Despite two decades of experience, no dedicated classification system exists to document and prognosticate patterns of endoleak encountered after endovascular therapy of type-B aortic dissection. This nomenclature gap has led to inconsistent management and underreporting of significant findings associated with adverse outcomes after endovascular treatment of type-B aortic dissection. Our goal was to propose a reproducible and prognostically relevant classification.
Methods
A multidisciplinary team of seven experienced open and endovascular aortic surgeons was assembled to provide consensus opinion. Extensive literature review was conducted. Deficiencies in the current classification approach of the various patterns of persistent filling of false lumen after endovascular therapy were identified.
Results
Our focus was to categorize high-risk and low-risk subgroups within endoleaks after endovascular treatment of type-B aortic dissection. In this classification, type-Ia endoleak refers to persistent filling of the false lumen in an antegrade manner. Causes include failure to cover the primary entry tear and sizing or technical related proximal seal failure. False lumen filling via distal entry tears is classified as type Ib endoleak, which is further sub-classified into b1 (major branch-related tears), and b2 (multiple small branches related tears). Retrograde ascending aortic dissection and stent graft-induced new entry were classified as type-I endoleaks (type-Ir and type-Is, respectively). Another focus was reclassification type-II endoleaks, with type-IIa endoleak referring to conventional retroleak from one or more posterior branches and type-IIx referring to retroleak from major branches (visceral or left subclavian arteries).
Conclusions
The majority of endoleaks after endovascular treatment of type-B aortic dissection are related to persistent or new filling of the false lumen. We propose a new false lumen-based classification schema for endoleaks occurring after endovascular therapy of type-B aortic dissection.
BavariaJEBrinkmanWTHughesGC, et al.
Outcomes of thoracic endovascular aortic repair in acute Type b aortic dissection: results from the valiant United States investigational device exemption study. Ann Thorac Surg2015;
100: 802–809.
2.
ChaikofELBlankensteijnJDHarrisPL, et al.
Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg2002;
35: 1048–1060.
3.
ChaikofELDalmanRLEskandariMK, et al.
The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg2018;
67: 2–77.e2.
4.
FillingerMFGreenbergRKMcKinseyJF, et al.
Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg2010;
52: 1022–1033.
5.
HiratzkaLFBakrisGLBeckmanJA, et al.
ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol2010;
55: e27–e129.
6.
KhoynezhadADonayreCEOmariBO, et al.
Midterm results of endovascular treatment of complicated acute type B aortic dissection. J Thorac Cardiovasc Surg2009;
138: 625–631.
7.
PreventzaOWheatleyGHRamaiahVG, et al.
Management of endoleaks associated with endovascular treatment of descending thoracic aortic diseases. J Vasc Surg2008;
48: 69–73.
8.
WangGJJacksonBMFoleyPJ, et al.
National trends in admissions, repair, and mortality for thoracic aortic aneurysm and type B dissection in the national inpatient sample. J Vasc Surg2018;
67: 1649–1658.
9.
SzeDYvan den Bosch Maaj DakeMD, et al.
Factors portending endoleak formation after thoracic aortic stent-graft repair of complicated aortic dissection. Circ Cardiovasc Interv2009;
2: 105–112.
10.
GrabenwögerMAlfonsoFBachetJ, et al.
Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J2012;
33: 1558–1563.
11.
NienaberCARousseauHEggebrechtH, et al.Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation2009;
120(25): 2519–228.
12.
LombardiJVCambriaRPNienaberCA, et al.
Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg2012;
55: 629–640.
13.
PatelSDConstantinouJSimringD, et al.
Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification. J Vasc Surg2015;
62: 319–325.
14.
ZhangLZhaoZChenY, et al.
Reintervention after endovascular repair for aortic dissection: A systematic review and meta-analysis. J Thorac Cardiovasc Surg2016;
152: 1279–1288.
15.
ZhuTSiYFangY, et al.
Early outcomes of the conformable stent graft for acute complicated and uncomplicated type B aortic dissection. J Vasc Surg2017;
66: 1644–1652.
16.
CambriaRPConradMFMatsumotoAH, et al.
Multicenter clinical trial of the conformable stent graft for the treatment of acute, complicated type B dissection. J Vasc Surg2015;
62: 271–278.
17.
ConwayAMQatoKMondryLR, et al.
Outcomes of thoracic endovascular aortic repair for chronic aortic dissections. J Vasc Surg2018;
67: 1345–1352.
18.
NienaberCAKischeSRousseauH, et al.
Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv2013;
6: 407–416.
19.
ConradMFCrawfordRSKwolekCJ, et al.
Aortic remodeling after endovascular repair of acute complicated type B aortic dissection. J Vasc Surg2009;
50: 510–517.
20.
RoselliEE.Thoracic endovascular aortic repair versus open surgery for type-B chronic dissection. J Thorac Cardiovasc Surg2015;
149: S16-3S7.
21.
ZhuCHuangBZhaoJ, et al.
Influence of distal entry tears in acute type B aortic dissection after thoracic endovascular aortic repair. J Vasc Surg2017;
66: 375–385.
22.
LangerSMommertzGKoeppelTA, et al.
Surgical correction of failed thoracic endovascular aortic repair. J Vasc Surg2008;
47: 1195–1202.
23.
InvestigatorsVR.Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE registry. Eur J Vasc Endovasc Surg2014;
48: 363–371.
24.
FanelliFCannavaleAO’SullivanGJ, et al.
Endovascular repair of acute and chronic aortic type B dissections: main factors affecting aortic remodeling and clinical outcome. JACC: Cardiovasc Interv2016;
9: 183–191.
25.
VerhoevenELParaskevasKIOikonomouK, et al.
Fenestrated and branched stent-grafts to treat post-dissection chronic aortic aneurysms after initial treatment in the acute setting. J Endovasc Ther2012;
19: 343–349.
26.
QinY-LDengGLiT-X, et al.
Risk factors of incomplete thrombosis in the false lumen after endovascular treatment of extensive acute type B aortic dissection. J Vasc Surg2012;
56: 1232–1238.
27.
SzetoWYDesaiNDMoellerP, et al.
Reintervention for endograft failures after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg2013;
145: S165–SS70.
28.
RoselliEEAbdel-HalimMJohnstonDR, et al.
Open aortic repair after prior thoracic endovascular aortic repair. Ann Thorac Surg2014;
97: 750–756.
29.
BoufiMPattersonBOGrimaMJ, et al.
Systematic review of reintervention after thoracic endovascular repair for chronic type B dissection. Ann Thorac Surg2017;
103: 1992–2004.
30.
LeshnowerBGThouraniVH.Thoracic endovascular aortic repair for chronic distal aortic dissection: the jury is still out. J Thorac Cardiovasc Surg2015;
149: S168–S1S9.
31.
LiuFGeYYGuoW, et al.
Preoperative thoracic false lumen branches are predictors of aortic enlargement after stent grafting for DeBakey IIIb aortic dissection. J Thorac Cardiovasc Surg2018;
155: 21–29.
32.
HannaJMAndersenNDGanapathiAM, et al.
Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg2014;
59: 96–106.
33.
QingKXChanYCTingACW, et al.
Persistent intraluminal pressure after endovascular stent grafting for type B aortic dissection. Eur J Vasc Endovasc Surg2016;
51: 656–663.
34.
MenichiniCChengZGibbsRGJ, et al.
A computational model for false lumen thrombosis in type B aortic dissection following thoracic endovascular repair. J Biomech2018;
66: 36–43.
35.
GirishAPadalaMKalraK, et al.
The impact of intimal tear location and partial false lumen thrombosis in acute type B aortic dissection. Ann Thorac Surg2016;
102: 1925–1932.
36.
KammanAVBrunkwallJVerhoevenEL, et al.
Predictors of aortic growth in uncomplicated type B aortic dissection from the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) database. J Vasc Surg2017;
65: 964–971.
37.
PetersonBGEskandariMKGleasonTG, et al.
Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg2006;
43: 433–439.
38.
MaleuxGVaninbroukxJHeyeS.Failed surgical ligation of the proximal left subclavian artery during hybrid thoracic endovascular aortic repair successfully managed by percutaneous plug or coil occlusion: a report of 3 cases. J Cardiothorac Surg2011;
6: 45.
39.
TholpadyAHendricksDEBozlarU, et al.
Percutaneous occlusion of the left subclavian and celiac arteries before or during endograft repair of thoracic and thoracoabdominal aortic aneurysms with detachable nitinol vascular plugs. J Vasc Interv Radiol2010;
21: 1501–1507.
40.
OikonomouKKatsargyrisARitterW, et al.
Endovascular management of chronic post-dissection aneurysms. Ann Cardiothorac Surg2014;
3: 307–313.
41.
SongS-WKimTHLimS-H, et al.
Prognostic factors for aorta remodeling after thoracic endovascular aortic repair of complicated chronic DeBakey IIIb aneurysms. J Thorac Cardiovasc Surg2014;
148: 925–933.
42.
FaureEMCanaudLAgostiniC, et al.
Reintervention after thoracic endovascular aortic repair of complicated aortic dissection. J Vasc Surg2014;
59: 327–333.
43.
KitagawaAGreenbergRKEagletonMJ, et al.
Fenestrated and branched endovascular aortic repair for chronic type B aortic dissection with thoracoabdominal aneurysms. J Vasc Surg2013;
58: 625–634.
44.
EvangelistaASalasARiberaA, et al.
Long-term outcome of aortic dissection with patent false lumen. Predictive role of entry tear size and location. Circulation2012;
125: 3133–3141.
45.
RudenickPABijnensBHGarcía-DoradoD, et al.
An in vitro phantom study on the influence of tear size and configuration on the hemodynamics of the lumina in chronic type B aortic dissections. J Vasc Surg2013;
57: 464–474.
46.
NienaberCAKischeSRousseauH, et al.;
INSTEAD-XL trial. Endovascular repair of type B aortic dissection. Long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv2013;
6(4): 407–216.
47.
SinghCWangXMorsiY, et al.
Importance of stent-graft design for aortic arch aneurysm repair. AIMS Bioeng2017;
4: 133–150.
48.
TsaiTTSchlichtMSKhanaferK, et al.
Tear size and location impacts false lumen pressure in an ex vivo model of chronic type B aortic dissection. J Vasc Surg2008;
47: 844–851.
49.
TolenaarJLVan KeulenJWTrimarchiS, et al.
Number of entry tears is associated with aortic growth in type B dissections. Ann Thorac Surg2013;
96: 39–42.
50.
TolenaarJLvan KeulenJWJonkerFHW, et al.
Morphologic predictors of aortic dilatation in type B aortic dissection. J Vasc Surg2013;
58: 1220–1225.
51.
OikonomouKKasprzakPKatsargyrisA, et al.
Mid-term results of fenestrated/branched stent grafting to treat post-dissection thoraco-abdominal aneurysms. Eur J Vasc Endovasc Surg2018;
57: 102–109.
52.
XueYSunLZhengJ, et al.
The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair. Eur J Cardio-Thorac Surg2014;
47: 623–629.
53.
BischoffMSGeisbüschPKotelisD, et al.
Clinical significance of type II endoleaks after thoracic endovascular aortic repair. J Vasc Surg2013;
58: 643–650.
54.
SharafuddinMJBhamaJKBashirM, et al.
Distal landing zone optimization before endovascular repair of aortic dissection. J Thorac Cardiovasc Surg2019;
157: 88–98.
55.
SpearRHertaultAVan CalsterK, et al.
Complex endovascular repair of postdissection arch and thoracoabdominal aneurysms. J Vasc Surg2018;
67: 685–693.
56.
ChungJOuzounianM.Tearing it up: addressing the septum during endovascular repair of chronic distal aortic dissections.J Thorac Cardiovasc Surg2019;
157(1): 99–100.
57.
SharafuddinMJBhamaJKBashirM, et al.Distal landing zone optimization before endovascular repair of aortic dissection. J Thorac Cardiovasc Surg2019;
157(1): 88–98.
58.
LiuYHuangSLiuY, et al.Treatment of Type I endoleak after thoracic endovascular aortic repair and stent extension via false lumen catheterization and coil embolization. Ann Vasc Surg2018;
53: e13–268.e16.
59.
OikonomouKKasprzakPKatsargyrisA, et al.Mid-term results of fenestrated/branched stent grafting to treat post-dissection thoraco-abdominal aneurysms. Eur J Vasc Endovasc Surg2018;
57(1): 102–109.
60.
KischeSEhrlichMPNienaberCA, et al.
Endovascular treatment of acute and chronic aortic dissection: midterm results from the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg2009;
138: 115–124.
61.
RudenickPASegersPPinedaV, et al.
False lumen flow patterns and their relation with morphological and biomechanical characteristics of chronic aortic dissections. Computational model compared with magnetic resonance imaging measurements. PLoS One2017;
12: e0170888.
62.
van BogerijenGHWvan HerwaardenJAContiM, et al.
Importance of dynamic aortic evaluation in planning TEVAR. Ann Cardiothorac Surg2014;
3: 300–306.
63.
LuC-yDiaoY-KGuoY-Q, et al.
l. Can multiphase dynamic CT angiography provide a better assessment of aortic dissection compared with the standard triphasic protocol?Acta Radiol2018;
59: 58–64.
64.
MonastiriotisSLauILohS, et al.
Evolution of type II endoleaks based on different ultrasound-identified patterns. J Vasc Surg2018;
67: 1074–1081.
65.
RoyINChanTYCzannerG, et al.
Prospective, single UK centre, comparative study of the predictive values of contrast-enhanced ultrasound compared to time-resolved CT angiography in the detection and characterisation of endoleaks in high-risk patients undergoing endovascular aneurysm repair surveillance: a protocol. BMJ Open2018;
8: e020835.
66.
FlorsLLeiva-SalinasCNortonPT, et al.
Imaging follow-up of endovascular repair of type b aortic dissection with dual-source, dual-energy CT and late delayed-phase scans. J Vasc Interv Radiol2014;
25: 435–442.
67.
CloughREWalthamMGieseD, et al.
A new imaging method for assessment of aortic dissection using four-dimensional phase contrast magnetic resonance imaging. J Vasc Surg2012;
55: 914–923.
68.
ThompsonMIvazSCheshireN, et al.
Early results of endovascular treatment of the thoracic aorta using the valiant endograft. Cardiovasc Intervent Radiol2007;
30: 1130–1138.
69.
SherrahAGGrieveSMJeremyRW, et al.
MRI in chronic aortic dissection: a systematic review and future directions. Front Cardiovasc Med2015;
2: 5.
70.
TolenaarJLKernJAJonkerFHW, et al.
Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR. Ann Cardiothorac Surg2014;
3: 255–263.
71.
TrimarchiSJonkerFHWvan BogerijenGHW, et al.
Predicting aortic enlargement in type B aortic dissection. Ann Cardiothorac Surg2014;
3: 285–291.
72.
WeissGWolnerIFolkmannS, et al.
The location of the primary entry tear in acute type B aortic dissection affects early outcome. Eur J Cardio-Thorac Surg2012;
42: 571–576.
73.
NollenGJGroeninkMTijssenJGP, et al.
Aortic stiffness and diameter predict progressive aortic dilatation in patients with Marfan syndrome. Eur Heart J2004;
25: 1146–1152.
