Provisional extension to induce complete attachment after stent-graft placement in type B aortic dissection: the PETTICOAT concept.
OBJECTIVE
To report the use of a technique (PETTICOAT: provisional extension to induce complete attachment) to obliterate sustained abdominal false lumen flow and pressurization despite successful stent-graft sealing of the thoracic entry tear in patients with complicated type B aortic dissection.


METHODS
Of 100 initial patients subjected to stent-graft repair for complex type B aortic dissection with thoracoabdominal extension, 12 patients (10 men; mean age 58.7 years, range 44-76) demonstrated distal true lumen collapse and a perfused abdominal false lumen despite successful sealing of the proximal tears. As an adjunctive or staged procedure, a scaffolding stent was placed for distal extension of the previously implanted stent-graft. In each case, a Sinus aortic stent, Fortress stent, or a Z-stent system was customized with maximum 2-mm oversizing versus the original stent-graft diameter. Magnetic resonance or computed tomographic angiography was performed at discharge, at 3 months, and then annually to determine false channel thrombosis, true and false lumen dimensions, and re-entry flow.


RESULTS
Delivery was successful in all cases (100%). The compressed distal true lumen (mean 4+/-3 mm) was reconstructed to a mean width of 21+/-3 mm, and malperfusion was abolished without any obstruction of the abdominal side branches. At up to 1-year follow-up, there were no signs of expansion or distal progression of the scaffolded dissected aorta. All patients with complete thoracic thrombosis showed evidence of improved aortic remodeling; 1 patient with no false lumen thrombosis died at 11 months from thoracoabdominal aortic rupture.


CONCLUSIONS
The PETTICOAT technique may offer a safe and promising adjunctive endovascular maneuver for patients with distal malapposition of the dissecting membrane and false lumen flow. The technique can both abolish distal true lumen collapse and enhance the remodeling process of the entire dissected aorta.
Nienaber
Christoph A
CA
Department of Cardiology, University Hospital Rostock, Rostock School of Medicine, Ernst-Heydemann-Strasse 6, 18057 Rostock, Germany. christoph.nienaber@med.uni-rostock.de
Kische
Stephan
S
Zeller
Thomas
T
Rehders
Tim C
TC
Schneider
Henrik
H
Lorenzen
Björn
B
Bünger
Carsten
C
Ince
Hüseyin
H
D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000145:classification / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000379:methods*; D017544:Aortic Aneurysm, Abdominal / Q000145:classification / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D017545:Aortic Aneurysm, Thoracic / Q000145:classification / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D015897:Comorbidity; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015607:Stents / Q000009:adverse effects; D016019:Survival Analysis; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014654:Vascular Patency