Mechanisms of and treatment strategies for
dSINE after TEVAR for acute and chronic type B
aortic dissection- insights from EuREC
Martin Czerny
EuREC
• Independent (no industry funding) scientific platform to collect rare unusual
complications of TEVAR
• Founded by interventional cardiologist, interventional radiologist, vascular
surgeon, cardiothoracic surgeon
•estimate the incidence
•understand pathologic mechanisms and identify patient and procedure-
related factors
•characterize current management and outcomes of patients
EuREC
• Previous projects
•Retrograde type A aortic dissection Circulation 2009
•Symptomatic spinal cord injury JEVT 2012
•Aorto-esophageal fistulation EJCTS 2014
•Aorto-bronchial fistulation EJCTS 2015
Contributing centers
Berne, Budapest, Essen, Freiburg, Heidelberg, Innsbruck, Cologne,
Milano, Munich, Nieuwegein, Tübingen, Toulouse
Methods
1999-2017
Total case load (type B) 1417 TEVAR procedures (12 centers)
66 patients indentified (4.3%)
Patients CharacteristicsBaseline patient characteristics n=66
Demographics
Male, No. (%) 43 (65)
Age, mean ± SD, y 57.7 ± 13,5
Medical history
Hypertension, No (%) 59 (89,4)
Coronary artery disease, No (%) 10 (15,2)
Previous CABG, No (%) 3 (4,5)
Previous aortic surgery/ intervention, No (%) 15 (22,7)
Ascending 13
(19,7)
Arch 4
(6,1)
Descending 2
(3,0)
Abdominal
0(0)
Aortic CharacteristicsAortic characteristics n=66
Underlying aortic disease
Acute type B dissection (<14 d), No. (%) 31 (47,0)
Chronic type B dissection (> 14d), No. (%) 30 (45,5)
IMH, No. (%) 2 (3,0)
Other, No. (%) Acute type A dissection 3 (4,5)
Chronic type B dissection
Days between acute event and TEVAR, mean ± SD 485±738
Presumed etiology
Atherosclerotic/ hypertensive, No. (%)
Degenerative, No. (%)
55 (83,3)
7 (10,6)
Connective tissue disease, No. (%) 4 (6,1)
Traumatic, No. (%)
Other, No. (%)
2 (3,0)
1 (1,5)
Aortic CharacteristicsAortic characteristics n=66
Extension of dissection
Descending Iliacs, No. (%) 24
(36,4)
Arch Iliacs, No. (%) 19
(28,8)
Descending Abdominal, No. (%) 12
(18,2)
Arch Abdominal, No. (%) 8
(12,1)
TreatmentTreatment n=66
Type of procedure
Elective, No. (%) 39 (59,1)
Emergency, No. (%)
N/A, No. (%)
Type of prosthesis
Medtronic©, No. (%)
Gore©, No. (%)
Bolton Medical©, No. (%)
Thoraflex hybrid©, No. (%)
N/A, No. (%)
25 (37,9)
2 (3,0)
31 (47,0)
16 (24,2)
13 (19,7)
4 (6,1)
2 (3,0)
Number of prosthesis
n=1, No. (%) 54 (81,8)
n=2, No. (%) 8 (12,1)
n=3, No. (%) 4 (6,1)
TreatmentTreatment n=66
Landing zone
Criado zone 2, No. (%) 42 (63,6)
Criado zone 3, No. (%)
Intended or accidental overstenting of arch
vessels
Yes, left subclavian artery, No. (%)
No, No. (%)
24 (36,4)
31 (47,0)
35 (53,0)
Supraaortic transpositions
No, No. (%) 48 (72,7)
Yes, No. (%)
Distal part of stent-graft crossing
thoracoabdominal transition, No. (%)
Distal extension with bare stent, No. (%)
18 (27,3)
9 (13,6)
1 (1,5)
ResultsResults,
Initial completion CT after TEVAR
n=66
Endoleak No. (%)
False lumen status at stent-graft level
14 (21,2)
thrombosed, No. (%) 39 (59,1)
partially thrombosed, No. (%)
patent, No. (%)
N/A, No. (%)
False lumen status at TA transition
thrombosed, No. (%)
partially thrombosed, No. (%)
patent, No. (%)
N/A, No. (%)
23 (34,8)
3 (4,5)
1 (1,5)
14 (21,2)
25 (37,9)
25 (37,9)
2 (3,0)
ResultsResults,
Distal Stent-graft induced new entry (dSINE)
n=66
Occurrence of dSINE, days since TEVAR
mean ± SD
Endoleak No. (%)
False lumen status at stent-graft level
938± 702
40 (60,6)
thrombosed, No. (%) 23 (34,8)
partially thrombosed, No. (%)
patent, No. (%)
N/A, No. (%)
False lumen status at TA transition
thrombosed, No. (%)
partially thrombosed, No. (%)
patent, No. (%)
N/A, No. (%)
32 (48,5)
9 (13,6)
2 (3,0)
13 (19,7)
23 (34,8)
27 (40,9)
3 (4,5)
ResultsManagement and follow- up n=66
Management
Conservative 21 (31,8)
TEVAR extension 41 (62,1)
Classical surgery
N/A, No. (%)
FUP , days after diagnosis of dSINE
mean ± SD
Recurrence of dSINE
No, No. (%)
Yes, No. (%)
Not treated, No. (%)
3 (4,5)
1 (1,5)
1397± 1150
41 (62,1)
4 (6,1)
21 (31,8)
Conclusions
dSINE after TEVAR is not rare in both acute and chronic scenarios
The timepoint of occurence is not predictable
A mismatch between true lumen size and stent-graft diameters have an impact
Occurs with low and high radial force devices
Distal TEVAR extension and classical surgery are options for treatment
Life-long surveillance of patients after TEVAR for type B remains mandatory