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Hybrid Repair of Type II Dissecting Thoracoabdominal Aneurysm Using Amplatzer Vascular Plugs for Entry Tear Closure
Case Reports Hybrid Repair of Type II Dissecting Thoracoabdominal Aneurysm Using Amplatzer Vascular Plugs for Entry Tear Closure Rapha€el Coscas,1,2 Clement Capdevila,1,2 Giovanni Colacchio,3 Olivier Go€eau-Brissonniere,1,2 and Marc Coggia,1,2 Boulogne-Billancourt and Paris, France, and San Giovanni Rotondo, Italy
Endovascular repair of chronic aortic dissections (CAD) intend to promote false lumen thrombosis (FLT). This article describes a technique using Amplatzer vascular plugs (AVPs) for entry tear closure of CAD. A 70-year-old man presented with a type II dissecting thoracoabdominal aneurysm. Computed tomography scan showed a very tight true lumen, partial FLT, and 2 entry tears at the level of the left subclavian artery and the visceral aorta, respectively. During a first procedure, aortic debranching was performed using the ascending aorta as bypass inflow. In a second intervention entry tears were closed using AVPs protected by short stent grafts. Technical success was achieved. No paraplegia occurred. Eighteen months later, FLT was complete and aortic diameter decreased. Entry tear closure using AVPs is feasible and allows FLT. Further reports are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify technical aspects of the procedure.
Partial false lumen thrombosis (FLT) of chronic aortic dissection (CAD) is associated with increased mortality.1,2 Currently available techniques intending to promote complete FLT achieve mitigating results.3,4 Open surgical repair carries a high risk of mortality and paraplegia,5,6 and technical issues and late failures have been largely described with stent-graft exclusion.3,4 This article reports a new
Conflict of interest: None. 1 Department of Vascular Surgery, Ambroise Pare University Hospital, Boulogne-Billancourt, France. 2 Faculte de Medecine Paris-Ile de France-Ouest, University Versailles Saint Quentin en Yvelines, Paris, France. 3 Department of Vascular Surgery M.A.S., Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
Correspondence to: Rapha€el Coscas, MD, Department of Vascular Surgery, Ambroise Pare University Hospital, 9 Avenue Charles de Gaulle, 92104 Boulogne Cedex, France; E-mail: [email protected] Ann Vasc Surg 2013; 27: 972.e1e972.e5 http://dx.doi.org/10.1016/j.avsg.2013.03.004 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: June 5, 2012; manuscript accepted: March 4, 2013.
technique using Amplatzer vascular plugs (AVPs) and short stent grafts to achieve FLT of a type II dissecting thoracoabdominal aortic aneurysm (TAAA).
CASE REPORT A 70-year-old man presented with an asymptomatic type II dissecting TAAA. Seventeen years ago he was managed medically for a type B aortic dissection in another center. Computed tomography (CT) scan (Fig. 1) showed a type II dissecting TAAA extending from the left subclavian artery (LSCA) to the left iliac bifurcation. Maximum aortic diameter was 63 mm at the level of the visceral aorta. The celiac artery, the superior mesenteric artery, and the right renal artery were perfused through the true lumen, whereas the left renal artery was perfused through the false lumen. The true lumen was extremely reduced through the whole TAAA, with an oval section on axial cuts (12 33 mm) and a thick intimal flap. Two entry tears were identified: one was located just below the left subclavian artery (LSCA; 11 mm in diameter) and the other was at the level of the left renal artery (7 mm in diameter). The patient rejected open surgical repair because of the risk
972.e1
972.e2 Case reports
Fig. 1. Preoperative CT scan revealed partial false lumen (FL) thrombosis. (A) The proximal entry tear located just below the left subclavian artery (arrow). (B) The true lumen (TL) was extremely reduced through the whole
Fig. 2. Schematic representation of the preoperative (A) and postoperative (B) aspect of the repair. of paraplegia. An endovascular repair sparing most intercostal and lumbar arteries was then decided. Two procedural steps were planned. The first step consisted of abdominal trunks debranching from the ascending aorta (Fig. 2). A 10-mm Dacron tube graft was implanted using a videoscopic approach and side-bitting clamping of the ascending aorta.7 Three 7-mm polytetrafluoroethylene grafts were sutured to the Dacron tube, and the celiac artery, the superior mesenteric artery, and both renal arteries were revascularized. At day 1, systematic echocardiography showed an asymptomatic ascending aortic dissection. The patient was transferred to the cardiac department for emergent surgical repair. An entry tear was located at the heel of the clamping zone. Coronary arteries were not involved and the dissection was limited to the ascending aorta. The ascending aorta was replaced by a supracoronary tube graft and the debranching graft was reimplanted in the tube. The procedure was uneventful and the patient was discharged to a rehabilitation center. Four months later, the second step consisted of left supra-aortic trunks debranching and concomitant endovascular occlusion of intimal entry tears. A right-to-left crossover subclavian bypass with direct reimplantation
Annals of Vascular Surgery
TAAA with an oval section on axial cuts (12 33 mm) and a thick intimal flap. (C) The other entry tear was located at the level of the left renal artery (arrow).
of the left carotid artery was performed. Through femoral accesses via groin incisions, both proximal and distal entry tears were easily catheterized with a vertebral and a C2 catheter, respectively. A 90-cm 7 Fr Flexor Sheath (Cook Inc, Bloomington, IN) was pushed sequentially in each entry tear. An AVP II (AGA Medical, Golden Valley, MN) was positioned and deployed at the level of each entry tear (16 mm at the level of the LSCA and 10 mm at the level of the visceral aorta). For each AVP, 2 of the 3 segments were positioned into the false lumen (Fig. 2). To avoid direct contact between AVPs and the systemic bloodstream, both AVPs were covered with short stent grafts. A tapered covered stent graft (Converter ESC 321280, Cook, Bloomington, IN) mated with a limb extension (TFLE 2056, Cook, Bloomington, IN) was positioned proximally just below the brachiocephalic artery ostium, whereas the distal AVP was covered using a 12 60-mm Fluency Plus stent graft (Bard Peripheral Vascular, Tempe, AZ). The procedure was technically successful, with complete exclusion of the false lumen on completion angiography. The postoperative course was uneventful. The patient was discharged home at day 10. Eighteen months later, he was healthy. CT scan showed complete FLT, wellpositioned devices, patent grafts, and a decreased aortic diameter (60 mm; Fig. 3).
DISCUSSION Endovascular repair of CAD is based on closing entry tears to favor FLT and long-term aortic remodeling.3,4 Current methods intending to promote endovascular FLT use stent grafts.3,4 However, in this case, entry tear closure using conventional aortic stent grafts alone would have been associated with several technical issues. The proximal entry tear was located just below the LSCA, where an important change of the true lumen diameter was noted (33 32 mm in diameter just above the LSCA and 33 12 mm at 2 cm below this level). Stent graft repair would have necessitated a tapered stent graft
Vol. 27, No. 7, October 2013
Case reports 972.e3
Fig. 3. Postoperative CT scan confirmed complete false lumen (FL) thrombosis and the patency of the true lumen (TL) after entry tears closure with Amplatzer vascular plug (arrows). (A) Proximal entry tear closure. (B) Distal entry tear closure.
Fig. 4. Multiplanar reconstruction analysis of the proximal entry tear on the preoperative CT scan. After centering the analysis of the entry tear on the (A) sagittal
(arrow) and (B) axial (arrow) views, the coronal view (C) shows the circular and regular shape of the entry tear (arrow).
to ensure proximal and distal sealing, but the oval shape of the true lumen rendered stent graft sizing and sealing uncertain in this case, especially in the setting of a thick intimal flap. A secure option would have been to use proximally an aortouniiliac device or a converter in association with several limb extensions to achieve sealing in a tubular zone of the true lumen in the abdominal aorta. However, this technique would have led to more extensive coverage of the aorta with an increased risk of paraplegia. For these reasons, the authors elected to close entry tears using AVPs protected by short stent grafts. Covering the entry tear located at the level of the visceral aorta with a stent graft would have carried a risk of visceral malperfusion. Visceral debranching8e10 seemed to be a reasonable option to revascularize critical side branches. In this case, the choice of the inflow site was difficult. The left iliac
artery was included in the dissection process. Choosing the right iliac artery might have been associated with several risks, because the true aortic lumen was extremely reduced through the whole aorta above this vessel. There also might have been a risk of visceral malperfusion during the endovascular step of the procedure when the large stentgraft sheaths were introduced through this inflow site. Therefore, the authors decided to perform the visceral debranching through the ascending aorta to use an apparently healthy inflow site. However, the postoperative ascending aortic dissection that occurred highlights aortic wall fragility in patients with CAD, although the primary dissection episode occurred 17 years prior in this patient. This adverse event tempers the final satisfactory result of the technique. CT scan examination revealed that both entry tears had a circular and a regular shape (Fig. 4).
972.e4 Case reports
Therefore, AVPs seemed to be a feasible option to allow their closure. AVPs were initially used for cardiologic purposes, but are now widely used in endovascular procedures for peripheral arterial occlusions.11,12 The AVP is a self-expanding cylindrical device made of Nitinol metal mesh, fixed at both extremities by platinum strips. Four types of AVPs are currently available. The AVP II was chosen because of its specific shape, allowing deployment of a small part of the device into the true lumen. Diameters of AVPs were calculated based on 20% oversizing compared with entry tear diameters. Technically, precise deployment was performed through starting to unsheathe the 2 distal parts of the device into the false lumen, then pulling the device to anchor it to the intimal flap and achieve deployment of the proximal part of the device in the true lumen. One could question whether entry tear closure was achieved with AVPs or with short stent graft placement. In fact, the observation of contrast flow in the true lumen outside the stent graft despite FLT (Fig. 3) shows that entry tear closure was achieved with AVPs. This finding emphasizes the idea that stent grafts alone might have been not sufficient to induce FLT. Although AVPs allowed FLT in this patient with CAD, the authors would not recommend their use in an acute setting. In these cases, the aortic wall is probably more fragile and there might be a risk of increasing or creating entry tears. The technique described was effective to induce FLT, but the short-term and long-term consequences of AVP placement in the thoracoabdominal aorta are currently unknown. A risk of device migration13 or thrombus formation14 might be present in this setting. To avoid contact between the surface of AVPs and the true aortic lumen, short covered stent grafts were positioned at the level of the AVPs. However, the authors are unsure whether this adjunct to the technique is mandatory, because contrast flow can be visualized in the true lumen around the stent grafts despite FLT (Fig. 3). Moreover, AVPs have been previously deployed in the setting of CAD without being protected, with satisfactory results in the short-term.15,16 In this case, this would have avoided aortic debranching and its consequences. Future reports regarding AVPs will probably provide answers to these questions. Closing entry tears with AVPs provides new perspectives regarding the approach of CAD. However, the strategy reported might have several limitations. To be efficient, preoperative planning must be based on CT scan with millimeter cuts to clearly identify all existing entry tears. Moreover,
Annals of Vascular Surgery
AVPs should only be used when entry tears are limited in surface and circular in shape (Fig. 4), which is not always the case in CAD. This technique also achieves FLT, but diseased aortic segments are not covered. Therefore, meticulous long-term follow-up remains mandatory to ensure the stability of aortic diameter over time.
CONCLUSION Entry tear closure of CAD using AVPs is feasible and allows FLT. Further reports with long-term followup are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify the technical aspects of the procedure. REFERENCES 1. Tsai TT, Evangelista A, Nienaber CA, et al. International Registry of Acute Aortic Dissection. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007;357:349e59. 2. Bernard Y, Zimmermann H, Chocron S, et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001;87:1378e82. 3. Nienaber CA, Kische S, Akin I, et al. Strategies for subacute/ chronic type B aortic dissection: the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD) trial 1-year outcome. J Thorac Cardiovasc Surg 2010;140:S101e8. 4. Kang WC, Greenberg RK, Mastracci TM, et al. Endovascular repair of complicated chronic distal aortic dissections: intermediate outcomes and complications. J Thorac Cardiovasc Surg 2011;142:1074e83. 5. Svensson LG, Crawford ES, Hess KR, et al. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82:IV24e38. 6. Haverich A, Miller DC, Scott WC, et al. Acute and chronic aortic dissectionsddeterminants of long-term outcome for operative survivors. Circulation 1985;72(3 Pt 2):II22e34. 7. Javerliat I, Coggia M, Di Centa I, et al. Total videoscopic bypass graft implantation on the ascending aorta for lower limb revascularization. J Vasc Surg 2005;42:361e4. 8. Black SA, Wolfe JH, Clark M, et al. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg 2006;43:1081e9. 9. B€ ockler D, Kotelis D, Geisb€ usch P, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissectionsda single center experience in 28 patients. J Vasc Surg 2008;47:724e32. 10. Torsello G, Can A, Umscheid T, et al. Hybrid thoracoabdominal aneurysm repair with simultaneous antegrade visceral revascularization and supra-aortic debranching from the ascending aorta. J Endovasc Ther 2007;14:342e6. 11. Vandy F, Criado E, Upchurch GR Jr, et al. Transluminal hypogastric artery occlusion with an Amplatzer vascular plug during endovascular aortic aneurysm repair. J Vasc Surg 2008;48:1121e4. 12. Tholpady A, Hendricks DE, Bozlar U, et al. Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs. J Vasc Interv Radiol 2010;21:1501e7.
Vol. 27, No. 7, October 2013
13. Chen F, Zhao X, Zheng X, et al. Incomplete endothelialization and late dislocation after implantation of an Amplatzer septal occluder device. Circulation 2011;124:e188e9. 14. Yorgun H, Canpolat U, Kaya EB, et al. Thrombus formation during percutaneous closure of an atrial septal defect with an Amplatzer septal occluder. Tex Heart Inst J 2011;38: 427e30.
Case reports 972.e5
15. Tang X, Fu W, Xu X, et al. Use of a vascular occluder to treat a re-entry tear in a patient with stanford type B aortic dissection: acute and 1-year results. J Endovasc Ther 2008;15: 566e9. 16. Yeom SK, Lee SH, Chung HH, Shin JS. Endovascular repair of growing chronic type B aortic dissection with a vascular plug. Acta Radiol 2012;53:648e51.
Endovascular repair of chronic aortic dissections (CAD) intend to promote false lumen thrombosis (FLT). This article describes a technique using Amplatzer vascular plugs (AVPs) for entry tear closure of CAD. A 70-year-old man presented with a type II dissecting thoracoabdominal aneurysm. Computed tomography scan showed a very tight true lumen, partial FLT, and 2 entry tears at the level of the left subclavian artery and the visceral aorta, respectively. During a first procedure, aortic debranching was performed using the ascending aorta as bypass inflow. In a second intervention entry tears were closed using AVPs protected by short stent grafts. Technical success was achieved. No paraplegia occurred. Eighteen months later, FLT was complete and aortic diameter decreased. Entry tear closure using AVPs is feasible and allows FLT. Further reports are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify technical aspects of the procedure.
Partial false lumen thrombosis (FLT) of chronic aortic dissection (CAD) is associated with increased mortality.1,2 Currently available techniques intending to promote complete FLT achieve mitigating results.3,4 Open surgical repair carries a high risk of mortality and paraplegia,5,6 and technical issues and late failures have been largely described with stent-graft exclusion.3,4 This article reports a new
Conflict of interest: None. 1 Department of Vascular Surgery, Ambroise Pare University Hospital, Boulogne-Billancourt, France. 2 Faculte de Medecine Paris-Ile de France-Ouest, University Versailles Saint Quentin en Yvelines, Paris, France. 3 Department of Vascular Surgery M.A.S., Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy.
Correspondence to: Rapha€el Coscas, MD, Department of Vascular Surgery, Ambroise Pare University Hospital, 9 Avenue Charles de Gaulle, 92104 Boulogne Cedex, France; E-mail: [email protected] Ann Vasc Surg 2013; 27: 972.e1e972.e5 http://dx.doi.org/10.1016/j.avsg.2013.03.004 Ó 2013 Elsevier Inc. All rights reserved. Manuscript received: June 5, 2012; manuscript accepted: March 4, 2013.
technique using Amplatzer vascular plugs (AVPs) and short stent grafts to achieve FLT of a type II dissecting thoracoabdominal aortic aneurysm (TAAA).
CASE REPORT A 70-year-old man presented with an asymptomatic type II dissecting TAAA. Seventeen years ago he was managed medically for a type B aortic dissection in another center. Computed tomography (CT) scan (Fig. 1) showed a type II dissecting TAAA extending from the left subclavian artery (LSCA) to the left iliac bifurcation. Maximum aortic diameter was 63 mm at the level of the visceral aorta. The celiac artery, the superior mesenteric artery, and the right renal artery were perfused through the true lumen, whereas the left renal artery was perfused through the false lumen. The true lumen was extremely reduced through the whole TAAA, with an oval section on axial cuts (12 33 mm) and a thick intimal flap. Two entry tears were identified: one was located just below the left subclavian artery (LSCA; 11 mm in diameter) and the other was at the level of the left renal artery (7 mm in diameter). The patient rejected open surgical repair because of the risk
972.e1
972.e2 Case reports
Fig. 1. Preoperative CT scan revealed partial false lumen (FL) thrombosis. (A) The proximal entry tear located just below the left subclavian artery (arrow). (B) The true lumen (TL) was extremely reduced through the whole
Fig. 2. Schematic representation of the preoperative (A) and postoperative (B) aspect of the repair. of paraplegia. An endovascular repair sparing most intercostal and lumbar arteries was then decided. Two procedural steps were planned. The first step consisted of abdominal trunks debranching from the ascending aorta (Fig. 2). A 10-mm Dacron tube graft was implanted using a videoscopic approach and side-bitting clamping of the ascending aorta.7 Three 7-mm polytetrafluoroethylene grafts were sutured to the Dacron tube, and the celiac artery, the superior mesenteric artery, and both renal arteries were revascularized. At day 1, systematic echocardiography showed an asymptomatic ascending aortic dissection. The patient was transferred to the cardiac department for emergent surgical repair. An entry tear was located at the heel of the clamping zone. Coronary arteries were not involved and the dissection was limited to the ascending aorta. The ascending aorta was replaced by a supracoronary tube graft and the debranching graft was reimplanted in the tube. The procedure was uneventful and the patient was discharged to a rehabilitation center. Four months later, the second step consisted of left supra-aortic trunks debranching and concomitant endovascular occlusion of intimal entry tears. A right-to-left crossover subclavian bypass with direct reimplantation
Annals of Vascular Surgery
TAAA with an oval section on axial cuts (12 33 mm) and a thick intimal flap. (C) The other entry tear was located at the level of the left renal artery (arrow).
of the left carotid artery was performed. Through femoral accesses via groin incisions, both proximal and distal entry tears were easily catheterized with a vertebral and a C2 catheter, respectively. A 90-cm 7 Fr Flexor Sheath (Cook Inc, Bloomington, IN) was pushed sequentially in each entry tear. An AVP II (AGA Medical, Golden Valley, MN) was positioned and deployed at the level of each entry tear (16 mm at the level of the LSCA and 10 mm at the level of the visceral aorta). For each AVP, 2 of the 3 segments were positioned into the false lumen (Fig. 2). To avoid direct contact between AVPs and the systemic bloodstream, both AVPs were covered with short stent grafts. A tapered covered stent graft (Converter ESC 321280, Cook, Bloomington, IN) mated with a limb extension (TFLE 2056, Cook, Bloomington, IN) was positioned proximally just below the brachiocephalic artery ostium, whereas the distal AVP was covered using a 12 60-mm Fluency Plus stent graft (Bard Peripheral Vascular, Tempe, AZ). The procedure was technically successful, with complete exclusion of the false lumen on completion angiography. The postoperative course was uneventful. The patient was discharged home at day 10. Eighteen months later, he was healthy. CT scan showed complete FLT, wellpositioned devices, patent grafts, and a decreased aortic diameter (60 mm; Fig. 3).
DISCUSSION Endovascular repair of CAD is based on closing entry tears to favor FLT and long-term aortic remodeling.3,4 Current methods intending to promote endovascular FLT use stent grafts.3,4 However, in this case, entry tear closure using conventional aortic stent grafts alone would have been associated with several technical issues. The proximal entry tear was located just below the LSCA, where an important change of the true lumen diameter was noted (33 32 mm in diameter just above the LSCA and 33 12 mm at 2 cm below this level). Stent graft repair would have necessitated a tapered stent graft
Vol. 27, No. 7, October 2013
Case reports 972.e3
Fig. 3. Postoperative CT scan confirmed complete false lumen (FL) thrombosis and the patency of the true lumen (TL) after entry tears closure with Amplatzer vascular plug (arrows). (A) Proximal entry tear closure. (B) Distal entry tear closure.
Fig. 4. Multiplanar reconstruction analysis of the proximal entry tear on the preoperative CT scan. After centering the analysis of the entry tear on the (A) sagittal
(arrow) and (B) axial (arrow) views, the coronal view (C) shows the circular and regular shape of the entry tear (arrow).
to ensure proximal and distal sealing, but the oval shape of the true lumen rendered stent graft sizing and sealing uncertain in this case, especially in the setting of a thick intimal flap. A secure option would have been to use proximally an aortouniiliac device or a converter in association with several limb extensions to achieve sealing in a tubular zone of the true lumen in the abdominal aorta. However, this technique would have led to more extensive coverage of the aorta with an increased risk of paraplegia. For these reasons, the authors elected to close entry tears using AVPs protected by short stent grafts. Covering the entry tear located at the level of the visceral aorta with a stent graft would have carried a risk of visceral malperfusion. Visceral debranching8e10 seemed to be a reasonable option to revascularize critical side branches. In this case, the choice of the inflow site was difficult. The left iliac
artery was included in the dissection process. Choosing the right iliac artery might have been associated with several risks, because the true aortic lumen was extremely reduced through the whole aorta above this vessel. There also might have been a risk of visceral malperfusion during the endovascular step of the procedure when the large stentgraft sheaths were introduced through this inflow site. Therefore, the authors decided to perform the visceral debranching through the ascending aorta to use an apparently healthy inflow site. However, the postoperative ascending aortic dissection that occurred highlights aortic wall fragility in patients with CAD, although the primary dissection episode occurred 17 years prior in this patient. This adverse event tempers the final satisfactory result of the technique. CT scan examination revealed that both entry tears had a circular and a regular shape (Fig. 4).
972.e4 Case reports
Therefore, AVPs seemed to be a feasible option to allow their closure. AVPs were initially used for cardiologic purposes, but are now widely used in endovascular procedures for peripheral arterial occlusions.11,12 The AVP is a self-expanding cylindrical device made of Nitinol metal mesh, fixed at both extremities by platinum strips. Four types of AVPs are currently available. The AVP II was chosen because of its specific shape, allowing deployment of a small part of the device into the true lumen. Diameters of AVPs were calculated based on 20% oversizing compared with entry tear diameters. Technically, precise deployment was performed through starting to unsheathe the 2 distal parts of the device into the false lumen, then pulling the device to anchor it to the intimal flap and achieve deployment of the proximal part of the device in the true lumen. One could question whether entry tear closure was achieved with AVPs or with short stent graft placement. In fact, the observation of contrast flow in the true lumen outside the stent graft despite FLT (Fig. 3) shows that entry tear closure was achieved with AVPs. This finding emphasizes the idea that stent grafts alone might have been not sufficient to induce FLT. Although AVPs allowed FLT in this patient with CAD, the authors would not recommend their use in an acute setting. In these cases, the aortic wall is probably more fragile and there might be a risk of increasing or creating entry tears. The technique described was effective to induce FLT, but the short-term and long-term consequences of AVP placement in the thoracoabdominal aorta are currently unknown. A risk of device migration13 or thrombus formation14 might be present in this setting. To avoid contact between the surface of AVPs and the true aortic lumen, short covered stent grafts were positioned at the level of the AVPs. However, the authors are unsure whether this adjunct to the technique is mandatory, because contrast flow can be visualized in the true lumen around the stent grafts despite FLT (Fig. 3). Moreover, AVPs have been previously deployed in the setting of CAD without being protected, with satisfactory results in the short-term.15,16 In this case, this would have avoided aortic debranching and its consequences. Future reports regarding AVPs will probably provide answers to these questions. Closing entry tears with AVPs provides new perspectives regarding the approach of CAD. However, the strategy reported might have several limitations. To be efficient, preoperative planning must be based on CT scan with millimeter cuts to clearly identify all existing entry tears. Moreover,
Annals of Vascular Surgery
AVPs should only be used when entry tears are limited in surface and circular in shape (Fig. 4), which is not always the case in CAD. This technique also achieves FLT, but diseased aortic segments are not covered. Therefore, meticulous long-term follow-up remains mandatory to ensure the stability of aortic diameter over time.
CONCLUSION Entry tear closure of CAD using AVPs is feasible and allows FLT. Further reports with long-term followup are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify the technical aspects of the procedure. REFERENCES 1. Tsai TT, Evangelista A, Nienaber CA, et al. International Registry of Acute Aortic Dissection. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007;357:349e59. 2. Bernard Y, Zimmermann H, Chocron S, et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001;87:1378e82. 3. Nienaber CA, Kische S, Akin I, et al. Strategies for subacute/ chronic type B aortic dissection: the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD) trial 1-year outcome. J Thorac Cardiovasc Surg 2010;140:S101e8. 4. Kang WC, Greenberg RK, Mastracci TM, et al. Endovascular repair of complicated chronic distal aortic dissections: intermediate outcomes and complications. J Thorac Cardiovasc Surg 2011;142:1074e83. 5. Svensson LG, Crawford ES, Hess KR, et al. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82:IV24e38. 6. Haverich A, Miller DC, Scott WC, et al. Acute and chronic aortic dissectionsddeterminants of long-term outcome for operative survivors. Circulation 1985;72(3 Pt 2):II22e34. 7. Javerliat I, Coggia M, Di Centa I, et al. Total videoscopic bypass graft implantation on the ascending aorta for lower limb revascularization. J Vasc Surg 2005;42:361e4. 8. Black SA, Wolfe JH, Clark M, et al. Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization. J Vasc Surg 2006;43:1081e9. 9. B€ ockler D, Kotelis D, Geisb€ usch P, et al. Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissectionsda single center experience in 28 patients. J Vasc Surg 2008;47:724e32. 10. Torsello G, Can A, Umscheid T, et al. Hybrid thoracoabdominal aneurysm repair with simultaneous antegrade visceral revascularization and supra-aortic debranching from the ascending aorta. J Endovasc Ther 2007;14:342e6. 11. Vandy F, Criado E, Upchurch GR Jr, et al. Transluminal hypogastric artery occlusion with an Amplatzer vascular plug during endovascular aortic aneurysm repair. J Vasc Surg 2008;48:1121e4. 12. Tholpady A, Hendricks DE, Bozlar U, et al. Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs. J Vasc Interv Radiol 2010;21:1501e7.
Vol. 27, No. 7, October 2013
13. Chen F, Zhao X, Zheng X, et al. Incomplete endothelialization and late dislocation after implantation of an Amplatzer septal occluder device. Circulation 2011;124:e188e9. 14. Yorgun H, Canpolat U, Kaya EB, et al. Thrombus formation during percutaneous closure of an atrial septal defect with an Amplatzer septal occluder. Tex Heart Inst J 2011;38: 427e30.
Case reports 972.e5
15. Tang X, Fu W, Xu X, et al. Use of a vascular occluder to treat a re-entry tear in a patient with stanford type B aortic dissection: acute and 1-year results. J Endovasc Ther 2008;15: 566e9. 16. Yeom SK, Lee SH, Chung HH, Shin JS. Endovascular repair of growing chronic type B aortic dissection with a vascular plug. Acta Radiol 2012;53:648e51.