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

Thoracic endovascular aortic repair (TEVAR) has become the cornerstone surgical operation of choice for treatment of type B aortic dissection (TBAD), especially in acute and subacute phases. The primary goal of TEVAR in these situations to seal proximal entry tear in the aortic dissection to promote false lumen thrombosis, prevent aneurysmal degeneration and rupture. In patients with large fenestrations between the true and false lumen in the perivisceral aorta, false lumen may still be perfused via retrograde flow from the fenestrations. As a result, complete FL thrombosis is achieved in only 40% of patients who undergo TEVAR for TBAD. Management of large fenestrations in chronic TBAD is not standardized and there is no single technique which can be used in all cases. This review summarizes different techniques that can be used to obliterate large fenestrations between true and false aortic lumens. For thoracic FL involvement without abdominal aortic segment, Knickerbocker, Candy-Plug and Cork-in-the-Bottle techniques have demonstrated good outcomes. In cases where the dissection flap extends into the perivisceral segment, PETTICOAT and STABILISE techniques can be useful. More complex dissections involving visceral branches coming off the false lumen may require F/BEVAR. Additional techniques include septotomy, transcatheter fenestration, re-entry specific therapy using plug embolization and the streamliner multilayer flow modulator. While current data support these strategies, further prospective studies are needed to establish clear guidelines for optimizing long-term management of TBAD.