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Use Of Petticoat Technique During Subacute Treatment Of Aortic Dissections Is Associated With Minimal Risk Of Spinal Cord Ischemia And High Rates Of False Lumen Thrombosis
Thomas FX O'Donnell, MD, Ariela Zenilman, MD, Lydia Miller, MD, Hiroo Takayama, MD, PhD, Adham Elmously, MD, Virendra I. Patel, MD, MPH.
Columbia University Irving Medical Center, New York, NY, USA.
OBJECTIVES: A variety of treatment paradigms for uncomplicated Acute Type B dissection currently exist, ranging from medical therapy alone, to aggressive treatment with covered stents down to the celiac artery. At our institution, we have taken an aggressive approach with TEVAR in the subacute phase (14 days-3 months), and more recently we have transitioned to the use of a single TEVAR piece proximally, extended distally with uncovered dissection stents with visceral and iliac interventions as needed.
METHODS: This is a retrospective single-institution cohort study of all patients with uncomplicated Type B dissection or Type A with residual thoracoabdominal dissection after proximal repair who underwent treatment in the subacute phase from 2018-2024.
RESULTS: There were 39 patients in the study cohort (30 Type B and 9 Type A), with 69% males, 32% White, 44% Hispanic treated at a median of 79 days post-dissection with a median follow-up of 1 year [IQR 44 days-2.3 years]. Zone 2 was the most common proximal landing zone (72%), all of whom underwent left subclavian revascularization(62% carotid-subclavian bypass/transposition and 10% branch grafts). Spinal drains were placed prophylactically in 38% and rescue in 2 patients. The mean length of covered aortic coverage was 170mm ±53mm, and 82% of patients underwent distal uncovered stenting, 54% extending into one or more iliac arteries. There were 3 celiac stents, 3 superior mesenteric artery stents, and 16 renal stents. Perioperative mortality was 0%, with 7.7% acute kidney injury, no dialysis, and 0% permanent spinal cord ischemia (2 transient paraparesis). On follow-up imaging, rates of full or partial thrombosis/obliteration of the false lumen were 94% in the proximal descending thoracic aorta (68% full), 89% distal descending (47% full), 59% visceral segment (22% full), and 37% infrarenal (20% full). Aortic diameter regressed or was stable in 95% of patients in the proximal descending, 92% distal descending, 85% visceral segment, and 92% infrarenal. Five patients (13%) underwent reintervention (two endovascular distal extensions with embolization, one groin infection, and two distal open conversions).
CONCLUSIONS:Subacute treatment of Type B dissection with limited covered thoracic aortic coverage in combination with aggressive use of uncovered aortic and iliac stents, zone 2 landing, and renal/visceral stenting, is safe and feasible, balancing the elimination/reduction of permanent paralysis with high rates of false lumen thrombosis.
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