Intimo-intimal Intussusception during Endovascular Repair in Type B Aortic Dissection

Abstract

Objective: Stent graft induced aortic intimo-intimal intussusception (SAoII) during thoracic endovascular aortic repair (TEVAR) of type B aortic dissection (TBAD) is a rare complication. This study aimed to report reliable imaging features of SAoII and to avoid such a potentially catastrophic event. This retrospective, multicentre observational analysis was registered as a Chinese Clinical Trial (ChiCTR2300073780).

Methods: Patients undergoing TEVAR for TBAD in three centres were reviewed from January 2014 to December 2022. SAoII was defined as intra-procedural partial or circumferential disruption of the aortic intima because of TEVAR, excluding those created by natural disease progression. The imaging features and management of SAoII were summarised.

Results: 1 643 patients undergoing TEVAR for TBAD were reviewed. Among them, SAoII was observed in 20 patients (mean age, 44.5 ± 11.8 years; 16 men). TEVAR was performed in the acute phase (8 of 20), subacute phase (11 of 20), or chronic phase (1 of 20). Imaging features including displacement of the intima/wire/delivery system were observed in eight (40%), floating endograft in 17 (85%), intussusception of the intima layer in 13 (65%), true lumen occlusion and visceral artery loss in three (15%), and a single lumen sign without intimal septa in three (15%) patients. SAoII was observed in 60% (12 of 20) after deployment of the stent graft, in 20% (4 of 20) after introduction of a stent graft delivery system, and in 20% (4 of 20) after the introduction of a super stiff wire. All patients who developed SAoII were endovascularly managed by an additional stent graft; no aorta related death was observed among these patients with SAoII during the median follow up of 51.5 months.

Conclusion: SAoII is a rare but potentially fatal iatrogenic complication during or after TEVAR; endovascular interventions could be effective to manage this acute complication. Timely and accurate identification of decisive imaging features are key to successful treatment.

Keywords: Iatrogenic complications; Stent graft induced aortic intimo-intimal intussusception; Thoracic endovascular aortic repair; Type B aortic dissection.