Stent Assisted Balloon Induced Intimal Disruption
and Relamination in Aortic Dissection Repair: The
STABILISE Concept
Sophie C. Hofferberth1, Andrew E. Newcomb2, Michael Y. Yii2, Ian K. Nixon2,
Peter J. Mossop3
1. Department of Medicine, University of Melbourne (St. Vincent’s)
2. Department of Cardiac Surgery
3. Department of Medical Imaging
St. Vincent’s Hospital, Melbourne, Australia
Background
• Existing endovascular techniques fail to achieve complete
repair of the distal thoracoabdominal aorta.
• Residual FL patency, high velocity re-entry jets and
retrograde flow into treated zones increase risk of;
-aneurysmal degeneration, rupture, distal reoperation
• STABLE technique (combined proximal endograft + distal
bare metal stenting)
-improved rates of aortic remodelling through stent
support of distal true lumen
-incomplete intimal relamination: >50% patients
with residual FL perfusion at midterm FU
We evolved STABLE to the STABILISE technique to address
the problem of residual FL perfusion
STABILISE CONCEPT
OBJECTIVE
To achieve complete aortic reconstruction during
endovascular AD repair via stent-assisted, balloon
induced intimal rupture and relamination; leading
to elimination of false lumen perfusion and
subsequent prevention of remote phase
complications.
Methods
April 2007- Sept 2011: 27 patients underwent endovascular AD repair
i)
STABILISE Inclusion Criteria
Descending thoracoabdominal aortic diameter (distal endograft landing zone) ≤ 40mm
ii) Non aneurysmal abdominal aorta with true lumen collapse
iii) No evidence of periaortic hematoma / rupture in zone to be stented
STABILISE treatment (n=11)
7 type A, 4 acute Type B
Mean age: 50 ± 9 years
Outcomes Measured
• Clinical: Procedural, 30 Day morbidity/mortality, Intermediate FU
• Aortic remodelling: CT angiogram assessment: Aortic diameter, TL index, FL perfusion
-Thoracic Aorta: Level of Carina
-Abdominal Aorta: Level of celiac axis, Renal arteries, Infrarenal
STABILISE: Combined Zenith TX2- Zenith
Dissection Stent /CODA balloon therapy
• Time from Initial Event to STABILISE Procedure = 4.6 (1-12) days
• Mean No. devices deployed = 3.3 ± 1.0
TX2 Exclusion
ZDS Re-lamination
CODA Expansion
Post-Procedure
Operative Technique
Early Outcomes
• Technical success in all patients: n=11
• 30 Day mortality: n= 1 (9%)
-49 y.o, acute type A AD, presented post-proximal repair
-unexpected aortic rupture: autopsy reported localised
dehiscence at distal anastomosis site of ascending aortic graft
• No strokes
• No spinal cord/limb/visceral ischemia
• No renal failure
• No respiratory failure
• Mean Length Hospital stay: 15 ± 13 days
Infrarenal
Renal
Celiac
Carina
Maximal Aortic Diameter (mm)
Aortic Remodelling
45
40
35
30
25
20
15
Latest F/U
10
Post
5
Pre
0
Aortic Remodelling
True Lumen Reconstitution
1
*p<0.01
Fate of False Lumen
*
*
*
TA (%)
AA (%)
Latest FU
Latest FU
Obliterated/
Thrombosis
100
91
0.2
Partial
Thrombosis
0
9
0.1
Patent
0
0
0.9
False Lumen
status
*
True Lumen Index
0.8
0.7
0.6
0.5
0.4
0.3
0
Carina
celiac
Celiac
Renal
Infrarenal
Aortic Level
Pre-Operative
3 months
Latest Follow up
Ti = TL/AD
Intermediate Clinical Outcomes
• Mean follow-up 18 months (range, 4-54)
• Aortic-specific survival: 91%
• 2 patients required secondary endovascular reintervention
- patient 1: type 1 endoleak treated 8 days post primary
procedure
-patient 2: type 1 endoleak, resolved at 1 month CTA
• No late cardiovascular events
• No late aortic-related deaths
Intermediate Radiological Outcomes
Pre Repair
Post STABILISE Repair
Conclusions
• STABILISE is safe and technically feasible
• Achieves very high rates of false lumen obliteration in aortic
dissection
• Prevents thoracoabdominal aortic growth at intermediate
follow up
• May reduce need for future reintervention as complete aortic
remodelling is achieved in acute setting