Coil-assisted false lumen thrombosis in complicated chronic type B dissection

Type B dissections complicated by pain, malperfusion, or aneurysm expansion mandate surgical intervention. Success of this therapy is predicated on exclusion and thrombosis of the false lumen of the aneurysm. We report a case where cessation of flow was achieved using covered stent grafts in conjunction with coil embolization of the false lumen. The introduction of coils into the false lumen is a novel approach and may provide a helpful adjunct in endovascular treatment of complicated type B aortic dissections.     

Coil embolization of persistent false lumen after stent graft repair of type B aortic dissection

Patent false lumen after endovascular stent graft treatment of type B aortic dissection is a predictor for late death and retreatment. Between June 2008 and March 2010, five men with patent false lumen, due to a type B dissection previously treated with thoracic stent graft, underwent endovascular coiling treatment. Within a 30-day period, there were no deaths or major complications. The follow-up duration ranged from 1 to 22 months (mean 10.6 ± 8.5). Endovascular coiling of patent false lumen after endovascular stent graft treatment for type B aortic dissection avoided the risk of rupture or death due to secondary aneurysm formation.     

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??Management of distal reentry in type B dissection and evaluation??A report of 43 cases FANG Qing-bo??CI Hong-bo??GE Xiao-hu. Department of Vascular Surgery,People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830000??China
Corresponding author??GE Xiao-hu??E-mail??xj_gexiaohu@163.com
Abstract Objective To discuss the management of distal reentry in type B dissection??evaluate the influence of isolating the distal reentry in thoracic aorta and embolization of the reverse flow channel in the false lumen and selective closure of distal reentry. Methods From June 2015 to August 2018??43 patients with TBAD ??type B aortic dissection?? with distal reentry after TEVAR admitted in People's Hospital of Xinjiang Uygur Autonomous Region were collected.All patients underwent complete treatment of the thoracic aorta segment of the false lumen??TEVAR or short cuff were applied to managing the reentry above the visceral artery.The reverse flow channel from the distal reentry was blocked by coil or closure device.Renal artery stent graft placement was performed in 11 cases??8 cases of thoracic aortic false lumen thrombosis after TEVAR??but the diameter of the abdominal aorta increased significantly??they were performed EVAR. The morphological changes of aorta were compared. Results The time of follow-up was 1 year. The maximal diameter of aorta after distal reentry treatment in 43 patients was significantly lower than preoperative diameter [??27.36±4.92??mm vs.??32.03±6.35??mm??t=5.899??P??0.001]. The range of unthrombosed false lumen significantly shrank after operation. There were 6 cases of complete aortic thrombosis. Conclusion Occlusion of distal reentry in thoracic aorta during subacute phase, blocking the reverse blood flow channel and selective closure of distal reentry are safe and effective.     

Aortic stent grafting and side-branch embolization in an expanding chronic type B dissection

OBJECTIVE: This is a report of endovascular treatment of a case of type B thoracoabdominal aortic dissection in a patient with progressive dyspnea, dorsolumbar pain, and expanding aortic diameter over a 1-year period. METHODS: Pretreatment imaging evaluation showed that the false lumen supplied only the celiac trunk. Endovascular treatment combined (1) embolization of the first segment of the celiac trunk to avoid distal back-flow into the false lumen and (2) stent grafting to occlude the initial entry tear. RESULTS: The treatment resulted in technical and clinical success. The patient remains asymptomatic 12 months after treatment. CONCLUSION: Stent grafting offers an interesting therapeutic alternative to exclude the initial entry tear in aortic dissection and may be combined with other endovascular procedures.     

Placement of a branched stent graft into the false lumen of a chronic type B aortic dissection

The treatment of chronic type B aortic dissections remains challenging and controversial. Currently most centers advocate open or endovascular intervention for patients with evidence of malperfusion, rupture or impending rupture, continued pain, or aneurysm formation. Regardless of the type of intervention, the incidence of complications or death remains high, even when undertaken in an elective setting. The standard endovascular treatment usually involves placement of a stent graft into the true lumen of the dissection in an effort to exclude the false lumen. This case report describes the placement of a branched stent graft into the false lumen of a patient with chronic type B dissection to encourage exclusion and thrombosis of the true lumen whilst maintaining flow to all visceral vessels.     

Remodeling of the thoracic aorta after stent grafting of type B dissection: a Swedish multicenter study

AIM: Endovascular repair of complicated type B dissections has evolved as a promising alternative to open repair. Previous studies have indicated that continued false lumen flow is a predictor of continued aortic dilatation and risk of rupture during follow-up. This multicenter study was conducted to analyze the postoperative changes of the false lumen after endografting of complicated type B dissections. METHODS: All patients treated with endovascular stent grafts for thoracic type B dissections at 5 major Vascular Centers in Sweden were identified through local databases. Review of charts and all available pre- and postoperative CT scans were performed to identify demographics, indications for repair as well as postoperative changes of the aorta and false lumen. RESULTS: A total of 129 patients treated for type B dissections between 1994 and December 2005 were identified. Median radiological follow-up was 14 months. Fourteen patients died perioperatively leaving 115 patients available for analysis. Seventy-four of these had CT imaging of sufficient quality for morphological analysis. The vast majority of acute patients were treated for rupture or end-organ ischemia whereas most chronic patients were treated for asymptomatic aneurysms. In 80% of patients, the false lumen thrombosed along the stent graft but it remained perfused distal to the stent graft fixation in 50% of patients. Only 5% of patients presented with aortic enlargement of the stent grafted area when adequate proximal sealing was achieved. The distal, uncovered aorta displayed expansion in 16% of patients. CONCLUSIONS: The stent grafted thoracic aorta after type B dissection appears to be stabilized by covering the primary entry site with a stent graft in the majority of both acute and chronic dissections. The uncovered portion of the aorta distal to the stent graft, however, remains at risk of continuous dilatation. Stent grafting for complicated type B thoracic dissections seems to be a treatment option with reasonable morbidity and mortality even though the incidence of severe complications is still significant.     

Transluminal stent-assisted coil embolization of a vertebral confluence aneurysm: technique report

BACKGROUND: Recent advances in stent technology have allowed for negotiation of often tortuous posterior circulation intracranial vasculature. Stent-assisted coil embolization is a novel treatment for complex wide-necked aneurysms, as stents provide a buttress that allows for coil deposition while preventing coil herniation into the parent vessel lumen. We describe a case of stent-assisted coil embolization of a complex wide-necked vertebral confluence aneurysm. CASE DESCRIPTION: A 61-year-old woman presented with a Hunt-Hess III, Fisher Grade III subarachnoid hemorrhage secondary to a ruptured vertebral confluence aneurysm demonstrated on angiography. The patient underwent emergent angiography and attempted coiling of a vertebral confluence aneurysm. Because of the aneurysm's complex wide neck and the presence of subclavian steal syndrome, the coils repeatedly herniated into the left vertebral and basilar artery lumina. A flexible coronary stent was deployed across the aneurysm neck, preventing coil herniation and allowing for greater coil deposition. The patient tolerated the procedure and underwent repeat coiling 2 months postoperatively because of mild coil compaction. This resulted in 100% occlusion and the patient is neurologically normal except for a sixth nerve palsy which had been present after the hemorrhage. CONCLUSION: Recent advances in stent technology allow negotiation of the tortuous posterior circulation vasculature. Stent-assisted coil embolization of complex, wide-necked vertebral confluence aneurysms may be an alternative intervention for these surgically challenging lesions.     

False lumen embolization for type B dissection complicated by hemoptysis.

In this report, we describe successful treatment of a patient with hemoptysis by false lumen embolization of a type B aortic dissection.     

Parent vessel Guglielmi detachable coil herniation during wide-necked aneurysm embolization: treatment with intracranial stent placement: two technical case reports

OBJECTIVE AND IMPORTANCE: Despite recent advances in technology, parent vessel coil herniation occasionally complicates successful Guglielmi detachable coil embolization, particularly in wide-necked aneurysms. We report endovascular stent deployment performed in two patients specifically to treat this complication. CLINICAL PRESENTATION: Two patients underwent Guglielmi detachable coil embolization of cavernous segment aneurysms. Both developed coil herniation into the internal carotid artery. In one patient, the herniation occurred during the initial procedure; in the other, it was discovered in a delayed fashion during a follow-up examination for ocular symptoms. INTERVENTION: In both patients, endovascular stent deployment was performed to isolate the herniated portion of the coil from the internal carotid lumen. Follow-up angiography at 6 months demonstrated no aneurysm recanalization and no stenosis of the parent internal carotid artery in the stented region in either patient. CONCLUSION: The use of intraluminal stents has been reported to be a helpful technical adjunct to the conventional endovascular treatment of aneurysms and balloon angioplasty. One additional indication for the use of this technology is sequestering herniated coils from the lumen of the parent artery to reduce potential embolic or occlusive sequelae.     

Technique to detect coil migration using mask images of rotational angiography during stent-assisted coil embolization for ultra-wide necked aneurysms: technical note

A novel technique was developed to detect coil migration to the stent interior using mask images of rotational angiography. Stent-assisted coil embolization under x-ray fluoroscopy control was simulated with a hand-made vessel model. The stent interior was observed with a rigid endoscope during coil embolization. After insertion of the coil, mask images using rotational angiography were acquired and multi-planar reformation (MPR) images were reconstructed on a workstation. The stent interior could be observed during coil embolization. Longitudinal MPR images showed the positional relationships between the stent, coil, and tip of the microcatheter. This technique was successfully employed in a patient to detect displacement of the tip of the microcatheter inside the stent. This technique is useful for monitoring stent-assisted coil embolization of an ultra-wide necked aneurysm, but requires extra time and increased radiation exposure, so we recommend use only if coil migration is strongly suspected.     

Value of intravascular ultrasound for endovascular stent-graft placement in aortic dissection and aneurysm

BACKGROUND: Endovascular stent-graft placement is a new concept for the treatment of aortic dissection and aneurysm. Intravascular ultrasound (IVUS) with established diagnostic features may be instrumental in guiding endovascular procedures. METHODS: We performed IVUS and digital angiography before, during, and after implantation of 47 stent grafts in 40 patients with Stanford type B dissection (26 patients, 28 stent grafts), thoracic aneurysm (9 patients, 11 stent grafts), and abdominal aneurysm (5 patients, 8 stent grafts). RESULTS: IVUS could clearly identify the aortic anatomy and differentiate between true and false lumen in all cases of dissection. In four patients with type B dissection extending from the thoracic to the abdominal aorta the true lumen was exclusively identified by IVUS, and thus, essential for safe execution of the procedure. In another patient stent-graft placement in the aorta was optimized by covering a second entry detected by IVUS, but undetected by angiography. The site of stent implantation, the true and false lumen, as well as entry and reentry were always identified in both thoracic and abdominal aorta. In comparison with angiography, IVUS information led to additional balloon molding due to incomplete stent apposition in seven cases. CONCLUSIONS: As an adjunctive imaging modality IVUS is likely to improve stent-graft placement in aortic type B dissection, especially in patients with abdominal extension.     

Review of endovascular stent‐assisted embolization for management of intracranial aneurysms

Objective: This was a retrospective review of the results using stent‐assisted coil embolization for management of intracranial aneurysms. Methods: The records of seven patients treated with stent‐assisted Gugliemi detachable coil (GDC) embolization were retrieved from the authors’ prospectively maintained database. The clinical presentation, site and type of aneurysms, treatment procedure and complications, and outcome of these identified cases were reviewed. Results: Between January 2002 and May 2004, seven patients with intracranial aneurysms, four of which were ruptured, were treated by stent‐assisted GDC embolization. Four aneurysms were located at the anterior circulation and three were at the posterior circulation. The indications for stent use were: giant aneurysm (>2.5 cm), dissecting pseudo‐aneurysm, broad‐necked aneurysm and the need for preservation of important parent arteries or branches. Concerning the technical aspect, all except one had successful stent deployment. One stent dislodged after apparent successful deployment. GDC embolization was continued and the aneurysm was partially occluded. More than 90% occlusion of aneurysm sac was achieved in six aneurysms. Intraoperative complications included over‐coagulation, failure in stent deployment, displacement of stent, coil entrapment and thromboembolism. One patient had added focal neurological deficit after the procedure, and one became vegetative due to an unrelated cause. The patient in whom the stent was dislodged suffered another subarachnoid haemorrhage 4 months later and died. Conclusion: Percutaneous intracranial stent is a new and useful device to assist embolization of cerebral aneurysms that were previously not amenable to endovascular therapy. These preliminary results suggest that this procedure could achieve satisfactory outcomes without significant complications.     

A case of a vertebral artery fusiform aneurysm treated with stent assisted coil embolization: technique to prevent coil migration

Placement of a stent over the aneurysm neck and secondary coil embolization prevents coil migration and allows attenuated packing of the coils. However, during the course of the embolization, coils project over and obscure the parent vessel. Here we report a novel technique for endovascular parent vessel reconstruction with aneurysm embolization. A 73-year-old male had an incidental fusiform aneurysm at the V4 segment of the left vertebral artery. The size of the aneurysm increased from 7 mm to 8 mm in diameter. Since the right vertebral artery was hypoplastic, endovascular parent vessel reconstruction with coil embolization was performed. A flexible balloon-expandable coronary stent was navigated to the lesion and deployed successfully followed by coil embolization using a microcatheter through the stent. The balloon was inflated intermittently during coil insertion avoiding coil migration to inside the stent. Furthermore, the angle of the image intensifier was manipulated to visualize the inside of the stent. Postoperative course was uneventful and follow-up MRI three moths later demonstrated obliteration of the aneurysm and patency of the parent artery. This technique provides a practical treatment strategy for the management of a circumferential aneurysm.     

Verzögerter symptomatischer Kollaps des wahren Lumens bei Typ-B-Dissektion

A symptomatic true lumen collapse within the descending aorta due to extensive false lumen thrombosis is a rare morphology in type B dissection. Because of organ malperfusion, it represents a life-threatening situation. Here we present successful management of a symptomatic true lumen collapse in a 65-year-old patient. She suffered from sudden paraparesis in both legs combined with acute renal failure 5 weeks after acute type B dissection and underwent thoracic stent grafting in an emergency setting. The true lumen collapse was caused by extensive thrombosis of the false lumen in combination with the absence of a distal reentry point.     

Successful treatment of an infected thoracic endovascular stent graft

A 70-year-old man with a chronic type B aortic dissection was treated with two stent grafts deployed in the descending thoracic aorta. The patient was re-admitted to the hospital at 16 months after thoracic endovascular stent grafting because of a high fever. A blood culture showed sepsis due to a Staphylococcus species. A CT scan showed an increase in the size of the thrombosed false lumen. Complete excision of the infected descending aortic wall and infected stent graft were performed. The descending thoracic aorta was reconstructed using a rifampicin-bonded Dacron graft and omental wrapping. The combination of in situ graft replacement using a rifampicin-bonded graft and omental wrapping is considered an effective treatment for thoracic stent graft infection.     

Repair of the thoracic aorta by transaortic stent grafting (open stenting)

BACKGROUND: The late results of direct open stent grafting of the aortic arch for aortic arch repair have not been reported previously. METHODS: Between September 1997 and December 2000 19 patients underwent open stent grafting with carotid artery bypass for thoracic arteriosclerotic aneurysms (TAA) of the distal aortic arch. In addition, 21 patients underwent open stent grafting with total aortic arch replacement for Stanford type A acute aortic dissection and 7 patients underwent stenting with carotid bypass for Stanford type B chronic aortic dissection. RESULTS: The early mortality rate was 11% for TAA, 10% for type A dissection, and 0% for type B dissection. Whereas none of the TAA or type A dissection required a second operation on the thoracic aorta, 1 TAA patient died 6 months postoperatively after sudden aortic rupture and 1 type B patient required descending aortic replacement because of ulceration caused by the stent graft at 11 months postoperatively. On follow-up computed tomography scan, in TAA patients, true aneurysms excluded by the stent graft showed early thrombosis, but the absorption of thrombosed aneurysms started from 1 to 6 months postoperatively and gradually progressed. In patients with type B chronic dissection, the false lumen showed early thrombosis and the true lumen was dilated at the central portion of the graft, which might increase turbulent flow by interaction with the stent. In patients with type A acute dissection, the false lumen showed both early thrombosis and early absorption. CONCLUSIONS: Early and late results of open stenting are acceptable and follow-up computed tomography scan may be able to predict late results of open stenting.     

Antegrade recanalization of parent artery in internal trapping of vertebral artery dissecting aneurysm: a case report

BACKGROUND: We describe a case involving technical success with internal trapping using controllable detachable coils yet antegrade recanalization of the occluded vertebral artery, in the vertebral artery dissecting aneurysm. Possible explanations for the antegrade recanalization of the occluded vertebral artery and lessons from the case are also discussed. CASE DESCRIPTION: A 42-year-old woman with a history of stupor (Hunt and Hess grade III) and right vertebral artery dissecting aneurysm, was admitted to our hospital. Endovascular treatment was performed. The dissecting aneurysm and affected right vertebral artery were both completely occluded, whereas the right PICA was preserved. Nine months after the embolization, follow-up angiography was performed, which revealed recanalization of the occluded right vertebral artery with a normal arterial configuration and antegrade flow into the basilar artery. The recanalized vertebral artery was located just superior and lateral to the deployed coil meshes. It was decided that no further intervention was needed. At the last clinical follow-up 15 months after the initial treatment, the patient was fully recovered. CONCLUSION: Even in the case of technical angiographic success in the endovascular management of a dissecting aneurysm, a prompt follow-up angiography is still crucial. Plus, if the false lumen cannot be separated from the true lumen, treatment with just a stent may not be adequate.     

Endovascular treatment of acute type B aortic dissection

Intervention is currently reserved in acute aortic dissection for Stanford Type A and for complications of Type B. Endovascular techniques such as fenestration of the intimal flap and stenting of vessel origins have been used to alleviate end-organ ischaemia due to compromised branches. The introduction of stent grafts has offered a realistic alternative to surgery for Type B dissections. Closure of the primary entry tear encourages thrombosis of the false lumen, which is associated with good long-term outcome. Many questions remain unanswered and randomised controlled trials need to be performed to establish the role of stent grafts in uncomplicated Type B dissections, and the use of bare stents to encourage thrombosis of the more distal false lumen. Improvements in the design and engineering of stent grafts may help to establish endoluminal repair as the first line treatment of aortic dissection.     

Setting up of a multicentric European registry dealing with type B dissections in chronic and acute phases with thoracic EndoFit devices

AIM: This registry aims at evaluating the use and efficacy of the EndoFit stent graft (LeMaitre Vascular, Burlington MA, USA) for the treatment of acute and chronic aortic type B dissections. METHODS: Indications for treatment are: recurrent pain, persistent hypertension, serious organ malperfusion in patients with acute or subacute type B aortic dissection and progression of aneurysm size despite maximal medical therapy in patient with chronic type B dissection. Exclusion criteria are: age under 18 years old, pregnancy, coagulopathy or bleeding disorders, connective tissue disease. Straight or tapered EndoFit stent graft will be used in acute or chronical dissection respectively. RESULTS: The primary endpoint is the assessment of the safety and the efficacy of the EndoFit Thoracic Endoluminal Stent Graft in the exclusion of the thoracic aortic false lumen in acute and chronic type B aortic dissections. The assessment includes: technical success, thrombosis of the thoracic false lumen at 6 months, rate of aorto-enteric, aorto-esophageal and aorto-bronchial fistula, serious adverse events including death, stroke, paraplegia, myocardial infarction, multi-organ failure and renal insufficiency. Secondary endpoints are: the technical feasibility of device implantation in 2 different shapes (straight for acute dissection and tapered for chronic dissection), the technical feasibility of endovascular placement of tapered grafts in vessels of different size and shape, the integrity of the device fabric and wire structure, the occurrence of device migration, the patient's neurological, cardiac and cardiovascular status, the blood flow supply to abdominal and visceral organs arteries and any secondary intervention including stentgraft extension, coiling or surgical conversion. One hundred patients enrolled have been defined to allow reliable findings and results. CONCLUSION: The DEDICATED is the first prospective data collection registry focusing on the role of tapered stentgrafts in chronic aortic dissection and their efficacy in excluding the dissected thoracic false lumen.     

Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.