Accepted Manuscript Aortic dissection with acute malperfusion syndrome: Endovascular fenestration by the funnel technique Anne Vendrell, MD, Julien Frandon, MD, Mathieu Rodiere, MD, Olivier Chavanon, MD PhD, Jean-Philippe Baguet, MD PhD, Ivan Bricault, MD PhD, Bastien Boussat, MD, Gilbert Raymond Ferretti, MD PhD, Frédéric Thony, MD PII:
S0022-5223(15)00507-3
DOI:
10.1016/j.jtcvs.2015.03.056
Reference:
YMTC 9483
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 8 January 2015 Revised Date:
18 March 2015
Accepted Date: 30 March 2015
Please cite this article as: Vendrell A, Frandon J, Rodiere M, Chavanon O, Baguet J-P, Bricault I, Boussat B, Ferretti GR, Thony F, Aortic dissection with acute malperfusion syndrome: Endovascular fenestration by the funnel technique, The Journal of Thoracic and Cardiovascular Surgery (2015), doi: 10.1016/j.jtcvs.2015.03.056. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Title Page:
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Manuscript type: Original Research Article
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Title: Aortic dissection with acute malperfusion syndrome: Endovascular fenestration by the
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funnel technique
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Authors name:
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Anne VENDRELL, MD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble
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Julien FRANDON, MD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble
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Mathieu RODIERE, MD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble
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Olivier CHAVANON, MD PhD
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Clinique Universitaire de Chirurgie Cardio-Thoracique
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CHU de Grenoble
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Jean-Philippe BAGUET, MD PhD
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Service de Cardiologie
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Clinique des Eaux Claires – Groupe Hospitalier Mutualiste
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Ivan BRICAULT, MD PhD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble
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Bastien BOUSSAT, MD
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Université Joseph Fourier, Laboratoire TIMC-IMAG
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CHU de Grenoble
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Gilbert Raymond FERRETTI, MD PhD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble
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Frédéric THONY, MD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble
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Relationship with industry: No relation
Conflicts of interests: None
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ACCEPTED MANUSCRIPT Correspondence to:
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Anne VENDRELL, MD
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Clinique Universitaire de Radiologie et d’Imagerie Médicale CURIM
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CHU de Grenoble, BP 10217, 38043 GRENOBLE Cedex 09 (France)
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Tel: 00 334.76.76.52.41
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[email protected] Fax : 00 334.76.76.88.30
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Total word count: 2537 excluding abstracts and references
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Structured Abstract:
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Objective: To analyze the short- and long-term results of an original aortic fenestration
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method using the funnel technique during aortic dissection complicated by malperfusion
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syndrome.
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Methods: The funnel technique consists in the deployment of an uncovered aortic stent graft
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placed from the false to the right lumen through an intimal flap aortic fenestration made by
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balloon angioplasty. Twenty-eight patients presenting with an aortic dissection (type A n=19,
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type B n=9) were treated for malperfusion syndrome due to dynamic compression (16 renal,
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17 bowel, and 13 lower limb ischemia) using the aforementioned technique, and were
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followed-up at short (30 days) and long term (mean 55 ± 40 months). Eight patients had
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severe ischemia upon arrival (6 bowel, 7 renal, 3 lower limb ischemia).
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Results: Technical success was achieved in 27 of 28 patients (96%) and ischemic symptoms
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have disappeared in 25 of 28 patients (89%) at short term. Five patients presented
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postprocedure complications: four minor and one major with arterial thrombosis which
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caused technical failure (3.6%). The 30-day mortality rate was 7% (n=2), related to bowel
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ischemia complications. At long-term, 21 patients had a stable thoracic aortic diameter (91%).
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Conclusion: The funnel technique in cases of malperfusion syndrome following aortic
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dissection safely improves the clinical outcome at short and long term, and could represent an
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interesting alternative in the management of patients. The hemodynamic efficiency of this
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technique may account for a lower mortality in our series.
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Word count: 232 words
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Key words: Aortic dissection, Aortic fenestration, Stent, Malperfusion
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Ultramini Abstract:
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The funnel technique is a novel aortic fenestration method using a stent graft through the
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intimal flap for patients with malperfusion syndrome. Among the 28 patients treated, the
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clinical success rate was 89% (n=25) and the 30-day mortality rate was 7% (n=2), with only
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one self-limited major complication.
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Units of measurement: None
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Abbreviations:
AD: Aortic dissection
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MPS: Malperfusion syndrome
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FT: Funnel technique
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LL: Lower limbs
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MOF: Multiple organ failure
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Text:
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Introduction:
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Acute aortic dissection (AD) is a rare but serious disease1, inducing a high mortality rate
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(50%) at 48 hours2,3. The Stanford classification of AD4 differentiates type A requiring
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surgical management5, from type B treated medically6.
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Malperfusion syndrome (MPS) due to a reduced flow in the aortic branch vessels, is the
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second most common complication (20-50%) of AD7 after cardiac complications8 and causes
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higher mortality (51% versus 29% in survivors patients)9–11. Two ischemic mechanisms have
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been described12: dynamic compression due to an aortic true lumen collapse and static
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compression related to direct extension of AD into an aortic branch.
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In cases of dynamic compression MPS, closing the primary entry tear of the dissection by
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using a covered stent is the recommended treatment13–16. When this is unfeasible, aortic
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fenestration (AF) has been proposed as an alternative technique17–20; however, high
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postprocedural complications (11–20%) and mortality rates (17–34%) have been reported.
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In our center, a new and original AF technique consisting of an uncovered aortic stent graft
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insertion between the false and the right lumen called the “funnel technique” (FT) was
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performed on selected patients. The aim of this study was to assess the safety and efficacy of
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this technique at short- and long-term follow-up.
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Methods:
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Study design:
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The local Institutional Review Board (N°5891) approved this retrospective study. Relevant
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and follow-up data were collected and reviewed, using the medical files and imaging exams
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of included patients.
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From January 1, 2000 to December 31, 2013 all consecutive patients presenting renal,
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digestive and/or lower limbs (LLs) ischemia due to dynamic compression MPS following
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type A or B AD admitted to our center received this new procedure. These patients could not
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be treated by thoracic aortic stent graft because of anatomic constraints, as entry tear in the
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aortic segment II or next to the supra aortic trunks.
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Diagnosis of MPS was based on clinical, biological, and/or radiological features, according to
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the following criteria:
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Renal ischemia: uncontrolled arterial hypertension, defined as blood systolic pressure
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>120 mmHg despite two intraveinous antihypertensive therapy, variation of serum
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creatinine ≥ 44 µmol/L or decreased glomerular filtration rate >25%21, evidence of
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renal malperfusion on the CT scan in the non-severe forms; anuria in the severe forms; -
non-severe forms; sensorimotor deficit in the severe forms;
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LL ischemia: absent pulse, claudication, cool limb, low flow in the iliac arteries in the
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Bowel ischemia: abdominal pain, diarrhea in the non-severe forms; bowel tract bleeding, high lactates level, and/or lack of enhancement of bowel wall on CT scan in severe forms.
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The pre-operative CT scan also confirmed the dynamic compression, with the collapse of the
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true lumen, and the absence of concomitant disease which could explain the symptoms.
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These different types of ischemia and their severity are described in Table 1.
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MPS could occur immediately during the dissection, postoperatively, or later. The time from
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diagnosis to treatment varied from 3 hours to 72 hours.
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Procedure:
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A pre-procedure contrast enhanced CT-scan was systematically performed to determine the
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orientation of the intimal flap and the fenestration target, located 4 cm above the celiac trunk.
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All procedures were performed by two interventional radiologists with more than 10 years
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experience (FT, MR), under fluoroscopic guidance. Initial anteroposterior and lateral
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angiography in the true lumen was first done under local anesthesia, through a femoral sheath,
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to confirm the dynamic compression and identify the flap orientation. In a curved 5F catheter
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positioned 4 cm above the coeliac trunk facing the intima, a rigid 0.014 Spartacore®
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guidewire (Abbott Vascular, Santa Clara, CA, USA) was introduced in the reverse position
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(hard end first) pushed through the flap and advanced in the false lumen. The fenestration
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opening was then enlarged by using an 18 mm diameter balloon (Boston Scientific, Natick,
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MA, USA) after changing the introducer for a 10-F sheath and replacing the guidewire with a
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0.035 inch guidewire (Terumo, Yamanashi, Japan). An uncovered self-expanding steel stent
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(Wallstent, Boston Scientific, Natick, MA, USA) or nitinol stent (Memotherm, Bard
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Angiomed, Wachhausstrasse, Germany) of 18 mm to 24 mm diameter and 40-60 mm long,
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was then deployed from the false lumen toward the true lumen through the opening created,
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with its distal end placed above the ostium of celiac trunk.
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The final angiography was then performed in the false lumen above the fenestration, and had
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to confirm satisfactory flow in the true lumen (increased caliber, rapid and intense
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enhancement) and the aortic branches. Upstream of the stent, the true aortic lumen was
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expected to be collapsed by the stent (Figures 1, 2, 3 and 4).
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If the angiographic result was inadequate, an additional subrenal fenestration without stenting
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or peripheral stenting of side branches was discussed.
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For the following 6 months, patients received an antiplatelet treatment, except those treated
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with oral anticoagulants.
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Definitions:
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Technical success was defined as a normal blood flow velocity in the stent, the true lumen
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and the aortic branches, with a normal perfusion of end-organs on the final angiogram, in
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either a single procedure (primary technical success) or two procedures, whether or not
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simultaneous (secondary technical success).
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Clinical success was defined when clinical symptoms disappeared and biological parameters
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normalized between D+1 and D+30.
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The main evaluation criterion was clinical success. The secondary evaluation criteria were
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mortality and complication rate at short term (between D+1 and D+30); onset of late
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complications and evolution of thoracic aorta diameter at long term.
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Patients were followed up by MRI or CT at Day + 10, 6 months, 12 months, and then every
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2 years. The mean duration of follow-up was defined as the time between the initial imaging
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study and the last available images. The thoracic aorta was measured on the same levels in the
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axial plane. Increase aortic diameter was defined by a diameter greater than 60 mm or
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progressing more than 4 mm/year. Data were summarized using the mean and the median
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(25-75% interquartile range). The Kaplan-Meier technique was used to perform a survival
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curve. Growth rates for aortic diameter were estimated with linear regression using a linear
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mixed-effects model. Linear mixed-effect regression analysis using follow-up time, the
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localization of primary entry tear, the involvement of ascending aorta, age and pre-existing
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hypertension was carried out. The significance threshold was set at p≤0.05.
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Results:
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Population:
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Within thirteen years, 379 patients were admitted to our center for AD (type A n=259, type B
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n=120). Among patients presenting with type A, 247/259 (95.4%) underwent surgical aortic
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replacement and 12/259 (4.6%) died before the surgery. All patients with type B AD were
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treated medically. Sixty-nine of 379 patients (18.2%) presented dynamic compression MPS,
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treated with either thoracic endovascular aortic repair (TEVAR) (n=41) or AF by the funnel
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technique (n=28).
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Of the 28 treated by FT, 19 patients presented type A AD and underwent emergency cardiac
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surgery (14 aorto-aortic tubes, 4 Bentall procedures, and 1 hemiarch replacement), always
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performed first regardless of the severity of MPS. Nine patients presented type B AD.
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Patients’ characteristics and ischemic territories are summarized in table 2.
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Eight out of 28 patients (29%) presented severe ischemia: mesenteric (n=6), renal (n=7), or
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lower limb (n=3).
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Additional stenting for concomitant static compression was necessary in 13/28 patients: renal
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(n=7), superior mesenteric (n=5), and iliac (n=5).
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Recanalization:
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Primary technical success was 86% (24/28), secondary technical success 96% (27/28), with
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no intraprocedural complications. Three patients required a second subrenal AF: one patient
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angiogram, two patients later because of recurrence of their ischemic symptoms at D2 and
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D15.
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Clinical success was achieved in 25 of 28 patients (89%). Two patients (7%) with severe
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ischemia (1 renal and bowel ischemia, 1 all three sites), treated with cardiac surgery and then
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AF at D0 died before D30: the first at D2 of multisystem organ failure, the second of septic
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shock ending in death at D14.
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One patient was considered as technical and clinical failure, and major complication because
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of worsening of a right LL ischemia at the end of the procedure, related to the onset of a
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thrombosis of the common femoral artery on the sheath. He was treated with embolectomy
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and femoro-femoral bypass resulting in good postoperative evolution.
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Severe ischemia:
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Six out of 8 patients with severe ischemia survived. Of the 4 survivors with mesenteric
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ischemia, all patients evolved favorably, 3 of whom required bowel resection. Dialysis was
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reversible after AF for the 5 patients with severe renal ischemia. Of the two patients with
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severe LL ischemia, both improved after fenestration, although one of them required a
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femoral bypass as previously described. Table 3 summarizes the characteristics of the patients
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with severe ischemia.
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Complications:
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Five patients presented complications. The major complication was described above. Of the
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four minor complications, 3 were related to the puncture point (arterial thrombosis resolved
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with medical treatment; hematoma and infection resolved with antibiotics). The last
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complication was an aortic stent fracture on a nitinol stent discovered on the follow-up CT at
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D10, with no clinical or biological repercussions and was treated by placing a second stent
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within the fractured one.
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Follow-up:
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During the follow-up, three patients were lost to follow-up after hospitalization and three had
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died (Figure 5): two at one year of follow-up, the first after surgical replacement of the
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descending aorta and the second of a brain tumor; the third of fissuration of a descending
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thoracic aorta aneurysm at nine years of follow-up. Of the 23 patients followed up, one
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proximal fracture of a nitinol stent was detected on the 2 years follow-up CT with no
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consequences. No recurrence of ischemia was observed.
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Aortic diameter increased significantly over time (p= 0.0038) at a mean rate of 1.46 mm/year.
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Two patients had a significant increased aortic thoracic diameter (9%) and needed a surgical
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treatment. No risks factors among the localisation of entry tear, the involvement of ascending
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aorta, the age or pre-existing hypertension were identified.
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Concerning the 41 patients treated by TEVAR (type B n= 34, type A n=7), six patients died
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and three presented endoleaks with recirculation of the false lumen (type II n=2, type I n=1).
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These patients were treated by an embolization of the endoleaks and presented a good clinical
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outcome.
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Discussion:
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The current recommended treatment for MPS caused by dynamic compression is to close the
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primary entry tear of AD by a covered thoracic stent graft14,16,22,23. However, when it is not
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possible, AF can resupply the true lumen at the abdominal level by creating a communication
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between the two lumens. Two techniques of AF have been described: fenestration with
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patients17 and 40 patients20. Our technique is new and original because it enlarges the surface
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area of the re-entry orifice in the true lumen with an endoaortic stent positioned between the
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two lumens, which increases flow and pressure in the true lumen and reduces them in the
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false, thus improving the efficacy of fenestration.
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AF has been described as both a reliable (100% technical success) and effective technique,
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with clinical success between 70% and 93% at D+3017,20 versus 60% for surgery22. This series
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also shows that AF using the funnel technique is effective (89% clinical success).
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With balloon angioplasty AF, the 30-day mortality rate was 17–25%, with an approximately
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20% complication rate19,20,25. The scissor technique has shown 30% mortality at D+30 with
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roughly 10% complications17. Mortality in our series was much lower (7%) and the morbidity
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rate was equivalent (18%).
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Patients with severe ischemia account for 14% to 26% with a 33% to 66% mortality
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rate17,20,27. In our series, the severe ischemia rate was higher with 29%, with a lower mortality
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rate (25%). The mortality rate with the FT therefore does not stem from the population
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presenting globally less severe MPS, but probably from a more effective reapplication of
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pressure in the true lumen. This results in the disappearance of the clinical symptoms and the
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reversion of the acute ischemic lesions, preventing the onset of multi-organ failure. In the
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present study, only two patients (7%) died of multi-organ failure despite the AF, whereas this
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unfavorable outcome seems more frequent in the other series (15-25%)17,20.
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We did not observe stent malposition or stent migration during grafting, nor injury of the
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aortic wall or stent thrombosis at the long term. Two fractures of stents were discovered
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inadvertently, both asymptomatic and involving nitinol stents (Memotherm Bard Angiomed,
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Wallstents (Boston Scientific, Natick, MA, USA), with no new complications discovered to
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date. No collapse of the stent had been observed, probably due to the placement of the stent
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between the two lumens, which decreased pressure in the false lumen. Massman et al28 had
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described this type of complication in 4 of 14 patients treated by an uncovered aortic stent
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graft in the true lumen: this collapse could be due to the persistent pressure in the false lumen,
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which allowed the compression of the true lumen and the dilatation of the false lumen at long
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term.
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Three patients underwent an additional fenestration because the first was deemed insufficient.
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In these patients, an 18 mm diameter stent was selected for a mean 30 mm diameter aorta in
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the fenestration area. Finally, this stent diameter was considered too small for the size of the
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false lumen. Since this time, we have used stents with a larger diameter so that the re-entry
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orifice in the true lumen is at least two-thirds the total diameter of the aorta, thus ensuring that
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flow is greater than 50% between the true and false lumen. This is not always possible
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because the maximal diameter of a wallstent is 24mm.
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Over the long-term, decreased pressure in the false lumen seems to protect against the
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aneurysmal aortic evolution, since 91% of our patients (15 type A and 6 type B) presented a
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stable aortic diameter. The only one factor involved in the growth aortic diameter was the
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follow up-time, with a mean progression of 1.46mm/year, which we considered as natural
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evolution. As reported in the literature, the natural progression of AD is characterized by
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dilatation of the descending thoracic aorta in 20–50% of cases29 and up to 83% in the
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segment-by-segment study of the aorta30,31. This confirms the hypothesis postulating that
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blood pressure is reduced within the false lumen upon reapplication of pressure in the true
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lumen, thus avoiding progression toward aneurysm. Midulla et al.17 have reported the same
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observation.
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The small number of patients treated was the main limitation of this study. Further studies, as
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best comparative and multicentric, would be necessary to confirm the efficacy and safety of
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this new procedure. Another limitation was a recruitment bias concerning bowel ischemia as
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some patients have not been treated by the FT because of their gravity or the onset of death
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before the treatment.
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Aortic fenestration by the funnel technique, in patients with MPS during aortic dissection is
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an effective technique (clinical success: 89%) associated with low morbidity (30-day
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mortality: 7%; major complications: 3.6%). Over the long-term, no ischemic recurrence was
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observed, and decreasing the applied pressure of the false lumen seems to protect from
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increase aortic thoracic diameter. The hemodynamic efficiency of this technique may account
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for a lower mortality in our series but this result has to be confirmed.
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9. Di Eusanio M, Trimarchi S, Patel HJ, Hutchinson S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145(2):385-390.
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ACCEPTED MANUSCRIPT 15. Nienaber CA, Zannetti S, Barbieri B, Kirsche S, Scharek W, Rehders TC, et al. INvestigation of STEnt grafts in patients with type B Aortic Dissection: design of the INSTEAD trial--a prospective, multicenter, European randomized trial. Am Heart J. 2005;149(4):592-599.
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16. Botsios S, Schuermann K, Maatz W, Keck N, Walterbusch G. Complicated acute type B dissections: a single-center experience with endovascular treatment. Thorac Cardiovasc Surg. 2010;58(5):280-284. 17. Midulla M, Renaud A, Martinelli T, Koussa M, Mounier-Vehier C, Prat A, et al. Endovascular fenestration in aortic dissection with acute malperfusion syndrome: immediate and late follow-up. J Thorac Cardiovasc Surg. 2011;142(1):66-72.
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18. Beregi J-P, Haulon S, Otal P, Thony F, Bartoli JM, Crochet D, et al. Endovascular treatment of acute complications associated with aortic dissection: midterm results from a multicenter study. J Endovasc Ther Off J Int Soc Endovasc Spec. 2003;10(3):486-493.
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19. Patel HJ, Williams DM, Meerkov M, Meekov M, Dasika NL, Upchurch GR Jr, et al. Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: implications for thoracic aortic endovascular repair. J Thorac Cardiovasc Surg. 2009;138(2):300-308. 20. Slonim SM, Miller DC, Mitchell RS, Semba CP, Razavi MK, Dake MD. Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg. 1999;117(6):1118-1126.
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21. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care Lond Engl. 2004;8(4):R204R212.
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22. Fattori R, Tsai TT, Myrmel T, Cooper JV, Trimarchi S, Li J, et al. Complicated acute type B dissection: is surgery still the best option?: a report from the International Registry of Acute Aortic Dissection. JACC Cardiovasc Interv. 2008;1(4):395-402. 23. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120(25):2519-2528.
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24. Kos S, Gürke 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 Intervent Radiol. 2011;34(6):1296-1302. 25. Chavan A, Hausmann D, Dresler C, et al. Intravascular ultrasound-guided percutaneous fenestration of the intimal flap in the dissected aorta. Circulation. 1997;96(7):2124-2127. 26. Beregi JP, Prat A, Gaxotte V, Delomez M, McFadden EP. Endovascular treatment for dissection of the descending aorta. Lancet. 2000;356(9228):482-483.
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ACCEPTED MANUSCRIPT 27. O’Donnell S, Geotchues A, Beavers F, Akbari C, Lowery R, Elmassry S, et al. Endovascular management of acute aortic dissections. J Vasc Surg. 2011;54(5):1283-1289. 28. Massmann A, Kunihara T, Fries P, Schneider G, Buecker A, Schäfers H-J. Uncovered stent implantation in complicated acute aortic dissection type B. J Thorac Cardiovasc Surg. 2014;148(6):3003-3011.
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29. Trimarchi S, Jonker FHW, van Bogerijen GHW, et al. Predicting aortic enlargement in type B aortic dissection. Ann Cardiothorac Surg. 2014;3(3):285-291. 30. Tolenaar JL, van Keulen JW, Jonker FHW, Tolenaar JL, Moll FL, Czerny M, et al. Morphologic predictors of aortic dilatation in type B aortic dissection. J Vasc Surg. 2013;58(5):1220-1225.
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31. Sueyoshi E, Sakamoto I, Hayashi K, Yamaguchi T, Imada T. Growth rate of aortic diameter in patients with type B aortic dissection during the chronic phase. Circulation. 2004;110 (11 Suppl 1):II256-II261.
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548
549
550
551
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552
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554
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Tables:
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Table 1: Different types of ischemia and their severity: Definition
N
Severe
Lower limb ischemia Non-severe
560 561 562 563
Anuria
Renal malperfusion
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Variation of serum creatinine ≥ 44 µmol/L or decreased glomerular filtration rate >25%
Abdominal pain, diarrhea Bowel tract bleeding
Absent pulse, claudication, cool limb Sensorimotor deficit
High lactates level
9
7 11
Lack of enhancement of bowel wall
6
Low flow in iliac arteries
10 3
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559
Uncontrolled arterial hypertension
Radiological
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Severe 558
Biological
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Severe Bowel ischemia Non-severe
Clinical
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Renal ischemia Non-severe
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Ischemia territories
564 565 566
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Table 2: Population caracteristics: Characteristic
Value
Male
9
Female
19
56 (47-63)
Type A dissection
19
Type B dissection
9
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Median age (Y)
Three sites : Renal/Mesenteric/Lower Limb Two sites :
5
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Renal/Lower Limb
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Mesenteric Lower Limb
569
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Mesenteric/Lower Limb
Renal
4
10
Renal/Mesenteric
One site
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Ischemic Territories
568
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Sex
3 2 14 5 5 4
570 571 572
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Table 3: Treatment and evolution of patients with severe ischemia: Severe
ischemia N Bowel
sites
Bowel
resection monitoring 2
1
1
Renal/Bowel
2
1
2
1
1
Renal
1
Bowel
2
Lower limbs
1
1 1
2
1
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584
1
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578
583
1
1
577
582
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1
576
581
complications
2
575
580
Death Alive
Renal/Bowel/LL
574
579
Dialysis Major
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573
585
586
587
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Figures legends:
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Figure 1: 71-years-old patient admitted for acute type B AD with severe bowel ischemia
591
(bowel tract bleeding and high lactate level) due to dynamic compression and dissection of
592
the superior mesenteric artery. Angio CT-scan on axial views (A, B), sagittal (C) and coronal
593
reformations (D), showing thoraco-abdominal type B AD, with large primary entry tear
594
located in the aortic arch (arrowhead); compression of the true lumen (TL) by the false lumen
595
(FL) in the abdominal aorta, decreasing blood flow in the abdominal arteries.
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Figure 2: Illustration of the funnel technique: A, B: Illustration showing the dynamic
598
compression: the true lumen is collapsed by the large false lumen. C, D: AF with balloon
599
angioplasty of the fenestration opening and deployment of the stent graft across the false and
600
the true lumen.
601
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Figure 3: Aortic fenestration using the funnel technique in the same patient. A: Angiogram
603
showing a collapsed true lumen (TL). The right renal artery and the intercostal arteries
604
originate from the true lumen (arrowsheads). B: Angiogram of the false lumen (FL) after
605
insertion of a catheter through the intimal perforation, showing the celiac trunk, the left renal
606
artery, the superior and inferior mesenteric arteries (white arrows). Only the first part of the
607
superior mesenteric artery is supplied by the false lumen. D: Final angiogram with injection in
608
the false lumen (FL): The blood flow in the true lumen (TL) has been restored by the stent
609
graft (asterisk) with good patency of both renal arteries (solid arrows), the celiac trunk
610
(splenic and hepatic arteries) and the superior mesenteric artery (dashed arrows).
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613
(C) and VRT reformations (D) showing the stent graft (asterisk) within the true lumen (TL)
614
and the false lumen (FL) and the good patency of the aortic branchs. Another stent has been
615
placed in the superior mesenteric artery in the same procedure because of static compression
616
(arrowhead). Ischemic symptoms have disappeared after the procedure and the patient have
617
evolved favorably.
618
Figure 5: Survival rate after treatment by the funnel technique.
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619 620
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621 622 623 624
629 630 631 632
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628
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627
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625 626
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612
633 634 635 636
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Central picture:
638
Figure 4
639
The funnel technique: uncovered aortic stent graft between the false and the true lumen.
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640 641
Central Message:
643
The funnel technique is a novel aortic fenestration method using a stent graft through the
644
intimal flap for patients with malperfusion syndrome. Among the 28 patients treated, the
645
clinical success rate was 89% (n=25) and the 30-day mortality rate was 7% (n=2), with only
646
one self-limited major complication.
647
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Perspective:
649
The funnel technique in patients with malperfusion syndrome during aortic dissection seems
650
to be a better treatment considering his efficacy and low rate of morbidity compared to the
651
other aortic fenestration techniques. This method could become an interesting alternative to
652
the covering of the primary entry tear when this is unfeasible, because it protects from the
653
ischemic recurrence at short term. At long term, it also permits to decrease pressure in the
654
false lumen, which protect from potential thoracic aortic dilatation, which occur in 20-50% of
655
cases.
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AC C
656
TE D
648
657
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