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. 2024 Jul 25:27:19-28.
doi: 10.1016/j.xjtc.2024.07.007. eCollection 2024 Oct.

Transcatheter electrosurgical aortic septostomy optimizes distal landing zone in chronic dissection

Alexander P Nissen  1 , Yazan M Duwayri  2 , William D Jordan  2 , Vasilis C Babaliaros  3 , Robert J Lederman  4 , Bradley G Leshnower  1
Affiliations

Transcatheter electrosurgical aortic septostomy optimizes distal landing zone in chronic dissection

Alexander P Nissen et al. JTCVS Tech. .

Abstract

Objective: Efficacy of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection (CTBAD) is dependent on eliminating retrograde false lumen perfusion and remodeling the aorta. We describe the efficacy of a novel transcatheter electrosurgical technique to fenestrate the dissection flap and create a distal seal zone for TEVAR in CTBAD.

Methods: A retrospective review of the Emory Aortic Database from 2016 to 2023 identified 33 patients who underwent TEVAR with intentional endovascular rupture of the dissection flap (Knickerbocker; KNICK) for CTBAD. In 11 patients, we performed transcatheter electrosurgical aortic septostomy (TECSAS) before KNICK. The technical aspects of TECSAS + KNICK are described and results compared with TEVAR + KNICK alone.

Results: Dissection chronicity, aortic size, and preoperative demographics were similar between groups. Technical success was 100%, with zero stroke or paraplegia in both groups. Thirty-day mortality for TECSAS versus KNICK was 0% versus 13.6% (P = .199). Median follow-up was shorter after TECSAS versus KNICK, although not statistically significant (14.6 months vs 21.9 months; P = .065). Elimination of retrograde false lumen perfusion (TECSAS 100% vs KNICK 68.2%; P = .035) and complete false lumen thrombosis or obliteration (TECSAS 91.9% vs KNICK 54.6%; P = .037) were more frequent after the TECSAS procedure. Aortic reinterventions were less frequent after TECSAS versus KNICK (0% vs 13.6%, P = .199), although not statistically significant.

Conclusions: The addition of TECSAS to intentional endovascular rupture of the dissection flap in CTBAD improves distal seal, eliminating retrograde false lumen perfusion. This technique is a safe and precise method to fenestrate a dissection flap and optimize TEVAR in CTBAD.

Keywords: aortic dissection; aortic septostomy; chronic type B aortic dissection (CTBAD); electrosurgical; thoracic endovascular aortic repair (TEVAR).

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Conflict of interest statement

Y.M.D. serves as a consultant for Cook Medical. W.D.J. serves as a consultant for Gore, Medtronic, Cook Medical, and Endologix. V.C.B. serves as a consultant for Edwards, Abbott, Medtronic, Boston Scientific, and Transmural Systems, Inc. B.G.L. serves as a consultant for Endospan and as a Speaker's Bureau for Medtronic. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

None
Transcatheter electrosurgical aortic septostomy (TECSAS).
Figure 1
Figure 1
General transcatheter electrosurgery setup for controlled septal puncture during the transcatheter electrosurgical aortic septostomy.
Figure 2
Figure 2
Biplane imaging confirms orthogonal alignment of wire and snare in preparation for electrosurgical puncture from false to true lumen.
Figure 3
Figure 3
Retrograde false lumen angiogram confirms successful thoracic endovascular aortic repair apposition and obliteration of retrograde false lumen flow.
Figure 4
Figure 4
Preoperative (A), postoperative arterial phase (B), and postoperative (C) venous-phase computed tomography showing level of planned TECSAS TEVAR with preoperative false lumen flow that is obliterated with TEVAR apposition to the outer aortic wall after TECSAS technique at the distal landing zone. TECSAS, Transcatheter electrosurgical aortic septostomy; TEVAR, thoracic endovascular aortic repair.
Figure E1
Figure E1
Freedom from late reintervention after TECSAS versus Knickerbocker (KNICK). TECSAS: 0% (95% confidence interval, 0%-9.1%); KNICK: 13.6% (95% confidence interval, 9.3%-43.1%). Log-rank P = .199. TECSAS, Transcatheter electrosurgical aortic septostomy; TEVAR, thoracic endovascular aortic repair.
Figure E2
Figure E2
Overall mortality after TECSAS versus Knickerbocker (KNICK). TECSAS: 0% (95% confidence interval, 0%-9.1%); KNICK: 22.7% (95% confidence interval, 7.7%-46.3%). Log-rank P = .086. TECSAS, Transcatheter electrosurgical aortic septostomy; TEVAR, thoracic endovascular aortic repair.
Figure E3
Figure E3
Aorta-specific mortality after TECSAS versus Knickerbocker (KNICK). TECSAS: 0% (95% confidence interval, 0%-9.1%); KNICK: 13.6% (95% confidence interval, 6.7%-32.6%). Log-rank P = .244. TECSAS, Transcatheter electrosurgical aortic septostomy; TEVAR, thoracic endovascular aortic repair.
None
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