New technical approach for type B dissection: from the PETTICOAT to the STABILISE concept

Endovascular treatment of acute complicated type B aortic dissection (TBD) has recently acquired a primary therapeutic role when anatomically feasible. However, strategies meant to simply close the proximal entry tear leave the risk of persistent perfusion of the false lumen (FL) through additional tears in the thoracoabdominal aorta, and therefore the potential for aneurysmal degeneration remains significant over the years. Thus, additional bare stent implantation in the thoracoabdominal aorta has been proposed to promote true lumen (TL) expansion, malperfusion relief, and intimal lamella stabilization. This technique, also known as the Provisional Extension To Induce Complete Attachment Technique (PETTICOAT) offers good short- and mid-term results, but some degree of perfusion of the FL is still maintained, and the aorta showed a tendency to grow distally to the stent-graft. An evolution of PETTICOAT, mainly including aggressive ballooning of the covered stent-graft and of the distal bare stents deployed in the TL, in order to obtain full expansion of the stents in a single channeled aorta, has been proposed in 2012 and named Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STABILISE) technique. Although this approach produced excellent early results in single-center series, it did not gain immediate acceptance in the community, mainly because of concerns regarding the potential risk of rupturing the aorta during ballooning. In this review, we summarize the current evidence on the results of these strategies, we present a recently modified approach of the STABILISE technique, and report the early results in a cohort of patients treated in the last two years at our institution.