Landing zones optimization using transcatheter electrosurgical septotomy for endovascular repair of post-dissection aortic aneurysms

Abstract

Objective: Aortic dissection is the second most common cause of aneurysmal degeneration. Although endovascular repair is preferred over open techniques, multiple secondary interventions are required to manage complications related to the dissection of potential landing zones (LZs). This study aims to report the outcomes of adjunctive use of transcatheter electrosurgical septotomy (TEAS) to optimize LZs for endovascular repair of post-dissection aortic aneurysms (PD-AAs).

Methods: Consecutive endovascular repairs with adjunctive TEAS performed for PD-AAs between 2022 and 2023 at two institutions were reviewed. TEAS was systematically performed to ensure all grafts were deployed within false lumen-free LZs. Endpoints included TEAS technical success, defined as successful retraction of the dissection septum to obtain an adequate LZ, and clinical technical success, defined by the absence of any type Ia or Ib endoleak or entry flow, aortic true lumen diameter expansion, major adverse events, and 30-day mortality.

Results: Among 121 patients who underwent endovascular repair for PD-AAs, 20 (74% male; mean age, 63 ± 13 years) underwent adjunctive TEAS to create false lumen-free LZs for the endovascular repair of either acute (10%) or chronic (90%) aortic dissections. Three patients (16%) were treated for genetic-related aortic dissection including two Marfan and one Turner syndrome. The mean aneurysm sac diameter was 58 ± 13 mm, and the mean operative time was 203 minutes (interquartile range, 126-254 minutes). After TEAS, 21 optimized LZs were created. Sixteen distal LZs, including 12 aortic and four iliac, were optimized for 10 thoracic endovascular aneurysm repairs (EVARs), two endovascular aortic arch repairs, two fenestrated and branched EVARs, and two standard EVARs. Additionally, five optimized proximal LZs were achieved for 3 EVARs and 2 fenestrated and branched EVARs. TEAS technical success was 100%. Clinical technical success was 90%, with all grafts and stents deployed as planned. True lumen diameter increased from 12.2 ± 3.2 mm to 30 ± 8.4 mm (P < .001) following TEAS. The median follow-up was 15 months (interquartile range, 6-25 months). Two patients (10%) had a type Ib entry flow requiring reintervention. One patient had a TEAS-related major adverse event with a renal artery occlusion that required stenting. No 30-day mortality occurred.

Conclusions: TEAS can be used as an adjunct to create optimal LZs for endovascular repair of PD-AAs. Further studies should address the long-term outcomes of these repairs and identify long-term changes appreciated at the LZs.

Keywords: Endovascular repair; Landing zone; Post-dissection aortic aneurysms; Transcatheter electrosurgical aortic septotomy.