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Italian Journal of Vascular and Endovascular Surgery 2020 September;27(3):108-21

DOI: 10.23736/S1824-4777.20.01473-4


lingua: Inglese

Management of complicated aortic dissection: natural history, translational research, simulation, bioconvergence, clinical evidence and literature review

Niamh HYNES 1, 2, Ramon BERGUER 3, Juan C. PARODI 4, 5, 6, Yogesh ACHARYA 1, 2, Sherif SULTAN 1, 2

1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital of Galway, National University of Ireland Galway, Galway, Ireland; 2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland, National University of Ireland Galway affiliated Hospital, Galway, Ireland; 3 Vascular Mechanics Laboratory, Department of Vascular Surgery and Biomedical Engineering, Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA; 4 Department of Vascular Surgery and Biomedical Engineering, Hospital of Trinidad, Alma Mater University of Buenos Aires, Buenos Aires, Argentina; 5 Wake Forest University, Winston-Salem, NC, USA; 6 Washington University in Saint Louis, Saint Louis, MO, USA

Aortic remodeling by false lumen (FL) thrombosis is only achieved in around one-third of patients following thoracic endovascular aortic repair (TEVAR) for aortic dissection (AD), and FL patency is independently associated with poor long-term survival and aortic events. To address the pathological failure of aortic remodeling, it is necessary to understand the biomechanics of AD, in particular the variability in pressure between the true and false lumens and the effect of equalizing pressure on dissection repair. Implantation of aortic endografts has been associated with acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion. However, there is minimal insight in the cardiovascular community into aberrant cardiac remodeling after TEVAR, or fenestrated endovascular aortic repair (FEVAR), and branched endovascular aortic repair (BEVAR) of AD. During our endeavors to find the best solution for AD, we found that a 4-dimensional (4D) strategy, which takes account of time and cardiovascular hemodynamics, is crucial to ensure positive outcomes postintervention. The “4D strategy” with the shortening of the aortic metallic jacket and reduction of the number and stiffening of implanted devices through a staged hybrid single lumen reconstruction (TIGER) protocol offers the best solution until we have more compliant grafts. In this translational review, we provide an analytical overview for a combined approach to AD using abdominal aortic septotomy and proximal endografting by exploring the development of this technique from bench to bedside, followed by the discussion of the iterative clinical steps required for its optimization.

KEY WORDS: Aneurysm, dissecting; Endovascular procedures; Vascular remodeling

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