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Mechanisms of and treatment strategies for
dSINE after TEVAR for acute and chronic type B
aortic dissection- insights from EuREC
Martin Czerny
Content
EuREC
Contributors
dSINE
Mechanisms
Results
Summary
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
Content
EuREC
Contributors
dSINE
Mechanisms
Results
Summary
Contributing centers
Berne, Budapest, Essen, Freiburg, Heidelberg, Innsbruck, Cologne,
Milano, Munich, Nieuwegein, Tübingen, Toulouse
Content
EuREC
Contributors
dSINE
Mechanisms
Results
Summary
Methods
1999-2017
Total case load (type B) 1417 TEVAR procedures (12 centers)
66 patients indentified (4.3%)
Methods
Siena diameter correction
Content
EuREC
Contributors
dSINE
Mechanisms
Results
Summary
Functional imaging
Functional imaging
Functional imaging
Functional imaging
Functional imaging
Content
EuREC
Contributors
dSINE
Mechanisms
Results
Summary
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)
Content
EuREC
Contributors
dSINE
Mechanisms
Results
Summary
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