenestration was again dilated using a 10mm angioplasty balloon (Fig E1c [available online on the article’s Supplemental Material page at www.jvir.org]). An angiogram from the true lumen opacified the true lumen exclusively (Fig E1d [available online on the article’s Supplemental Material page at www.jvir.org]). Under tension applied at both ends of the guidewire, a back-and-forth see-sawing motion of the wire created a longitudinal septectomy starting 5 cm above the celiac trunk and extending to the level of the celiac artery (in 1 case to the superior mesenteric artery) (Fig E1e–g [available online on the article’s Supplemental Material page at www.jvir.org]). Aortography from the true lumen demonstrated a generous septectomy and good communication between true and false lumens, with simultaneous contrast opacification (Fig 1b, Fig E1h [available online on the article’s Supplemental Material page at www.jvir.org]). Then, standard TEVAR was performed using the single-lumen, supraceliac segment as a distal landing zone.
CTAG endograft (W. L .Gore and Associates, Flagstaff, Arizona). She had recently undergone bowel resection, complicated by prolonged supplemental tube feeding and total parenteral nutrition. She was not a surgical candidate due to poor nutrition and functional status. “Cheese wire” fenestration and TEVAR were successfully performed as described above. The aortic diameter 2 cm above the celiac trunk was 52 mm; therefore, extension of the distal landing zone to the level of the superior mesenteric artery was necessary. Consequently, the celiac artery was embolized, and multiple stent grafts (TX alpha, 28 x 109 mm, 36 x 113 mm, and 46 x 125 mm; Cook Medical) were placed. The distal stent graft was deployed just proximal to the superior mesenteric artery. Completion aortography demonstrated a type Ib endoleak. Fluoroscopy time was 38 minutes. The patient had an uneventful postoperative course. Postoperative computed tomography (CT) revealed a type Ib endoleak (Fig 2, Fig E2a [available online on the article’s Supplemental Material page at www.jvir.org]), which resolved spontaneously by 6-month follow-up (Fig E2b [available online on the article’s Supplemental Material page at www.jvir.org]). This patient progressed to have abdominal aorta repair at 18 months and was alive with demonstrated shrinking of her thoracic aneurysm at 24 months.
Case 2 RESULTS Case 1 A 47-year-old woman with Loeys-Dietz syndrome, aortic arch aneurysm, and chronic Stanford type B aortic dissection presented with expansion of her distal descending thoracic aorta to 6.7 cm. She had previously undergone total arch repair with frozen elephant trunk, using a 21 x100 mm
A 75-year-old man with a history of type A aortic dissection repair presented with aneurysmal degeneration of residual dissection in his descending aorta. Contrast-enhanced CT showed a 7.4-cm proximal descending thoracic aorta and marked true lumen collapse. Comorbidities included chronic lung disease, coronary artery disease, atrial fibrillation, and hypertension. The patient was unfit for open surgery due to frailty and comorbidities.
Volume ▪ ▪ Number ▪ ▪ Month ▪ 2019
3
lumen compression was seen through the thoracoabdominal aorta (Fig 3a), and his left renal artery was supplied by the aortic false lumen (Fig 3b). Having refused open surgery, the patient was offered endovascular repair. Cheese wire fenestration was performed as described above. A 31 x 100 mm CTAG thoracic endoprosthesis (W. L. Gore) was deployed just distal to the left subclavian artery within the surgical elephant trunk. Subsequent endografts—34 x 150 mm and 40 x 200 mm—were implanted to the level of the celiac artery with generous overlapping. Completion aortography demonstrated aneurysmal exclusion without endoleak. Fluoroscopy time was 45 minutes. This patient’s hospital course was complicated by left renal artery occlusion revealed on CT angiography on postoperative day 4 (Fig 3c, d). After TEVAR, shrinking and compression of the distal false lumen impinged on the original of the left renal artery. This was treated with an 8 x 20 mm Everflex (Medtronic, Inc, Plymouth, Minnesota) and a 7 x 29 mm Gore VBX stent, from the mid renal artery into the aortic true lumen. Pre-discharge CT angiography demonstrated a patent left renal artery and no aortic complications (Fig 4). At 1-month follow-up, CT angiography demonstrated a stable descending aortic aneurysm with no endoleak. The patient was alive at 16 months; however, imaging is unavailable.
DISCUSSION
Figure 2. Postoperative CT of Case 1 showing a type 1b endoleak (white arrow) that did not communicate with the aneurysm (white arrowhead).
Cheese wire fenestration was successfully performed as described above. A 45 x 200 mm CTAG thoracic endoprosthesis (W. L. Gore) was deployed in aortic zone 3. Two subsequent stent grafts—45 x 200 mm and 45 x 100 mm—were placed. The distal extent of TEVAR was just above the celiac trunk. Completion aortography demonstrated a good stent graft positioning and no endoleak. Fluoroscopy time was 79 minutes. Postoperative CT scan demonstrated a type III endoleak, which was successfully relined. The patient’s hospital course was otherwise unremarkable. CT angiography after TEAVR relining, and at 1 month, demonstrated good stent graft expansion, a stable descending aortic aneurysm, and no endoleak. Although the patient was alive at 24 months, no surveillance imaging beyond 1 month was available.
Case 3 A 49-year-old man with a history of ascending and aortic arch replacement with elephant trunk for type A aortic dissection presented with a new onset of shortness of breath. He was found to have aneurysmal degeneration of residual dissection in his descending thoracic aorta with a diameter of 6.2 cm, as well as a persistent intimal tear in the distal aortic arch. True
TEVAR for chronic aortic dissection is often hampered by a thick and organized intimal flap restricting stent graft expansion. This can allow retrograde perfusion of the descending thoracic aortic false lumen and type Ib endoleak. To control blood flow in the false lumen, devices such as the Knickerbocker stent (3) or Candy Plug (4,5) have been used. Balloon septal rupture has also been described to create a landing zone within the full diameter of the distal thoracic aorta (6). Cheese wire fenestration is an alternative technique to manage a thickened intimal flap and prevent retrograde false lumen filling. Case reports applying this technique to the infrarenal (2,7,8) and thoracoabdominal aorta (9) have described successful endografting in chronic dissection with aneurysm formation. An advantage of this technique is the reliance on standard off-the-shelf products. Other techniques using the Knickerbocker stent or Candy Plug require custom-designed or custom-made specialty devices. Additionally, the cheese wire technique may offer a decreased risk for rupture or stent graft-induced new entry compared to balloon angioplasty rupture of the dissection septum. The notable complications related to this technique include distal embolization, free flap migration, and prolapsing intimal flap tissue. A previous report also described these potential hazards (9). A possible cause of renal occlusion in the third case was distal embolization of intima. The more likely cause was static obstruction caused by an abrupt change in the hemodynamic balance of the true and false lumen, therefore narrowing the origin of the left renal
4 ▪ “Cheese Wire” Fenestration in Distal Thoracic Aorta
Iwakoshi et al ▪ JVIR
Figure 3. CT images of Case 3. (a) Preoperative: dilated aortic false lumen at the celiac artery. (b) Preoperative: left renal artery supplied by the aortic false lumen. (c) Postoperative: expansion of aortic true lumen and compression of aortic false lumen at the celiac artery. (d) Postoperative: left renal artery occlusion.
Figure 4. CT image after renal artery stenting in Case 3.
artery. Supporting this hypothesis is the “cul de sac” shape of the left renal artery and its origin from the false lumen. Renal artery stenting resolved the static obstruction and
successfully treated this complication. Endovascular surgeons should remain aware of the possibility for embolization or migration of septal tissue and resultant malperfusion with this technique. The characterization of post-procedure “type Ib” endoleak should be carefully considered in TEVAR for chronic dissection. Although some retrograde filling of the false lumen was recognized in Case 1, it was distal to an area of good stent graft seal without filling of the false lumen at the level of the aneurysm. This has been observed in association with the controlled balloon septal rupture technique as well. Technical considerations should include the compliance of the intimal flap and comparative size of the true and false lumen. The fenestrations in this report were performed from true to false lumen. It is unknown if the reverse direction would be better. In anatomy with true lumen compression and a large false lumen, directing the fenestration needle toward the larger false lumen may be safer. In these chronic dissection cases, the membrane was relatively immobile and did not require a fixation. However, fixation maybe necessary with more compliant dissection flaps. This consideration likely limits the use of this technique to chronic, rather than acute or subacute, dissections. The absence of an adequate distal landing zone in a degenerated, chronic type B dissection often limits the possibility for, or quality of, TEVAR. Cheese wire fenestration
Volume ▪ ▪ Number ▪ ▪ Month ▪ 2019
offers a technical solution to this common problem, provided the total aortic diameter of the distal landing zone is appropriate for TEVAR with standard endografts. In 3 patients, good anatomic results with manageable complications were obtained. These 3 cases demonstrate that an adequate distal seal can be achieved in TEVAR for chronic type B dissection, using the total aortic diameter after septal fenestration. In conclusion, cheese wire fenestration can be used to create a distal landing zone for TEVAR in challenging chronic aortic dissection. Further experience to elucidate possible indications, complications, and durability is necessary.
REFERENCES 1. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aoritc dissection. N Engl J Med 1999; 340: 1546–1552. 2. Gissler MC, Ogawa Y, Lee JT, et al. Percutaneous septectomy in chronic dissection with abdominal aortic aneurysm creates uniluminal neck for EVAR. Cardiovasc Inter Rad 2017; 40:1522–1528.
5
3. Kolbel T, Carpenter SW, Lohrenz C, et al. Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique. J Endovasc Ther 2014; 21:117–122. 4. Kolbel 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; 20:484–489. 5. Ogawa Y, Nishimaki H, Chiba K, et al. Candy-Plug technique using an excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection. J Endovasc Ther 2016; 23: 483–486. 6. Faure EM, El Batti S, Abou Rjeili M, et al. Mid-term outcomes of stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) in acute type B aortic dissection. Eur J Vasc Endovasc 2018; 56:209–215. 7. Tashiro J, Baqai A, Goldstein LJ, et al. “Cheese wire” fenestration of a chronic aortic dissection flap for endovascular repair of a contained aneurysm rupture. J Vasc Surg 2014; 60:497–499. 8. Kos S, Gurke L, Jacob AL. A novel fenestration technique for abdominal aortic dissection membranes using a combination of a needle re-entry catheter and the “cheese-wire” technique. Cardiovasc Inter Rad 2011; 34:1296–1302. 9. Barshes NR, Gravereaux EC, Semel M, et al. Endovascular longitudinal fenestration and stent graft placement for treatment of aneurysms developing after chronic type B aortic dissection. J Vasc Surg 2015; 61: 1366–1369.
5.e1 ▪ “Cheese Wire” Fenestration in Distal Thoracic Aorta
Iwakoshi et al ▪ JVIR
Figure E1. Fenestration of intimal flap. (a) Needle (white arrow) crossing septum at the level of the diaphragm. (b) Snaring of the 0.014inch guidewire (white arrow) by a tri-lobe snare in the false lumen. (c) Fenestration dilation with a 10-mm angioplasty balloon. (d–g) Longitudinal wire fenestration. (h) Post-fenestration aortography demonstrating a single aortic lumen excl.
Volume ▪ ▪ Number ▪ ▪ Month ▪ 2019
Figure E1. (continued).
Figure E2. Postoperative CT of Case 1 at 1 (a) and 6 (b) months, demonstrating resolution of the type Ib endoleak.
5.e2