Controlled Balloon Septal Rupture to Obliterate False Lumen Perfusion in Type B Aortic Dissection
Jason T. Lee, MD, Celine Deslarzes-Dubuis, MD, Ben D. Colvard, MD, Amelia Claire Watkins, MD, Shinichi Iwakoshi, MD, Michael Fischbein, MD, Michael D. Dake, MD.
Stanford University Medical Center, Stanford, CA, USA.
OBJECTIVES: The Knickerbocker technique was previously described with custom-made double-tapered stent-grafts dilated in the midsection to prevent retrograde false lumen perfusion in patients with chronic type B aortic dissection (TBAD). We sought to review our experience and modification of the technique in both acute and chronic TBAD.
METHODS: We size the distal thoracic stent-graft to the total aortic lumen diameter, and perform controlled rupture within the stent-graft with a compliant balloon in the region 5cm proximal to the distal fabric edge (FIGURE).
RESULTS: 15 patients (13 men, age 57yo) were treated since December 2017 with this technique. Six had TEVAR for acute complicated TBAD (4 malperfusion and 2 persistent pain) and nine patients had chronic TBAD associated with false lumen aneurysm (mean diameter 60mm). Proximal landing site was zone 1 in 5/6 acute patients and 4/9 chronic patients, the remainder were deployed just distal to the subclavian. Mean coverage length was 254.5cm with distal sealing in zone 5 for all patients. Average diameter of the distal stent-graft was 36mm (range 31-40) for the acute cases and 40mm (range 34-45) for the chronic cases. Technical success defined as angiographic and post-op CT-A false lumen obliteration was achieved in 14/15 cases. 30-day mortality was 0%, with one patient in the acute TBAD cohort suffering postoperative stroke, spinal cord ischemia, and mesenteric ischemia likely from diffuse atheroembolism. Two other acute patients required secondary procedures consisting of SMA and renal stenting, and iliac stenting for postoperative end organ malperfusion. In the chronic cohort, one patient had an epidural hematoma after lumbar drain removal requiring surgical evacuation. At latest followup CT-A, all but one patient has complete false lumen thrombosis, and three patients have small type 2 endoleaks without false lumen expansion.
CONCLUSIONS: Obliteration of the distal false lumen channel by controlled balloon septal rupture during TEVAR using commercially available devices is a safe and efficacious strategy in both acute and chronic TBAD presentations. Requirement of a distal aortic segment above the celiac <40mm in diameter to balloon is needed to appropriately identify patients that might be candidates for this technique that achieves false lumen thrombosis. 
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