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False lumen intercostal artery embolization to halt type R entry flow in chronic type B aortic dissection

Published:August 30, 2022DOI:https://doi.org/10.1016/j.avsg.2022.07.023

      Abstract

      Objective

      Treatment of aneurysmal type B aortic dissection (TBAD) often involves thoracic aortic endografting (TEVAR). However, persistent patency of the false lumen from type R entry flow is common and is associated with late complications including rupture. We describe nine patients with aneurysmal chronic TBADs and patent false lumens, seven despite prior TEVAR. The goal of the false lumen intercostal embolization in these patients was to achieve propagation of false lumen thrombosis (FLT) and to prevent spinal cord ischemia using a staged approach in the overall treatment of their complex aortic aneurysm.

      Methods

      A multicenter retrospective review was performed of all consecutive false lumen intercostal embolization procedures; nine were identified. Pre- and postoperative computed tomographic angiograms were compared. We hypothesized that embolization was safe and feasible treatment option. The primary outcome was procedural characteristics and spinal cord ischemia to establish safety and feasibility. Secondary outcomes included change in supraceliac patent false lumen length and other perioperative clinical outcomes.

      Results

      In total, 30 of 31 (97%) targeted false lumen intercostal arteries were successfully coiled. Median procedural time was 57 minutes (IQR [23-99]), median air kerma was 585 mGy (IQR [398-1644]), and median contrast dose was 141 ml (IQR [74-240]). After embolization, all patients demonstrated propagation of FLT, with mean false lumen length decreasing by 48% from 13.8 cm to 6.6 cm. There was no mortality associated with this procedure; two patients suffered a lumbar drain related complication; one with cerebrospinal fluid leak and one with a spinal hematoma that was managed conservatively with no neurological deficit. No other complications occurred.

      Conclusions

      In this review, false lumen intercostal coil embolization was technically feasible and did not result in any cases of spinal cord ischemia. The procedures required acceptable amounts of operative time, fluoroscopic dose, and contrast. All patients experienced propagation of false lumen thrombosis, and no long-term procedure-related morbidity was noted. More data will be required to ascertain whether this procedure is effective at halting type R entry flow, preventing future type II entry flow, and promoting aortic remodeling over time.

      Abbreviations:

      CTA (computed tomographic angiography), FLT (false lumen thrombosis), LOS (length of stay), MAP (mean arterial pressure), SCI (spinal cord ischemia), SVS (Society for Vascular Surgery), TBAD (type B aortic dissection), TEVAR (thoracic endovascular aortic repair)
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