Management options for large fenestrations between true and false lumens in aortic dissection

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Vascular Medicine

Background:

• Thoracic endovascular aortic repair (TEVAR) is the primary treatment for type B aortic dissection (TBAD).
• TEVAR aims to seal entry tears, promoting false lumen (FL) thrombosis and preventing complications.
• Large fenestrations between true and false lumens can impede complete FL thrombosis, occurring in over 60% of TEVAR patients.

Purpose of the Study:

• To review and summarize techniques for obliterating large fenestrations in type B aortic dissection.
• To discuss management strategies for persistent false lumen perfusion due to fenestrations.
• To highlight the need for standardized approaches and further research in chronic TBAD management.

Main Methods:

• Review of existing literature on fenestration management in TBAD.
• Categorization of techniques based on dissection extent and fenestration location.
• Discussion of specific endovascular techniques and their applicability.

Main Results:

• Several techniques exist for fenestration obliteration, including Knickerbocker, Candy-Plug, and Cork-in-the-Bottle for thoracic involvement.
• PETTICOAT and STABILISE techniques are useful for dissections involving the perivisceral segment.
• Fenestrated/branched endovascular repair (F/BEVAR), septotomy, and embolization are options for complex cases with visceral branch involvement.

Conclusions:

• Management of large fenestrations in chronic TBAD remains challenging and lacks standardization.
• Various endovascular techniques can be employed to obliterate fenestrations and promote FL thrombosis.
• Further prospective studies are essential to establish clear guidelines for optimal long-term management of TBAD with fenestrations.