Intentional False Lumen Thrombosis After Aortic Dissection

The best strategies for thrombosing the false lumen, how to execute various techniques, and intervention timing.

By Konstantinos Spanos, MD, MSc, PhD; Fiona Rohlffs, MD; Nikolaos Tsilimparis, MD, PhD; and Tilo Kölbel, MD, PhD
 

In 1999, Nienaber et al published the first report on the nonsurgical insertion of an endovascular stent graft in selected patients with thoracic aortic dissection.1 Since that time, thoracic endovascular aortic repair (TEVAR) has become the preferred treatment choice for type B aortic dissections (TBADs) over open surgical repair.2

Recently, endovascular treatment has expanded to aortic arch pathologies; thus, new stent grafts have been developed for the aortic arch with either fenestrations or branches to encompass the supra-aortic vessels in cases when a more proximal sealing zone is needed for the endovascular treatment of aortic dissections.3 The inner branched device by Cook Medical (a custom-made device designed with two inner side branches for the innominate trunk and the left common carotid) has been frequently used in cases of residual dissection after open repair of type A aortic dissection (TAAD).4 Additionally, a fenestrated custom-made device manufactured by Cook Medical constructed with fenestration and/or a scallop is another option for such cases.5 The arch branch device (Terumo Aortic) is constructed similarly to the Cook device, with two inner branches.6

Although TEVAR has been increasingly used for the treatment of aortic dissection, offering better outcomes in terms of mortality and morbidity compared to open surgical repair,2,7 complete false lumen (FL) thrombosis is only achieved in approximately 40% of patients by covering the proximal tear entry alone. New techniques have been developed during the last decade to treat patients with a patent FL after aortic dissection.

THE IMPORTANCE OF FALSE LUMEN THROMBOSIS IN AORTIC DISSECTION

Persistent perfusion from distal entry tears can maintain patency of the FL, leading to late FL expansion during follow-up in 30% of patients treated with TEVAR who require additional reinterventions.8,9 FL patency has been independently associated with poor long-term survival in patients with chronic TBAD (cTBAD),10 while thrombosis of the FL may be an independent predictor of no further growth.11

The presence of distal entry tears may increase the occurrence of late aortic events and inhibit aortic remodeling, although it has not been proven to have a negative impact on late survival.12 The use of fenestrated stent grafts covers an even longer segment of the aorta, occluding more entry points and reducing pressure and flow transmission into the FL.13,14 However, it was recently demonstrated that although combined proximal and distal stent grafting improves true lumen perfusion and diameter, it has failed to completely suppress FL patency15 and has increased the risk of spinal cord ischemia.16

Residual FL patency also remains a clinical problem after TAAD repair.17,18 Partial thrombosis of a residual FL after TAAD treatment may lead to a faster regional aortic sac growth rate and may predict an increase in the reintervention rate.18

After dissection with a perfused FL, the aorta has a significantly higher annual growth rate, most likely because of the higher pressurization of the FL.10-12,17,18 Patients with partial thrombosis may also require more intensive follow-up and may benefit from prophylactic intervention.19 Recently, the new imaging analysis of patients in the ADSORB trial demonstrated that the number of vessels originating from the FL may predict FL growth in patients with TBAD.20 Ge et al also showed that preoperative dissected thoracic branches fed by an FL are correlated with distal thoracic aortic enlargement after TEVAR in patients with TBAD.21

Patients with TBADs who present with branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FL thrombosis during follow-up.22 These patients may require a more extensive intervention and more intensive follow-up to prevent long-term complications.22

FIRST INTERVENTIONAL ATTEMPTS TO ACHIEVE FALSE LUMEN THROMBOSIS

In 2003, Loubert et al induced FL thrombosis by placing two 15-F Greenfield vena cava filters (Boston Scientific Corporation) or a 24-mm Talent occluder device (Medtronic) into the FL, followed by detachable balloons and thrombin.23 This acted like “a cork in the bottleneck” to block retrograde flow into the thoracic portion of the FL above the blockade.

Since then, a variety of devices and embolization materials (both solid and liquid) have been used to occlude the FL. However, these materials are limited by the diameter of the FL. The largest commercially available devices are 24 mm in diameter; thus, in many cases, occlusion cannot be easily achieved. Recently, a custom-made candy-plug device has been developed with a maximum diameter of 50 mm that may be used for thrombosis of a larger-diameter FL.

Figure 1. False lumen thrombosis with a combination of coils, plug, and glue.

CURRENT STRATEGIES

Vascular and Iliac Plugs: Coils and Glue Embolization Technique

Many reports in the literature describe FL embolization using different materials (Figure 1). Roselli et al used iliac plug devices for FL embolization.24 Because the delivery system for the iliac plug devices was too short to reach the intended target within the thoracic aorta, a 24-mm Zenith iliac plug occluder device (Cook Medical) was first delivered and deployed within the 18-F sheath. Next, the tip of the dilator of the 18-F sheath was removed on the backtable and was polished with a patch of sterile sandpaper to create a “pusher” for the occluder device. The occluder device was then delivered and deployed within the FL at the level of the distal end of the stent graft that was in the true lumen. An additional device was required because the area of the FL to be embolized was large. The access sheath was repositioned within the FL alongside the first occluder, and another device was deployed in the same manner as the first device. Idrees et al have recently reported the group’s expanded experience with the use of iliac plugs in patients with either cTBAD or residual dissection after open repair for TAAD, demonstrating good results.25

Wojtaszek et al attempted to induce FL thrombosis by occluding single entry tears with the Amplatzer Vascular Plug (Abbott Vascular) in two patients with positive results.26 Mendes et al filled the FL with several vascular plugs (18–22 mm).27 However, use of a combination of materials appears to be the most common practice; in many cases, coils were initially deployed in the FL with an adjacent material to complete the embolization (eg, glue injection, Onyx liquid embolic [Medtronic], inflation of a detachable occlusion balloon). Similarly, in cases of TAAD, coils combined with vascular plugs were used for the induction of FL thrombosis.23,28-31

On the other hand, Zhang et al attempted to induce thrombosis of the retrograde FL to enhance a proximal landing zone for the treatment of retrograde TAAD in a two-stage procedure.32 During the first stage, detachable coils (Interlock-35, Boston Scientific Corporation) were deployed into the retrograde FL most of the time, combined with the injection of Onyx glue. During the second stage, TEVAR with a single or double chimney was performed using a novel and more extensive proximal zone.

Of note, in almost all cases, FL thrombosis is achieved with intervention to the distal part of the dissection; however, in some cases, a proximal or mid aortic embolization may be needed. For example, Riga et al had to induce FL thrombosis in the mid thoracic segment because of anatomic restrictions of using coils proximally and distally and injection of Onyx in between, combined with the inflation of a detachable balloon at the narrowest point to slow down the flow.33

Figure 2. Knickerbocker technique.

The Knickerbocker Technique

The main advantage of the knickerbocker technique is that it does not mandate the access of the FL or the addition of more materials. The concept is based on the dilation of the middle part of a large-diameter stent graft that is placed in the true lumen (Figure 2). A short segment of the stent graft is forcefully dilated using a compliant balloon, aiming to rupture the dissection membrane, extending the stent graft to the FL. Instead of an oversized standard tubular stent graft, a double-tapered graft construction with a bulbous section can be used. After the stent graft is correctly placed, a compliant balloon is advanced to expand the bulbous section for septum rupture and FL occlusion. So far, this technique has been used in three patients with positive results.34

The Candy-Plug Technique

Kölbel et al described the candy-plug technique in 2013 using a backtable modification of a Zenith TX2 Pro-Form stent graft (Cook Medical) by adding a diameter-reducing suture between the third and fourth Gianturco Z-stents (Cook Medical) to restrict the opening to a maximum diameter of approximately 10 mm, which still allowed for retraction of the dilator tip.35 Then, a 20-mm Amplatzer Vascular Plug II (Abbott Vascular, formerly St. Jude Medical) was deployed in the waist of the candy wrapper–shaped plug. A distal segment of the descending thoracic aorta with a maximum 36-mm diameter in the FL was chosen for placement of the plug. The candy-plug technique follows placement of a thoracic stent graft into the true lumen to the level of the celiac artery (Figure 3).

Figure 3. Candy-plug technique.

The candy plug is then positioned into the FL down to the distal end of the true lumen stent graft, thereby occluding the FL proximal to the renovisceral segment to preserve flow to branch vessels while preventing FL backflow to the thoracic segment. The presence of a distal alignment of the candy plug and the stent graft is important to avoid a stent-induced new entry.36 The candy-plug technique can be used both in cases after cTBAD and TAAD, resulting in a positive outcome.37

TIMING OF THE INTERVENTION

Timing of the induction of FL thrombosis remains a critical issue. There is no evidence on the preferred time of intervention. For example, Idrees et al treated patients with FL thrombosis at a median interval of 31 months (range, 8–45 months) from the initial dissection treatment.25 Hofferberth et al treated patients at a mean of 7 months (range, 1–26 months) after initial repair.38 However, in a recent systematic review of the literature, most procedures were driven by clinical presentation. Thus, patients were treated either under elective circumstances (FL expansion > 5 mm over 6 months or FL aneurysm > 5.5 cm) or due to the presence of symptoms or rupture.39

COST

The induction of FL thrombosis using a variety of materials may raise the total cost of the procedure and variable up-front costs for capital equipment. Unfortunately, data on cost-effectiveness are lacking, and due to the small number of cases, it would be difficult to analyze. However, considering the preexisting cost of the initial procedures for treating aortic dissection and the fact that FL status influences late outcomes in aortic dissection, FL thrombosis interventions appear to be beneficial when comparing outcome versus cost.10,12,17,18

LEARNING CURVE

The learning curve associated with these techniques should also be acknowledged. Most FL occlusion techniques require a high level of technical skill and a certain degree of practice for the interventionalist to achieve confidence for successful use. The development of referral centers may increase operator experience with these techniques, thus producing even better outcomes.

CONCLUSION

Intentional FL occlusion is an effective and less invasive approach to treat patients after TEVAR with patent FLs compared to open surgery or complex thoracoabdominal repair with fenestrated and branched endografts. Timing of the intervention depends on the diameter increase of the dissected aneurysm or the FL diameter during follow-up or if the patient is exhibiting symptoms.

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2. 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.

3. Spanos K, Tsilimparis N, Rohlffs F, et al. Total endovascular arch repair is the procedure of the future. Part I. J Cardiovasc Surg (Torino). 2018;59:559-571.

4. Spear R, Haulon S, Ohki T, et al. Editor’s choice—subsequent results for arch aneurysm repair with inner branched endografts. Eur J Vasc Endovasc Surg. 2016;51:380-385.

5. Tsilimparis N, Debus ES, von Kodolitsch Y, et al. Branched versus fenestrated endografts for endovascular repair of aortic arch lesions. J Vasc Surg. 2016;64:592-599.

6. Anthony Lee W. Status of branched grafts for thoracic aortic arch endovascular repair. Semin Vasc Surg. 2016;29:84-89.

7. Cheng D, Martin J, Shennib H, et al. Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease: a systematic review and meta-analysis of comparative studies. J Am Coll Cardiol. 2010; 55: 986-1001.

8. Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120:2519-2528.

9. Tanaka A, Sakakibara M, Ishii H, et al. Influence of the false lumen status on clinical outcomes in patients with acute type B aortic dissection. J Vasc Surg. 2014;59:321-326.

10. Li D, Ye L, He Y, et al. False lumen status in patients with acute aortic dissection: a systematic review and meta-analysis. J Am Heart Assoc. 2016;10:5.

11. Kamman AV, Jonker FHW, Sechtem U, et al. IRAD investigators. Predictors of stable aortic dimensions in medically managed acute aortic syndromes. Ann Vasc Surg. 2017;42:143-149.

12. Zhu C, Huang B, Zhao J, et al. Influence of distal entry tears in acute type B aortic dissection after thoracic endovascular aortic repair. J Vasc Surg. 2017;66:375-385.

13. 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.

14. Simring D, Raja J, Morgan-Rowe L, et al. Placement of a branched stent graft into the false lumen of a chronic type B aortic dissection. J Vasc Surg. 2011;54:1784-1787.

15. Canaud L, Faure EM, Ozdemir BA, et al. Systematic review of outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection. Ann Cardiothorac Surg. 2014;3:223-233.

16. Bisdas T, Panuccio G, Sugimoto M, et al. Risk factors for spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms. J Vasc Surg. 2015;61:1408-1416.

17. Kimura N, Itoh S, Yuri K, et al. Reoperation for enlargement of the distal aorta after initial surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2015;149(2 suppl):S91-98.

18. Tsai MT, Wu HY, Roan JN, et al. Effect of false lumen partial thrombosis on repaired acute type A aortic dissection. J Thorac Cardiovasc Surg. 2014;148: 2140-2146.

19. Trimarchi S, Tolenaar JL, Jonker FH, et al. Importance of false lumen thrombosis in type B aortic dissection prognosis. J Thorac Cardiovasc Surg. 2013;145(3 suppl):S208-212.

20. Kamman AV, Brunkwall J, Verhoeven EL, et al. Predictors of aortic growth in uncomplicated type B aortic dissection from the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) database. J Vasc Surg. 2017;65:964-971.

21. Ge YY, Guo W, Cheshire N, et al. Preoperative thoracic false lumen branches relate to aortic remodeling after thoracic endovascular aortic repair for DeBakey IIIb aortic dissection. J Vasc Surg. 2017;65:659-668.

22. Tolenaar JL, Kern JA, Jonker FH, et al. Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR. Ann Cardiothorac Surg. 2014;3:255-263.

23. Loubert MC, van der Hulst VP, De Vries C, et al. How to exclude the dilated false lumen in patients after a type B aortic dissection? The cork in the bottleneck. J Endovasc Ther. 2003;10:244-248.

24. Roselli EE, Idrees J, Reside J, et al. Use of covered stent devices for false lumen embolization in chronic dissection: a novel approach. Ann Thorac Surg. 2014;98:737-739.

25. Idrees J, Roselli EE, Shafii S, et al. Outcomes after false lumen embolization with covered stent devices in chronic dissection. J Vasc Surg. 2014;60:1507-1513.

26. Wojtaszek M, Wnuk E, Maciag R, et al. Promoting false lumen thrombosis after thoracic endovascular aneurysm repair in type B aortic dissection by selectively excluding false-lumen distal entry tears. J Vasc Interv Radiol. 2017;28:168-175.

27. Mendes BC, Oderich GS, Erben Y, et al. False lumen embolization to treat disseminated intravascular coagulation after thoracic endovascular aortic repair of type B aortic dissection. J Endovasc Ther. 2015;22:938-941.

28. Rohlffs F, Tsilimparis N, Fiorucci B. The candy-plug technique: technical aspects and early results of a new endovascular method for false lumen occlusion in chronic aortic dissection. J Endovasc Ther. 2017;24:549-555.

29. Zink JN, Maness MR, Powell CS, et al. Coil embolization of persistent false lumen after type A dissection repair. Ann Thorac Surg. 2014;97:2193-2196.

30. Jeganathan R, Kennedy P, MacGowan S. Treatment of a persistent false lumen with aneurysm formation following surgical repair of type a dissection. Cardiovasc Intervent Radiol. 2007;30:491-493.

31. Ogawa Y, Nishimaki H, Chiba K, et al. Candy-plug technique using an excluder aortic extender for distal occlusion of a large false lumen aneurysm in chronic aortic dissection. J Endovasc Ther. 2016;23:483-486.

32. Zhang R, Zhou J, Feng J, et al. Inducing false lumen thrombosis for retrograde type A aortic dissection. J Thorac Cardiovasc Surg. 2017;153:57-65.

33. Riga C, Bicknell C, Jenkins M, et al. Coil embolization of an aneurysmal type B dissection persistent false lumen after visceral hybrid repair. J Vasc Interv Radiol. 2009;20:130-132.

34. Kölbel T, Carpenter SW, Lohrenz C, et al. Addressing persistent false lumen flow in chronic aortic dissection: the knickerbocker technique. J Endovasc Ther. 2014;21:117-122.

35. Kölbel T, Lohrenz C, Kieback A, et al. Distal false lumen occlusion in aortic dissection with a homemade extra-large vascular plug: the candy-plug technique. J Endovasc Ther. 2013;20:484-489.

36. Jang H, Kim MD, Kim GM, et al. Risk factors for stent graft-induced new entry after thoracic endovascular aortic repair for Stanford type B aortic dissection. J Vasc Surg. 2017;65:676-685.

37. Rohlffs F, Tsilimparis N, Fiorucci B. The candy-plug technique: technical aspects and early results of a new endovascular method for false lumen occlusion in chronic aortic dissection. J Endovasc Ther. 2017;24:549-555.

38. Hofferberth SC, Nixon IK, Mossop PJ. Aortic false lumen thrombosis induction by embolotherapy (AFTER) following endovascular repair of aortic dissection. J Endovasc Ther. 2012;19:538-545.

39. Spanos K, Kölbel T, Rohlffs F, et al. Intentional targeted false lumen occlusion after aortic dissection: a systematic review of the literature. Ann Vasc Surg. In press.

Konstantinos Spanos, MD, MSc, PhD
German Aortic Center Hamburg
Department of Vascular Medicine
University Heart Center
Hamburg, Germany
Disclosures: None.

Fiona Rohlffs, MD
German Aortic Center Hamburg
Department of Vascular Medicine
University Heart Center
Hamburg, Germany
Disclosures: None.

Nikolaos Tsilimparis, MD, PhD
German Aortic Center Hamburg
Department of Vascular Medicine
University Heart Center
Hamburg, Germany
Disclosures: Proctor, receives travel grants, and receives speaker’s fees from Cook Medical.

Tilo Kölbel, MD, PhD
German Aortic Center Hamburg
Department of Vascular Medicine
University Heart Center
Hamburg, Germany
Disclosures: Proctor, receives travel and educational grants, and has intellectual property with Cook Medical.

 

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