Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 185-187

Total endovascular repair with chimney grafts for distal stent graft-induced new entry after Type B aortic dissection


Department of Cardiovascular Surgery, Isesaki Municipal Hospital, Gunma, Japan

Date of Submission11-May-2021
Date of Decision22-Jun-2021
Date of Acceptance02-Jul-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Tadashi Umeno
Department of Cardiovascular Surgery, Isesaki Municipal Hospital, Gunma
Japan
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_50_21

Rights and Permissions
  Abstract 


The parallel graft technique is valuable for high-risk patients who are unfit for open repair and who have complex aortic lesions, such as distal stent graft-induced new entry (SINE). The patient had undergone thoracic descending aortic graft replacement because of dilatation of the distal aortic arch after optimal medical therapy for Type B aortic dissection. After 9 years, a new entry occurred at the level of the diaphragm. He was treated with thoracic endovascular aortic repair (TEVAR) due to rapid dilatation and his back pain. However, distal SINE occurred 1 month after TEVAR. Therefore, we performed chimney endovascular aortic repair to maintain perfusion to superior mesenteric artery and bilateral renal arteries. When using a prefabricated branched device in a narrow dissected true lumen, the possibility of selectively catheterizing a visceral branch often has no straightforward solution. However, parallel grafting is a flexible technique that had paramount importance for the surgical outcome in our case.

Keywords: Chronic type B aortic dissection, stent graft-induced new entry, thoracic endovascular aortic repair


How to cite this article:
Umeno T, Ohki S, Yasuhara K, Obayashi T. Total endovascular repair with chimney grafts for distal stent graft-induced new entry after Type B aortic dissection. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:185-7

How to cite this URL:
Umeno T, Ohki S, Yasuhara K, Obayashi T. Total endovascular repair with chimney grafts for distal stent graft-induced new entry after Type B aortic dissection. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:185-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/185/336024




  Introduction Top


Thoracic endovascular aortic repair (TEVAR) for chronic Type B aortic dissection may provide more perioperative hemodynamically stability. On the other hand, it is difficult to close the re-entry point near the abdominal branch, and attention should also be paid to stent graft-induced new entry (SINE) due to oversizing. Here, we describe a case of successful total endovascular repair with parallel graft technique for distal SINE after TEVAR for enlargement of aortic aneurysm due to chronic Type B aortic dissection.


  Case Report Top


A 51-year-old man with mental retardation had a severe back pain. He had a history of an optimized medical therapy for acute Type B aortic dissection 9 years ago, and 1 year later, he underwent descending aortic replacement owing to the dilatation of the distal aortic arch [Figure 1]a. The remaining descending aorta had expanded over time [Figure 1]b. Computed tomography (CT) angiography during this admission revealed a new entry occurred at the level of the diaphragm and rapid dilatation of the aortic diameter. Due to the emergency and his severe respiratory dysfunction, we chose to perform TEVAR considering the risk of rupture. Two Zenith Tx2 (Cook Medical Incorporated, Bloomington, IN, USA), 32 mm and 28 mm were placed from a prosthesis of the descending aorta to the peripheral just above the ostium of celiac artery (CA). CT angiography (CTA) on the 5th day after TEVAR revealed that the blood flow of the false lumen from the reentry had almost disappeared [Figure 1]c. However, CT 1 month after TEVAR revealed a distal SINE at the distal edge of the stent graft [Figure 1]d. The risk of rupture was considered, and additional TEVAR was performed. The bilateral external iliac artery (EIA) was exposed above the inguinal ligament, and the left axillary artery was exposed for chimney access. Because we had analyzed the collaterals communications between CA and superior mesenteric artery (SMA) by preoperative CTA, the root of the CA was plugged with a 10-mm AMPLATZER Vascular Plug II (AGA Medical Corporation, Plymouth, MN, USA). The right renal artery (RA) and SMA had been cannulated from the left axillary artery in advance. A 32-mm Endurant aortic extension (Medtronic Cardiovascular, Santa Rosa, CA, USA) was deployed between the previous Tx 2 and just above SMA to cover the part of the distal SINE. Next, 6- and 8-mm VIABAHN (W. L. GORE, Flagstaff, AZ, USA) chimney grafts were inserted into the right RA and SMA, respectively. A 28-mm AFX (Endologix, Irvine, CA, USA) was inserted from the left EIA and placed on the terminal aorta; a catheter from the side of the AFX ipsilateral leg was inserted into the left RA, and a 7-mm VIABAHN as a chimney graft was deployed. Finally, a 34-mm AFX VELA cuff was deployed between the Endurant cuff and the 28-mm AFX via a sandwich technique. Thereafter, all balloons were expanded, and the aortic cuff was crimped to prevent chimney graft occlusion [Figure 2]a and [Figure 2]d. The disappearance of the blood flow to the distal SINE region and patency of all chimney grafts were confirmed.
Figure 1: Three-dimensional computed tomography showing a dilated thoracic descending aorta. (a) Postreplacement of the thoracic descending aorta. (b) Expanded distal anastomosis after replacement with a double barrel. (c) Postthoracic endovascular aortic repair for re-dissection of the residual dilated thoracic descending aorta. (d) Follow-up computed tomography revealing distal stent graft-induced new entry (arrow)

Click here to view
Figure 2: (a) Chimney endovascular aortic repair for distal stent graft-induced new entry. All balloons were expanded at the same time, and the aortic cuff was crimped to prevent chimney graft occlusion. The patency of all chimney grafts were confirmed (b) Postoperative computed tomography after chimney endovascular aortic repair. No distal stent graft-induced new entry could be confirmed. (c) and (a) VIABAHN placed in the superior mesenteric and right renal arteries, which ran parallel to the gap between the aortic cuffs. (b) VIABAHN inserted in the left renal artery. (c) VIABAHN opened in the right renal artery. (d) Chimney grafts are inserted in the space between the two aortic main bodies and opened in the true lumen of the main body

Click here to view


Postoperative CTA showed no endoleak, and the contrast effect in the SINE region disappeared [Figure 2]b and [Figure 2]c. CT 1 year after chimney EVAR revealed no endoleak and shrinkage of the thoracoabdominal aortic diameter [Figure 3]. All chimney grafts were patent and had a good course without renal dysfunction.
Figure 3: Changes in computed tomography 1 year after chimney endovascular aortic repair. All chimney grafts were patent, and abdominal perfusion was maintained. (a) At the descending aorta level, false lumen shrinkage was confirmed (aortic diameter from 54.3 to 51.8 mm). (b) At the distal stent graft-induced new entry level, false lumen shrinkage and thrombosis in the gutter were confirmed (from 60.1 to 57.3 mm). (c) At the left renal artery level, the false lumen partially thrombosed and the size decreased (from 40.9 to 36.9 mm)

Click here to view



  Discussion Top


SINE is considered a serious complication that affects the mortality rate of endovascular repair for a chronic aortic dissection.[1],[2],[3] In particular, the oversizing of stent graft contributes to its occurrence of distal SINE.[1],[2] In our case, the distal edge at the time of the previous TEVAR was just above the CA, and the aortic diameter was 36.8 mm, including the false lumen at that level; thus, tapered stent graft was selected considering the 28-mm diameter, but it could have been oversized. Furthermore, 9 years had passed since the first onset; furthermore, it was considered that the intimal flap had already lost its elasticity, resulting in the distal SINE. On the other hands, we need to consider whether the tapered grafts for preventing SINE and its radial force can obtain good aortic remodeling.

In stent grafting for short neck and juxtarenal abdominal aortic aneurysms, the chimney technique extends the proximal landing zone with persisting blood flow in the RA by simultaneously deploying the main body and a stent graft inserted into the RA in parallel.[4] Lobato and Camacho-Lobato[5] mentioned the sandwich technique as a method for maintaining the visceral and renal blood flow when treating complex thoracoabdominal aortic aneurysm, as in our case; a chimney graft is inserted in the space between the two aortic main bodies and opened in the true lumen of the main body. The PERICLES registry[6] showed a high surgical success rate of 97.1% and an early patency rate of 94.1% for chimney grafts during an average observation period of 17.1 months. In contrast, one of the problems with these procedures is the Type Ia endoleak via the gutter.[4] According to a report by Ulley et al.,[7] only 3.3% of cases actually required re-intervention owing to sac enlargement, and the gutter-related endoleak was benign. In addition, the self-expandable stent is superior in the flexibility to branch vessel angulation, but whether to choose the self- or balloon-expandable stent remains unknown. In our case, VIABAHN, which is a self-expandable stent, was selected to completely eliminate the blood flow to the SINE without organ malperfusion.

There was an option for thoracoabdominal aortic replacement in this case; however, it was difficult to reach the agreement with open surgery. When using a prefabricated branched device in a narrow dissected true lumen, the possibility of selectively catheterizing a visceral branch often has no straightforward solution. We believe that the chimney technique is a flexible technique and is of paramount importance for the surgical outcome in our case.


  Conclusions Top


The operative strategy with chimney EVAR was a very effective minimally invasive and safe treatment without any cardiovascular complications for reoperation case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pantaleo A, Jafrancesco G, Buia F, Leone A, Lovato L, Russo V, et al. Distal stent graft-induced new entry: An emerging complication of endovascular treatment in aortic dissection. Ann Thorac Surg 2016;102:527-32.  Back to cited text no. 1
    
2.
Dong Z, Fu W, Wang Y, Wang C, Yan Z, Guo D, et al. Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection. J Vasc Surg 2010;52:1450-7.  Back to cited text no. 2
    
3.
Li Q, Ma WG, Zheng J, Xu SD, Chen Y, Liu YM, et al. Distal stent graft-induced new entry after TEVAR of type B aortic dissection: Experience in 15 years. Ann Thorac Surg 2019;107:718-24.  Back to cited text no. 3
    
4.
Greenberg RK, Clair D, Srivastava S, Bhandari G, Turc A, Hampton J, et al. Should patients with challenging anatomy be offered endovascular aneurysm repair? J Vasc Surg 2003;38:990-6.  Back to cited text no. 4
    
5.
Lobato AC, Camacho-Lobato L. Endovascular treatment of complex aortic aneurysms using the sandwich technique. J Endovasc Ther 2012;19:691-706.  Back to cited text no. 5
    
6.
Donas KP, Lee JT, Lachat M, Torsello G, Veith FJ, PERICLES investigators. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: The PERICLES registry. Ann Surg 2015;262:546-53.  Back to cited text no. 6
    
7.
Ulley BW, Tran K, Itoga NK, Dalman RL, Lee JT. Natural history of gutter-related type Ia endoleaks after snorkel/chimney EVAR. J Vasc Surg 2017;65:981-90.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusions
   References
   Article Figures

 Article Access Statistics
    Viewed558    
    Printed14    
    Emailed0    
    PDF Downloaded35    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]