79 - Aortic Type B Dissection - How to Promote False Lumen Thrombosis
R. A. Dammrau
Purpose: The surgical treatment of aortic type B dissection is primarily endovascular with TEVAR. The aim is to close the proximal entry tear to ensure organ perfusion and prevent aneurysm formation. For the prognosis and further aortic remodeling the thrombosis of the false lumen is important. Because of the often multiple entries and reentries there are different techniques to occlude the false lumen or close endoleaks.
Material and Methods: In case of proximal endoleaks or retrograde flow via the left subclavian we treat with covered stents in the LSA or with vascular plugs, small endoleaks can be treated with coils. For occlusion of retrograde flow from distal to the false lumen there are special so called candy plugs, we even use normal vascular plugs am volume coils. Treating the thoracoabdominal segment with uncovered nitinol stents may even promote false lumen thrombosis, in some cases we need additional means.
Results: If we treat type B dissection with TEVAR we see only in selected cases complete false lumen thrombosis. In most cases we have to extend TEVAR, retrograde flow from distal is controlled with plugs and volume coils. Extension of true lumen with uncovered nitinol stents can reduce false lumen perfusion, some branches need covered stents. And even infrarenal endovascular treatment or branched or fenestrated grafts in the thoracoabdominal segment are sometimes necessary. Endoleaks are sometimes only with direct ct guided puncture accessible.
Conclusions: Endovascular therapy is first choice in aortic type B dissection. In uncomplicated type B dissections with risk constellation one should be liberal with indication for TEVAR. Perfused false lumen needs close follow up, aim of our therapy is to exclude false lumen from perfusion to avoid late complications. Beside coils, plugs, occluders we have dedicated techniques for false lumen occlusion. In chronic dissections it is often necessary to perform endovascular therapy as staged procedure with individual concepts, even in combination with open and hybrid procedures. Open surgery has still it´s place preferred in patients with connective tissue disease