Novel insights into thoracic endografts technology for prevention of distal stent-graft induced new entry (dSINE) following endovascular repair of type B aortic dissections: from bench to bedside

ABSTRACT

Introduction

Endovascular treatment of type B aortic dissections (TBAD) has currently acquired a primary therapeutic role when anatomically feasible. The main issue with thoracic endovascular aortic repair (TEVAR) for aortic dissection is the actual nature of the aortic wall, which is structurally compromised and more fragile. Indeed, a wealth of data have shown that TEVAR for TBAD will lead, in a substantial proportion of cases, to a device-related adverse event named distal stent-graft induced new entry (dSINE).

Areas Covered

Currently available aortic stent-grafts have not been specifically devised for the treatment of aortic dissection. A novel dissection specific stent-graft (DSSG) was developed, which is a custom-made device based on the Zenith Alpha Thoracic platform (Cook Medical). The DSSG has several unique properties that, in principle, make its use optimal in TBAD patients.

Expert Opinion

TEVAR in the setting of aortic dissections remains technically challenging. The occurrence of dSINE represents a unique complication in this scenario and may lead to high rates of aortic-related adverse events and need for secondary interventions. The use of a novel custom-made DSSG in the setting of chronic TBAD has been proven to be safe, feasible and effective. However, even this approach may fail to completely prevent dSINE formation.

KEYWORDS:

• Aortic disease
• aortic dissection
• dSINE
• complications
• thoracic endovascular aortic repair
• stent-graft

Article highlights

• Endovascular treatment of type B aortic dissections (TBAD) has currently acquired a primary therapeutic role when anatomically feasible. The main issue with thoracic endovascular aortic repair (TEVAR) for aortic dissection is the fragile nature of the aortic wall, which can lead to distal stent-graft induced new entry (dSINE).

• Several factors have been shown to play a role in the complex pathophysiology of dSINE, although the available literature is heterogeneous and at times difficult to navigate. The reported incidence of dSINE originates from retrospective single-center case series and varies substantially, up to 18% in the literature.

• Currently available aortic stent-grafts have not been specifically devised for treatment of aortic dissection. A novel dissection specific stent-graft (DSSG) was developed, which is custom-made device based on the Zenith Alpha Thoracic platform (Cook Medical). The DSSG has several unique properties that, in principle, make its use optimal in TBAD patients.

• From a purely mechanical point of view, dSINE occurs when the mechanical stresses acting on the aortic wall exceed the ability of the aortic tissue to bear those stresses. Hence, it is reasonable to postulate that a reduction in such mechanical stresses could lower dSINE occurrence. Based on this postulation, the DSSG was developed, to especially address the needs of dissected aortas.

• Use of a novel custom-made DSSG in the setting of chronic TBAD has been proven to be safe, feasible and effective. In the initial clinical experience with the device from a single center, sixteen patients (13 males, 3 females) with a median age of 66 years (range 31–79 years) underwent elective TEVAR for chronic TBAD using the DSSGHowever, even this approach may fail to completely prevent dSINE formation. After median survival follow-up of 23 months (range 2–35 months), one case of dSINE was noted.

• While dSINE may not be completely avoidable, there is certainly hope that with the broader implementation of newer technology and further refinement of techniques their incidence could be substantially reduced and/or their time of onset be delayed.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewers disclosure

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.