575279
research-article2015
JETXXX10.1177/1526602815575279Journal of Endovascular TherapyBarbante et al
Case Report
Fenestrated Endografting After Bare Metal Dissection Stent Implantation
Journal of Endovascular Therapy 2015, Vol. 22(2) 207–211 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602815575279 www.jevt.org
Matteo Barbante, MD1,2, Jonathan Sobocinski, MD, PhD1, Blandine Maurel, MD, PhD1, Richard Azzaoui, MD1, Teresa Martin-Gonzalez, MD1, and Stéphan Haulon, MD, PhD1
Abstract Purpose: To present a case that demonstrates the ability to deploy a 4-fenestrated endograft in an aorta previously treated with an endovascular graft and additional distal bare stents for acute type B dissection. Case Report: Five years ago, a 61-year-old man had a Zenith TX2 endovascular graft and 2 distal bare metal stents deployed for acute type B dissection. In follow-up, a distal extension endograft was deployed below the bare stent for false lumen reperfusion and aortic growth. The ascending aorta and the arch were replaced surgically at 3 years, with the distal end of the graft sewn to the existing endograft. At the current admission, a Crawford type III thoracoabdominal aortic aneurysm was found and excluded with a 4-fenestration endograft. Using 3-dimensional fusion imaging, there was no major conflict with the struts of the bare dissection stent during catheterization and bridging stent placement. A distal bifurcated endograft was also implanted. The total procedure time was 240 minutes, the radiation dose was 8066 cGy·cm2, and the contrast volume was 100 mL. The patient was discharged on the sixth postoperative day and continues to do well at 9 months. Conclusion: Prior dissection stent deployment within the thoracoabdominal segment does not preclude further fenestrated endograft placement. Intraoperative fusion imaging can be very helpful to the successful completion of these complex procedures. Keywords type B aortic dissection, thoracoabdominal aortic aneurysm, stent-graft, dissection stent, fenestrated stent-graft, fusion imaging
Introduction Endovascular repair is an option to treat chronic dissections.1 It is, however, usually a challenging approach because of the need to work in a narrow true lumen and to access aortic branches arising from the false lumen. The recent prospective multicenter STABLE trial (Study for the Treatment of Complicated Type B Aortic Dissection using Endoluminal Repair) examined the use of an additional bare metal stent within the distal aorta after having excluded the dominant proximal intimal tear with an endograft.2 One of the theoretical advantages of this approach is to promote aortic remodeling, but some patients still experience aortic dilatation during follow-up.3 The presence of bare struts across the visceral aorta is a potential contraindication to endovascular exclusion of the dilated aortic segment, but often the endovascular option is the only possible treatment that can be proposed to high-risk patients.
family history of cardiovascular disease was recorded, and dyslipidemia was the only cardiovascular risk factor. The initial computed tomographic angiogram (CTA) depicted an acute Stanford type B aortic dissection extending from the origin of the left subclavian artery (LSA) to both external iliac arteries. The dominant intimal entry tear was located just after the LSA origin. The true lumen was completely collapsed at the level of the infrarenal aorta and the left common iliac artery. All the visceral arteries arose from the true lumen except for the right renal artery. The index procedure included the implantation of a thoracic endograft (Zenith TX2 ZTEG-2P-42-162; Cook Medical, Bloomington, IN, USA) intentionally covering the origin of the LSA; 2 distal bare metal stents (Gianturco-Z Stent Dissection device 46-123; Cook Medical) were deployed from the thoracic 1
Lille University Hospital, Lille, France University of Rome Tor Vergata, Rome, Italy
2
Case Report A 61-year-old man was referred to our department for acute epigastric pain and bilateral acute lower limb ischemia. No
Corresponding Author: Stéphan Haulon, Chirurgie Vasculaire, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France. Email: [email protected]
208
Journal of Endovascular Therapy 22(2)
Figure 1. (A) Axial views of the preoperative computed tomographic angiogram (CTA) at acute presentation showing the right renal artery arising from the false lumen and true lumen collapse within the infrarenal aorta. (B) Sagittal, axial, and (C) 3-dimensional volume rendering reconstructions of the postoperative CTA showing good patency of the visceral, renal, and iliac arteries.
endograft down to the infrarenal aorta. The final angiogram and postoperative CTA confirmed expansion of the true lumen and correction of the malperfusion (Figure 1). The immediate postoperative course was uneventful, and the patient was discharged 10 days after the procedure with an optimized antihypertensive regimen. During follow-up, 2 reinterventions were performed. At 9 months, a large de novo secondary tear below the endograft (at the level of the bare stent) was found; it was associated with false lumen reperfusion and thoracic aortic growth. A distal endograft extension was implanted (ZTEG 2P-42-162; Cook Medical). At 36 months, the follow-up CTA depicted rapid enlargement of the ascending aorta and the arch, requiring open ascending and arch aortic replacement. The distal end of the graft was sewn to the existing endograft. Subsequent follow-up showed favorable remodeling of the true lumen at the level of the descending thoracic aorta, but not in the abdomen, where a large reentry tear was persistently feeding the false lumen. The 5-year CTA showed a Crawford type III thoracoabdominal aneurysm with a maximal diameter of 62 mm (Figure 2). Endovascular exclusion was decided because he had severe respiratory insufficiency requiring prolonged intensive
care following his open arch repair. The device planned was custom made (Cook Medical) and included 4 fenestrations for the renal arteries, the superior mesenteric artery, and the celiac trunk. Preoperative cerebrospinal fluid drainage was performed to prevent spinal cord ischemia. The endovascular procedure was performed in our hybrid operating room (Discovery IGS 730; GE Healthcare, Chalfont St Giles, UK). Two successive proximal thoracic endografts were implanted from the previous thoracic endografts to the distal thoracic aorta prior to the deployment of the fenestrated device. Access to the target arteries through their dedicated fenestrations was managed from a left femoral approach; the procedure was assisted by 3-dimensional (3D) fusion imaging software, with overlay of a 3D volume rendering reconstruction of the aorta and its branches (generated from the preoperative CTA) on top of the fluoroscopic images. The right renal artery was catheterized through a reentry tear located in front of its origin. Covered bridging stents (Advanta V12; Maquet Cardiovascular, Rastatt, Germany) were positioned between each fenestration and its respective target artery. There was no major conflict with the struts of the bare dissection stent during catheterization and bridging stent placement. A distal bifurcated endograft was
Barbante et al
209
Figure 2. (A) Multiplanar reconstructions and (B) 3-dimensional volume rendering of the computed tomographic angiogram 5 years after the initial endovascular graft procedure: the origin of the right renal artery arising from the false lumen was dilated. (C) An intravascular view reconstruction (right panel) shows the origin of the visceral and renal arteries through the struts of the bare metal stent (from top to bottom: right renal, left renal, superior mesenteric, and celiac arteries).
also implanted. The total procedure time was 240 minutes, the radiation dose was 8066 cGy·cm2, and the contrast volume was 100 mL. Postoperative CTA confirmed good patency of the endograft and its branches and complete exclusion of the false aortic lumen (Figure 3). Early followup was uneventful, with no neurological complication; the serum creatinine level remained unchanged. The patient was discharged on the sixth postoperative day. At 6-month follow-up, the patient underwent a contrast-enhanced ultrasound that depicted a type II endoleak, a stable aneurysm sac diameter, and confirmed target vessel patency. He continues to be well 9 months after the fenestrated endograft was implanted.
Discussion Invasive therapy is considered in the acute setting of a type B aortic dissection when complications occur, such as aortic rupture and/or visceral/renal or lower limb ischemia.4 Recent reports support endovascular treatment as the firstline treatment in these situations.5,6 After the acute phase, the main concern is enlargement of the dissected aorta, which may occur in >70% of patients at 5 years.7,8 Exclusion of the dominant dissection tear does not always prevent
distal thoracic and abdominal aortic diameter expansion, even when endograft coverage includes the entire descending thoracic aorta.9,10 In 2005, Mossop et al11 proposed the STABLE concept concurrently investigated by Nienaber et al12 as the PETTICOAT concept, where an additional selfexpanding bare stent would enhance true lumen reexpansion along the entire thoracoabdominal segment, remove malperfusion, and promote aortic remodeling. This concept was evaluated in the prospective, multicenter STABLE study in 80 patients with complicated type B aortic dissection.2 The low radial strength of the self-expanding stainless steel bare stent seems to be more relevant in the acute setting when the intimal flap is movable.13 The dissection stent comes in 2 diameters (36 and 46 mm) on a 16-F sheath; its design was based on the Gianturco-Z scaffold, which has widely spaced stainless steel struts that theoretically permit access to visceral branches. In the STABLE study, catheterization of visceral vessels was always possible; 9 patients received 9 additional visceral stents after the deployment of the bare stent (8 renal arteries and 1 superior mesenteric artery).2 However, in our experience, when stenting of a visceral vessel was performed after implantation of the bare aortic stent because of persistent malperfusion, a conflict with the struts of the bare stent was sometimes
210
Journal of Endovascular Therapy 22(2)
Figure 3. Intraoperative images of the fenestrated endograft deployment. (A) On the left, catheterization of the visceral and renal arteries through their corresponding fenestrations and the struts of the bare stent; on the right, the final angiogram confirmed patency of the fenestrations, stents, and target arteries after deployment. (B) The 3-dimensional reconstructions of the immediate postoperative computed tomographic angiogram confirmed exclusion of the dilated aorta, with good patency of the fenestrated device.
encountered when the long sheath was advanced toward the target artery. If the 6-F or 7-F hydrophilic sheath did not track over a stiff wire, we withdrew the wire from the target vessel and catheterized it again from the other side of the strut. It was then always possible to advance the sheath into the target vessel to safely position and deliver a stent. In the current case, the additional aortic bare stents promoted aortic remodeling at the thoracic level but not further
down. Significant enlargement of the visceral and abdominal aorta required therapy, but the feasibility of fenestrated repair was questioned because of the presence of the aortic bare stents. Investigators have reported that custom-made fenestrated and/or branched endografts are a valuable therapeutic option to treat chronic dissections,1,13,14 but it has not been done to our knowledge in patients with previously implanted bare aortic stents in the thoracoabdominal segment.
Barbante et al Since 2013, we have performed all aortic procedures using fusion imaging to facilitate endovascular navigation, especially in complex anatomies. We have found it to significantly reduce radiation dose and contrast volume during complex procedures, as has been recently reported.15
Conclusion Prior dissection stent deployment within the thoracoabdominal segment does not preclude further custom-made fenestrated endograft placement. Preoperative high-quality images are mandatory to correctly plan the procedure and anticipate any subsequent challenge. Finally, recent imaging technologies, such as intraoperative fusion imaging, are very helpful in successfully completing these complex procedures. Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Stéphan Haulon is a consultant for Cook Medical and GE Healthcare.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Sobocinski J, Spear R, Tyrrell MR, et al. Chronic dissection indications for treatment with branched and fenestrated stentgrafts. J Cardiovasc Surg (Torino). 2014;55:505–517. 2. Lombardi JV, Cambria RP, Nienaber CA, et al. Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2012;55: 629.e2–640.e2. 3. Lombardi JV, Cambria RP, Nienaber CA, et al. Aortic remodeling after endovascular treatment of complicated type B aortic dissection with the use of a composite device design. J Vasc Surg. 2014;59:1544–1554. 4. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic
211 Dissection (IRAD). Eur J Vasc Endovasc Surg. 2009;37: 149–159. 5. Dake MD, Kato N, Mitchell RS, et al. Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340:1546–1552. 6. Fattori R, Tsai TT, Myrmel T, 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;1:395–402. 7. Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC Cardiovasc Interv. 2013;6: 876–882. 8. Jonker FH, Trimarchi S, Rampoldi V, et al. Aortic expansion after acute type B aortic dissection. Ann Thorac Surg. 2012;94:1223–1229. 9. Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry. J Vasc Surg. 2007;46:1103. e2–1111.e2. 10. Hanna JM, Andersen ND, Ganapathi AM, et al. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg. 2014;59:96–106. 11. Mossop PJ, McLachlan CS, Amukotuwa SA, et al. Staged endovascular treatment for complicated type B aortic dissection. Nat Clin Pract Cardiovasc Med. 2005;2:316–322. 12. Nienaber CA, Kische S, Zeller T, et al. Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther. 2006;13:738–746. 13. Kitagawa A, Greenberg RK, Eagleton MJ, et al. Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg. 2013;58:625–634. 14. Verhoeven EL, Paraskevas KI, Oikonomou K, et al. Fenestrated and branched stent-grafts to treat post-dissection chronic aortic aneurysms after initial treatment in the acute setting. J Endovasc Ther. 2012;19:343–349. 15. Kaladji A, Dumenil A, Castro M, et al. Endovascular aortic repair of a postdissecting thoracoabdominal aneurysm using intraoperative fusion imaging. J Vasc Surg. 2013;57: 1109–1112.
research-article2015
JETXXX10.1177/1526602815575279Journal of Endovascular TherapyBarbante et al
Case Report
Fenestrated Endografting After Bare Metal Dissection Stent Implantation
Journal of Endovascular Therapy 2015, Vol. 22(2) 207–211 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602815575279 www.jevt.org
Matteo Barbante, MD1,2, Jonathan Sobocinski, MD, PhD1, Blandine Maurel, MD, PhD1, Richard Azzaoui, MD1, Teresa Martin-Gonzalez, MD1, and Stéphan Haulon, MD, PhD1
Abstract Purpose: To present a case that demonstrates the ability to deploy a 4-fenestrated endograft in an aorta previously treated with an endovascular graft and additional distal bare stents for acute type B dissection. Case Report: Five years ago, a 61-year-old man had a Zenith TX2 endovascular graft and 2 distal bare metal stents deployed for acute type B dissection. In follow-up, a distal extension endograft was deployed below the bare stent for false lumen reperfusion and aortic growth. The ascending aorta and the arch were replaced surgically at 3 years, with the distal end of the graft sewn to the existing endograft. At the current admission, a Crawford type III thoracoabdominal aortic aneurysm was found and excluded with a 4-fenestration endograft. Using 3-dimensional fusion imaging, there was no major conflict with the struts of the bare dissection stent during catheterization and bridging stent placement. A distal bifurcated endograft was also implanted. The total procedure time was 240 minutes, the radiation dose was 8066 cGy·cm2, and the contrast volume was 100 mL. The patient was discharged on the sixth postoperative day and continues to do well at 9 months. Conclusion: Prior dissection stent deployment within the thoracoabdominal segment does not preclude further fenestrated endograft placement. Intraoperative fusion imaging can be very helpful to the successful completion of these complex procedures. Keywords type B aortic dissection, thoracoabdominal aortic aneurysm, stent-graft, dissection stent, fenestrated stent-graft, fusion imaging
Introduction Endovascular repair is an option to treat chronic dissections.1 It is, however, usually a challenging approach because of the need to work in a narrow true lumen and to access aortic branches arising from the false lumen. The recent prospective multicenter STABLE trial (Study for the Treatment of Complicated Type B Aortic Dissection using Endoluminal Repair) examined the use of an additional bare metal stent within the distal aorta after having excluded the dominant proximal intimal tear with an endograft.2 One of the theoretical advantages of this approach is to promote aortic remodeling, but some patients still experience aortic dilatation during follow-up.3 The presence of bare struts across the visceral aorta is a potential contraindication to endovascular exclusion of the dilated aortic segment, but often the endovascular option is the only possible treatment that can be proposed to high-risk patients.
family history of cardiovascular disease was recorded, and dyslipidemia was the only cardiovascular risk factor. The initial computed tomographic angiogram (CTA) depicted an acute Stanford type B aortic dissection extending from the origin of the left subclavian artery (LSA) to both external iliac arteries. The dominant intimal entry tear was located just after the LSA origin. The true lumen was completely collapsed at the level of the infrarenal aorta and the left common iliac artery. All the visceral arteries arose from the true lumen except for the right renal artery. The index procedure included the implantation of a thoracic endograft (Zenith TX2 ZTEG-2P-42-162; Cook Medical, Bloomington, IN, USA) intentionally covering the origin of the LSA; 2 distal bare metal stents (Gianturco-Z Stent Dissection device 46-123; Cook Medical) were deployed from the thoracic 1
Lille University Hospital, Lille, France University of Rome Tor Vergata, Rome, Italy
2
Case Report A 61-year-old man was referred to our department for acute epigastric pain and bilateral acute lower limb ischemia. No
Corresponding Author: Stéphan Haulon, Chirurgie Vasculaire, CHRU de Lille, INSERM U1008, Université Lille Nord de France, 59037 Lille Cedex, France. Email: [email protected]
208
Journal of Endovascular Therapy 22(2)
Figure 1. (A) Axial views of the preoperative computed tomographic angiogram (CTA) at acute presentation showing the right renal artery arising from the false lumen and true lumen collapse within the infrarenal aorta. (B) Sagittal, axial, and (C) 3-dimensional volume rendering reconstructions of the postoperative CTA showing good patency of the visceral, renal, and iliac arteries.
endograft down to the infrarenal aorta. The final angiogram and postoperative CTA confirmed expansion of the true lumen and correction of the malperfusion (Figure 1). The immediate postoperative course was uneventful, and the patient was discharged 10 days after the procedure with an optimized antihypertensive regimen. During follow-up, 2 reinterventions were performed. At 9 months, a large de novo secondary tear below the endograft (at the level of the bare stent) was found; it was associated with false lumen reperfusion and thoracic aortic growth. A distal endograft extension was implanted (ZTEG 2P-42-162; Cook Medical). At 36 months, the follow-up CTA depicted rapid enlargement of the ascending aorta and the arch, requiring open ascending and arch aortic replacement. The distal end of the graft was sewn to the existing endograft. Subsequent follow-up showed favorable remodeling of the true lumen at the level of the descending thoracic aorta, but not in the abdomen, where a large reentry tear was persistently feeding the false lumen. The 5-year CTA showed a Crawford type III thoracoabdominal aneurysm with a maximal diameter of 62 mm (Figure 2). Endovascular exclusion was decided because he had severe respiratory insufficiency requiring prolonged intensive
care following his open arch repair. The device planned was custom made (Cook Medical) and included 4 fenestrations for the renal arteries, the superior mesenteric artery, and the celiac trunk. Preoperative cerebrospinal fluid drainage was performed to prevent spinal cord ischemia. The endovascular procedure was performed in our hybrid operating room (Discovery IGS 730; GE Healthcare, Chalfont St Giles, UK). Two successive proximal thoracic endografts were implanted from the previous thoracic endografts to the distal thoracic aorta prior to the deployment of the fenestrated device. Access to the target arteries through their dedicated fenestrations was managed from a left femoral approach; the procedure was assisted by 3-dimensional (3D) fusion imaging software, with overlay of a 3D volume rendering reconstruction of the aorta and its branches (generated from the preoperative CTA) on top of the fluoroscopic images. The right renal artery was catheterized through a reentry tear located in front of its origin. Covered bridging stents (Advanta V12; Maquet Cardiovascular, Rastatt, Germany) were positioned between each fenestration and its respective target artery. There was no major conflict with the struts of the bare dissection stent during catheterization and bridging stent placement. A distal bifurcated endograft was
Barbante et al
209
Figure 2. (A) Multiplanar reconstructions and (B) 3-dimensional volume rendering of the computed tomographic angiogram 5 years after the initial endovascular graft procedure: the origin of the right renal artery arising from the false lumen was dilated. (C) An intravascular view reconstruction (right panel) shows the origin of the visceral and renal arteries through the struts of the bare metal stent (from top to bottom: right renal, left renal, superior mesenteric, and celiac arteries).
also implanted. The total procedure time was 240 minutes, the radiation dose was 8066 cGy·cm2, and the contrast volume was 100 mL. Postoperative CTA confirmed good patency of the endograft and its branches and complete exclusion of the false aortic lumen (Figure 3). Early followup was uneventful, with no neurological complication; the serum creatinine level remained unchanged. The patient was discharged on the sixth postoperative day. At 6-month follow-up, the patient underwent a contrast-enhanced ultrasound that depicted a type II endoleak, a stable aneurysm sac diameter, and confirmed target vessel patency. He continues to be well 9 months after the fenestrated endograft was implanted.
Discussion Invasive therapy is considered in the acute setting of a type B aortic dissection when complications occur, such as aortic rupture and/or visceral/renal or lower limb ischemia.4 Recent reports support endovascular treatment as the firstline treatment in these situations.5,6 After the acute phase, the main concern is enlargement of the dissected aorta, which may occur in >70% of patients at 5 years.7,8 Exclusion of the dominant dissection tear does not always prevent
distal thoracic and abdominal aortic diameter expansion, even when endograft coverage includes the entire descending thoracic aorta.9,10 In 2005, Mossop et al11 proposed the STABLE concept concurrently investigated by Nienaber et al12 as the PETTICOAT concept, where an additional selfexpanding bare stent would enhance true lumen reexpansion along the entire thoracoabdominal segment, remove malperfusion, and promote aortic remodeling. This concept was evaluated in the prospective, multicenter STABLE study in 80 patients with complicated type B aortic dissection.2 The low radial strength of the self-expanding stainless steel bare stent seems to be more relevant in the acute setting when the intimal flap is movable.13 The dissection stent comes in 2 diameters (36 and 46 mm) on a 16-F sheath; its design was based on the Gianturco-Z scaffold, which has widely spaced stainless steel struts that theoretically permit access to visceral branches. In the STABLE study, catheterization of visceral vessels was always possible; 9 patients received 9 additional visceral stents after the deployment of the bare stent (8 renal arteries and 1 superior mesenteric artery).2 However, in our experience, when stenting of a visceral vessel was performed after implantation of the bare aortic stent because of persistent malperfusion, a conflict with the struts of the bare stent was sometimes
210
Journal of Endovascular Therapy 22(2)
Figure 3. Intraoperative images of the fenestrated endograft deployment. (A) On the left, catheterization of the visceral and renal arteries through their corresponding fenestrations and the struts of the bare stent; on the right, the final angiogram confirmed patency of the fenestrations, stents, and target arteries after deployment. (B) The 3-dimensional reconstructions of the immediate postoperative computed tomographic angiogram confirmed exclusion of the dilated aorta, with good patency of the fenestrated device.
encountered when the long sheath was advanced toward the target artery. If the 6-F or 7-F hydrophilic sheath did not track over a stiff wire, we withdrew the wire from the target vessel and catheterized it again from the other side of the strut. It was then always possible to advance the sheath into the target vessel to safely position and deliver a stent. In the current case, the additional aortic bare stents promoted aortic remodeling at the thoracic level but not further
down. Significant enlargement of the visceral and abdominal aorta required therapy, but the feasibility of fenestrated repair was questioned because of the presence of the aortic bare stents. Investigators have reported that custom-made fenestrated and/or branched endografts are a valuable therapeutic option to treat chronic dissections,1,13,14 but it has not been done to our knowledge in patients with previously implanted bare aortic stents in the thoracoabdominal segment.
Barbante et al Since 2013, we have performed all aortic procedures using fusion imaging to facilitate endovascular navigation, especially in complex anatomies. We have found it to significantly reduce radiation dose and contrast volume during complex procedures, as has been recently reported.15
Conclusion Prior dissection stent deployment within the thoracoabdominal segment does not preclude further custom-made fenestrated endograft placement. Preoperative high-quality images are mandatory to correctly plan the procedure and anticipate any subsequent challenge. Finally, recent imaging technologies, such as intraoperative fusion imaging, are very helpful in successfully completing these complex procedures. Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Stéphan Haulon is a consultant for Cook Medical and GE Healthcare.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Sobocinski J, Spear R, Tyrrell MR, et al. Chronic dissection indications for treatment with branched and fenestrated stentgrafts. J Cardiovasc Surg (Torino). 2014;55:505–517. 2. Lombardi JV, Cambria RP, Nienaber CA, et al. Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2012;55: 629.e2–640.e2. 3. Lombardi JV, Cambria RP, Nienaber CA, et al. Aortic remodeling after endovascular treatment of complicated type B aortic dissection with the use of a composite device design. J Vasc Surg. 2014;59:1544–1554. 4. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic
211 Dissection (IRAD). Eur J Vasc Endovasc Surg. 2009;37: 149–159. 5. Dake MD, Kato N, Mitchell RS, et al. Endovascular stentgraft placement for the treatment of acute aortic dissection. N Engl J Med. 1999;340:1546–1552. 6. Fattori R, Tsai TT, Myrmel T, 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;1:395–402. 7. Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC Cardiovasc Interv. 2013;6: 876–882. 8. Jonker FH, Trimarchi S, Rampoldi V, et al. Aortic expansion after acute type B aortic dissection. Ann Thorac Surg. 2012;94:1223–1229. 9. Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) Registry. J Vasc Surg. 2007;46:1103. e2–1111.e2. 10. Hanna JM, Andersen ND, Ganapathi AM, et al. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg. 2014;59:96–106. 11. Mossop PJ, McLachlan CS, Amukotuwa SA, et al. Staged endovascular treatment for complicated type B aortic dissection. Nat Clin Pract Cardiovasc Med. 2005;2:316–322. 12. Nienaber CA, Kische S, Zeller T, et al. Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther. 2006;13:738–746. 13. Kitagawa A, Greenberg RK, Eagleton MJ, et al. Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg. 2013;58:625–634. 14. Verhoeven EL, Paraskevas KI, Oikonomou K, et al. Fenestrated and branched stent-grafts to treat post-dissection chronic aortic aneurysms after initial treatment in the acute setting. J Endovasc Ther. 2012;19:343–349. 15. Kaladji A, Dumenil A, Castro M, et al. Endovascular aortic repair of a postdissecting thoracoabdominal aneurysm using intraoperative fusion imaging. J Vasc Surg. 2013;57: 1109–1112.
