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Bridging stents in endovascular repair of chronic aortic dissection: a scoping review
Frida R Jonsdottir1, Timothy A Resch2,3
1Department of Vascular Surgery, Sjællands University Hospital, Roskilde, Denmark - frida.run.jonsdottir@regionh.dk.
Insights
Bridging stent selection for fenestrated and branched endovascular aortic repair (F/B-EVAR) in chronic aortic dissection (cAD) is complex. High reintervention rates underscore the need for better guidance on stent choice and close surveillance.
Area of Science:
- Vascular Surgery
- Endovascular Repair
- Aortic Dissection
Background:
- Fenestrated and branched endovascular aortic repair (F/B-EVAR) is increasingly used for chronic aortic dissection (cAD), especially post-dissection thoracoabdominal aortic aneurysms (PD-TAAA).
- PD-TAAA presents unique challenges due to true/false lumens, complex anatomy, and remodeling, impacting target vessel (TV) cannulation and bridging stent stability.
- Current guidelines for bridging stent selection in PD-TAAA are lacking, despite their critical role in sealing and TV patency.
Purpose of the Study:
- To assess the applicability and outcomes of available bridging stents in the endovascular treatment of PD-TAAA.
- To review current evidence on bridging stent use in F/B-EVAR for PD-TAAA.
- To identify factors influencing bridging stent performance in this complex patient population.
Main Methods:
- A scoping review following PRISMA-ScR guidelines.
- Systematic search of Ovid Medline for studies on chronic aortic dissection, bridging stents, FEVAR, and BEVAR.
- Inclusion of studies with ≥10 patients with PD-TAAA treated by F/B-EVAR, reporting TV-specific outcomes; exclusion of physician-modified endografts.
Main Results:
- Three retrospective studies involving 375 patients and 1396 TVs were included.
- Fenestrations typically used balloon-expandable covered stents (BESG), while branches used BESG or self-expanding covered stents (SESG).
- TV stenosis/occlusion was more common with branches; FEVAR showed better TV patency in one study. Reintervention rates approached 50% at two years, mainly for TV complications.
Conclusions:
- Bridging stent and F/B-EVAR/BEVAR choice in PD-TAAA is primarily based on anatomy and physician preference.
- High reintervention rates necessitate close postoperative surveillance for TV-related complications.
- Further research is crucial to optimize bridging stent selection and improve long-term outcomes in PD-TAAA treatment.
Introduction:
Fenestrated and branched endovascular aortic repair (F/B-EVAR) is increasingly used in the treatment of chronic aortic dissection (cAD), particularly for post-dissection thoracoabdominal aortic aneurysms (PD-TAAA). These aneurysms differ significantly from degenerative aneurysms due to the presence of a true and false lumen, complex target vessel (TV) anatomy, and the higher potential for ongoing aortic remodeling. These factors contribute to technical challenges in target vessel cannulation and raise concerns about the long-term stability of target vessel bridging stents. Although bridging stents play a critical role in achieving durable sealing and target vessel patency, there are currently no clear guidelines for their selection in the setting of PD-TAAA, where anatomical complexity and luminal remodeling pose unique challenges. Bridging stent performance may be influenced by stent design, anatomical configuration, and procedure type, yet evidence specific to this patient population remains limited. This scoping review aims to assess the applicability and outcomes of available bridging stents in the endovascular treatment of PD-TAAA.
Evidence Acquisition:
This scoping review followed PRISMA-ScR guidelines. A systematic search was conducted in Ovid Medline using keywords related to chronic aortic dissection, bridging stents, FEVAR, and BEVAR. Studies were included if they reported on ≥10 patients with CTBAD treated by FEVAR or BEVAR, with target vessel-specific outcomes. Physician-modified endografts were excluded. Data on patient numbers, stent types, follow-up, and target vessel outcomes (stenosis, occlusion, endoleaks) were extracted.
Evidence Synthesis:
Of 50 records screened, three studies met the inclusion criteria, encompassing 375 patients and 1396 treated TVs. All studies were retrospective analyses of prospectively collected data in patients with PD-TAAA. Two studies provided selection criteria for FEVAR vs. BEVAR and specified bridging stent preferences. Fenestrations were typically bridged with balloon-expandable covered stents (BESG), while branches used either BESG or self-expanding covered stents (SESG). Target vessel stenosis or occlusion was more frequently associated with branches, with FEVAR showing superior target vessel patency in one study. No study directly compared BESG and SESG patency. TV-related endoleaks occurred in all studies; two reported no significant difference between FEVAR and BEVAR. Reinterventions were common across all cohorts, primarily due to TV-related complications, with rates approaching 50% at two years.
Conclusions:
In PD-TAAA, the choice between FEVAR, BEVAR, and bridging stent type is largely driven by anatomy and physician preference. The high rate of reinterventions due to target vessel-related complications highlights the need for close postoperative surveillance. Further research is essential to guide optimal bridging stent selection and enhance long-term outcomes.
