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A Deep Dive into Aortic Dissections - with N. Tsilimparis · European Society for Vascular Surgery

0:04
Welcome to the ESVS podcast. I am Laurence Bertrand
0:08
and today we are recording live at the LMU University
0:10
Hospital in Munich, speaking with Professor Tsilimparis
0:12
, Head of Vascular Surgery and an internationally
0:15
recognized expert in aortic dissection management.
0:18
In this episode, we'll focus on the technical
0:20
aspects, planning and decision making involved
0:22
in treating aortic dissections, an area where
0:25
every millimeter and every decision counts. Professor
0:28
Tsilimparis, thank you for joining us today.
0:30
Thank you very much for having me with you. I
0:33
look forward to our discussion. Let's start with
0:35
the basics. We're going to talk about indications
0:37
and timing to begin with. In your practice, what
0:40
are the main indications for intervention in
0:43
aortic dissection? How do you approach the subacute
0:45
or inflammatory phase? Well, I think that, first
0:48
of all, one has to recognize this is the most
0:51
challenging part of the aortic work. These are
0:54
the cases where they come in all possible configurations.
0:58
What I like to call the Hamele. of aortic surgery
1:01
because of the different appearances that we
1:04
have. Having said that, the typical indications
1:06
of course for early intervention and the acute
1:09
setting is a rupture, which is very rare, and
1:12
most commonly the malperfusion of end organs
1:15
and the lower limbs. What is also something that
1:20
of course in the chronic phase the absolute indication
1:22
is the aneurysmal degeneration. When we have
1:25
an aneurysm more than 55, we start thinking about
1:27
intervention and operation. and of course over
1:30
60 for sure but there are also other more relative
1:35
indications like as we know the high risk features
1:39
that we need to consider when we see some dissections
1:43
and we're talking of course mainly here about
1:45
type b dissections some high risk features that
1:48
we see in some of these patients like the early
1:51
dilatation over 40 millimeters the very rapid
1:54
expansion the very high intensity pain which
1:58
is not controlled or the blood pressure that
2:01
is not controlled and is also sometimes associated
2:05
with renal malperfusion, even if it's not a complete
2:09
malperfusion of the target vessel. These are
2:11
just a few examples, and I think one should read
2:14
the guidelines, also the 2026 thoracic guidelines
2:17
that I had the pleasure and honor to work on,
2:20
which will give a lot of guidance in all of these
2:22
topics. Okay, we look forward to that. Let's
2:25
unpack that a little bit. You already talked
2:27
about high -risk features. We'll talk about that
2:28
in a minute. First, timing. Now, do you think
2:32
that there is a best window for intervention
2:34
during the subacute phase, balancing inflammation
2:37
and tissue fragility? Is there a moment where
2:39
you say, okay, this person really needs to be
2:41
done? What do you find is a good moment to sort
2:45
of try? Well, I think this is the question we're
2:49
all trying to figure out right now and we are
2:52
all trying to have these studies that will help
2:55
us figure out really what is the best timeline
2:59
for intervention in acute type B dissection and
3:02
whether it's hyperacute, acute or superacute
3:05
or... chronic is the best way to go, or if it
3:09
is the best way to go at all. Intervention, I
3:11
mean. And this is still an unanswered question.
3:13
I can tell you what we are currently doing in
3:15
our institution. We are still very cautious in
3:19
going into the acute phase, so the early 15 days,
3:23
and doing an aortic intervention. We try to get
3:26
patients, if they are in a stable condition,
3:29
which means they don't have a malperfusion, they
3:31
don't have signs of a... contained rupture or
3:35
periodic hematoma or anything that would be concerning
3:38
in our eyes. And they also don't have what I
3:42
like to call sometimes hidden malperfusion, so
3:44
an extremely high pressure that is not controlled
3:47
with multiple IV medication. Some patients have
3:51
five oral medications and sometimes still need
3:54
IV medicine. These are the patients that in my
3:59
eyes should be treated earlier, even in the acute
4:02
phase. If they don't have all these characteristics,
4:05
we try to get them all out of the acute in the
4:07
super acute phase. So after the 15 days for the
4:10
art extending. What we, however, still do in
4:15
this 15 days, if it's a younger patient, we still
4:18
have the practice that we always like to land
4:21
in an absolutely healthy landing zone, which
4:24
is in... 95 % of the cases in front of the left
4:28
subclavian artery, so between the left carotid
4:31
and the left subclavian. So we need to revascularize
4:34
the left subclavian artery. So what we do in
4:36
the younger patients where we... choose to go
4:40
for a carotid subclavian bypass for the revascularization
4:43
of the left subclavian is to first do the carotid
4:46
subclavian bypass in this window, even if it's
4:49
the acute phase, then make a pause and get the
4:52
back in the super acute phase to complete the
4:54
stenting. Right, so then in that case, if things
4:57
took a turn for the worse, you would actually
5:00
already have the bypass in place to react more
5:02
quickly if needed. Yes, pretty much. I see. You've
5:06
answered this a little bit already. We're going
5:08
to talk about this concept of high -risk features.
5:10
So in so -called uncomplicated type B aortic
5:14
dissections, there's still a concept of high
5:16
-risk features. That's something in between complicated
5:19
and uncomplicated. And it's kind of debated by
5:22
some people. Now, in your view, which of these
5:25
features truly matter when deciding whether to
5:27
interview early versus continue medical therapy?
5:32
Also a very, very hot debate indeed. Over the
5:35
years, we have had the situation that every paper
5:38
would come up with a risk factor based on five
5:41
patients, 10 patients, 15 patients that had an
5:45
event. Small caseloads. Very small caseloads
5:47
that had these characteristics. And still, this
5:50
came up as predictive factors for aneurysms growth
5:53
and late interventions in some studies. So I
5:56
would say that in the order of importance, the
6:00
very early aneurysmal dilatation over 40 millimeters
6:03
is probably the most convincing factor that we
6:08
should consider in terms of how the remodeling,
6:11
the early remodeling is going to happen. That's
6:14
what we know for the very few randomized control
6:17
studies that we have. And other factors like
6:21
the large entry point or the entry at... a small
6:26
curvature or the size of the false lumen compared
6:30
to the true lumen. These are things that are
6:33
really based on very weak evidence. And these
6:37
are things that we take into consideration, but
6:40
they do not reflect our absolute criteria to
6:43
go more forward with early intervention. A very
6:46
difficult topic for me is the topic of persisting
6:49
hypertension. because yes we do try to get those
6:54
patients on the conservative side and try to
6:57
manage them with high dose or multiple drugs
7:00
for antihypertensive care but having a patient
7:04
out there with 160 lat pressure and with a aortic
7:09
dissection that is still very fresh is not something
7:13
that can easily do. This is something that we
7:16
are still very cautious with and we are more
7:19
aggressive than what the evidence tell us. So
7:22
these patients we do go sometimes for early intervention
7:26
even if we know there is not. huge evidence behind
7:30
that, but that is also because we're probably
7:32
never going to get so much evidence. That's a
7:35
difficult topic. Even in the subacute phase,
7:38
you might consider that? These patients are the
7:40
patients that we might consider doing them even
7:42
in the acute phase. Okay. Thank you for that.
7:45
Let's move on to planning and sizing. When planning
7:47
endovascular treatment, what principles guide
7:49
your sizing of stent grafts? Oversizing, use
7:52
of barbs, particularly in terms of avoiding retrograde
7:55
dissections. Are we never using barbs or are
7:58
there moments where you think, actually, this
7:59
is a very old dissection, we're going to need
8:01
some grip there, that might be a reason to use
8:04
it? Or is this a no -go never? And how do you
8:07
feel about oversizing in dissections? I think
8:09
the key point is always a healthy landing zone.
8:12
One has to take a very good look at the landing
8:15
zone up front and make sure that there is no
8:18
intramural hematoma or the rest of dissection
8:22
in the area where you land. That's something
8:25
that we have seen a lot of times with people
8:27
who try to land right at the level of the left
8:30
subclavian artery where the dissection begins
8:32
and then the graft kind of... opens up, goes
8:36
to the outer curvature, perforates the membrane
8:38
and then you have a major bird pecking. So I
8:42
think the best way to avoid major complications
8:45
is to bring your stent graph in a straight parallel
8:48
segment of the aorta as much as good as it gets.
8:52
Of course the length of the proximal landing
8:55
zone cannot be the two, two and a half centimeters
8:57
width. Which you would want, yeah. We would want
9:00
also based on textbooks and also eye reviews.
9:05
But still having a healthy part of the aorta
9:07
there is very important. That is, in my experience,
9:10
as I said before, in the left carotid and the
9:13
left subclavian artery. But you really need to
9:15
make sure that there is no rest dissection or
9:18
intramural hematoma there as well. So in the
9:21
sense of the non -A, non -B dissection. Regarding
9:24
oversizing, it also depends for oversizing. phase
9:28
you are if you're in the acute super acute or
9:33
chronic phase usually we I don't go below 10
9:36
% because then it's no oversizing and you definitely
9:40
risk your seal zone try to stay not go much over
9:45
20 % either so our oversizing is healthy landing
9:50
zone between 10 to 20 % barbs I think barbs add
9:56
to the stability or in the in the wall i don't
10:00
think that barbs themselves create retrograde
10:04
dissections but what has happened and we know
10:07
can happen is that when you have partially released
10:10
the graft during deployment and you make movements
10:14
back and forth. That's a dangerous time where
10:18
you can create a new entry at the area of the
10:22
barbs if you move the graft during the time.
10:25
So should it be necessary to use a graft with
10:28
barbs, you should definitely make sure not to
10:30
move the graft a lot during deployment of the
10:34
first stents. I have two follow -up questions.
10:36
One, why would it be necessary to use barbs?
10:39
Well, not everybody has every stent on their
10:42
selves. And sometimes there are configurations
10:46
where also myself prefer to use certain stent
10:50
grafts that have barbs instead of other stent
10:52
grafts. So if I have a gothic arch with a very
10:57
high angulation, I believe there is, for example,
11:00
stent grafts like the alpha thoracic that take
11:03
that curve in the inner curvature better. And
11:06
I would prefer in that situation that. instead
11:08
of a stent graft that doesn't have bars. We are
11:12
doing now a multicenter study registry on a specific
11:17
stent graft which is not made for dissection
11:21
and we still see that 30 % of those patients
11:24
are treated with this graft for dissections.
11:27
So I think in the real life, people will use
11:31
in the acute setting What they have. Yeah, fair
11:34
enough. The second follow -up question I had
11:37
is, you said, if I understood correctly, you're
11:40
oversizing 10 % to 20%, and it depends on the
11:43
acute phase. Am I understanding that correctly,
11:45
that if you are closer to the subacute phase,
11:49
you might oversize less, and if it is a more
11:52
chronic dissection, you're going to be closer
11:54
to the 20 %? Yes. Is that right? Even in the
11:57
chronic phase where we know we have a... Pretty
11:59
much we're dealing with an aneurysm more than
12:01
a dissection. We can also go to 20, 25, 30 %
12:05
sometimes, depending on the configuration. But
12:08
10 to 20 is the golden rule. Okay, thank you
12:11
for clarifying. How do you approach oversizing
12:14
in the case of having a dilated SNA order? So
12:17
you have a type B dissection, but the ascending
12:20
order is also dilated, and you're a little bit
12:22
worried about a retrograde type A dissection
12:25
occurring. Yeah, and I think that's an amazing
12:29
question and an excellent point because we have
12:31
actually now running an analysis of some data.
12:35
We know that... Dilated ascending aorta is a
12:38
risk factor for retrograde type A dissections.
12:41
We have known that for some years. We have had
12:43
the experience also that sometimes we are very
12:46
aggressive with our arch branch devices landing
12:50
in the ascending aorta in more than 38 millimeters
12:53
diameters. And we saw that that could be a very
12:56
bad experience for some patients. So I think
12:59
when one sees that, we should be very cautious
13:03
and put the indication even more. conservatively
13:07
than we would in other cases. I'm not a big fan
13:10
of the idea that these patients should get a
13:14
frozen elephant trunk right away because we are
13:17
talking about a fully protective procedure for
13:20
early dilatation that then goes so far to get
13:25
a complete arch repair for a 40 mm Senninga aorta.
13:30
So long for something prophylactic. We make a
13:33
lot of rational conclusions from A to B to C
13:37
to reach a huge operation at Z. So I'm not a
13:42
great fan of that, but for sure these are the
13:45
patients we need to address a little more cautiously.
13:51
Especially if you have a young patient where
13:53
you also have possible suspicion of a genetic
13:56
aortic disease, then these patients are the ones
13:59
who need more attention than anybody. Fair enough.
14:03
When you're sizing and you have a true lumen
14:06
that is perhaps very small, are you going to
14:09
be sizing very differently? Do you favor oversizing
14:12
the true lumen only or are there situations where
14:14
different strategies are needed? I think there's
14:16
sometimes debate on how exactly we should be
14:18
measuring, especially when you have true lumen.
14:20
lumen collapse at certain areas and you're not
14:22
exactly sure what should i be using to measure
14:24
yes that's also a very very good point and an
14:28
excellent question no no definite answer for
14:32
sure in terms of data i can again tell you how
14:36
we are doing this yeah in most of the cases you
14:39
have a true lumen restriction or not collapse
14:43
always but at least it's much more than that
14:46
false lumen obviously and the goal is to get
14:50
from a healthy landing zone down to a dissected
14:54
portion of the aura without creating a distal
14:57
stand grafting use a new entry right so this
15:01
It can be very challenging sometimes because
15:04
all the grafts that we have have a certain amount
15:07
of tapering. The maximal is usually about 8 millimeters
15:11
from the top to the bottom. So just putting one
15:14
piece, which is actually what we say we want
15:17
in most cases, just cover the entry tear and
15:20
wait, will lead automatically in a lot of cases
15:23
to major oversizing in the mid thoracic aorta.
15:27
If you go further down, then you extend more
15:30
distally. you can do a second tapering which
15:32
will take you down to a more decent oversizing
15:36
but that's the situation we have to deal with
15:38
so what we usually use is the so -called croissant
15:42
measurement of the of the dissection which is
15:46
taking more or less the length of the dissection
15:49
membrane and using that as our target size of
15:54
the extent graft at the distal part, which is
15:57
the length of the dissection membrane, which
16:00
of course is much more than the second diameter
16:03
that you have in the order. My understanding
16:06
is correctly that instead of having a wall -to
16:08
-wall measurement, you're using the crescent
16:10
shape of the dissection membrane and the length
16:14
of this crescent shape to... the diameter you'd
16:17
go for? Pretty much, yes. Right, okay. Pretty
16:19
much, which means still there's oversize into
16:21
one of the dimensions, but you anticipate that
16:25
the stent graft will open up to that size. And
16:29
we definitely don't go for the total diameter
16:32
of the aorta, so true and false lumen, unless
16:35
you are trying to do something, a special technique
16:38
like stabilize, where you want to bring dissection
16:41
membrane to the outer wall. Thank you. Let's
16:44
move on to talking about target vessels and branch
16:46
management. How do you decide which branch vessels
16:48
to stent and how far into the dissected target
16:51
vessel to extend the stent? Because sometimes
16:53
the dissections go quite far. And you wonder,
16:56
like, do I really need to cover the dissection
16:58
all the way to the end? Or can I stop halfway
17:00
and look at the flow? And does your strategy
17:03
differ in the arch versus the descending aorta?
17:06
First of all, to differentiate again between
17:09
acute and chronic dissections and how you When
17:12
we have a situation where we have a dissection
17:15
in one of the branch vessels, the aorta, so renal,
17:19
sesame, celiac, we don't deal with that first.
17:22
We try in all of these cases to first address
17:25
centrally the problem, which means cover the
17:29
entry and redirect the flow into the true lumen.
17:34
Once you've done that, you will see that a lot
17:36
of those... dissected vessels all of a sudden
17:39
have normal flow again or in some cases they
17:43
completely lose the flow if they were coming
17:45
off the false lumen and probably and you have
17:48
then a change in the pattern of the dissection
17:51
membrane so after we have addressed the issue
17:55
centrally and we know we don't have a lot of
17:58
entry tears along the way we look at the target
18:01
vessels or the branch vessels and then If we
18:04
see there that there is still compromise of the
18:07
origin in the target vessel, we will try to decide
18:11
whether we do a stenting, a selective stenting
18:14
of the target vessel or not, which we usually
18:18
do if the dissection membrane goes... into the
18:21
target vessel and we only cover the origin also
18:26
in a way that it doesn't protrude too much in
18:29
the aorta so that we can also keep all our late
18:32
options for a fenestrated branch therapy open.
18:36
What we have learned not to do is try to bridge
18:41
vessels that are going off the false lumen and
18:47
have a greater distance to the true lumen, bridge
18:50
them all the way to the true lumen because the
18:53
dissection membrane is so mobile and that these
18:56
stent grafts or stents that you're trying to
18:59
place in the target vessel in the false lumen
19:02
and bridging them all the way to the true lumen,
19:05
they won't work and they might fall just in the
19:07
false lumen that have the counterproductive result.
19:10
So short stents, open up the origin and don't
19:14
follow it down the road unless you really have
19:16
a secondary problem in the course of the target
19:20
vessel. Okay, so you don't need to stent in the
19:22
target vessel all the way till the dissection
19:24
is over as long as your flow is good from the
19:26
orifice. Exactly. And you mentioned, okay, we're
19:30
not doing this very long bridging stance anymore
19:32
where the orifice of a target vessel might be
19:35
coming off a false lumen. Then we'd rather leave
19:38
it as is. But doesn't that mean that we might
19:40
be sacrificing one of these branches then? Well,
19:43
there are other techniques that one can use if
19:45
you have a feeling that there is a malperfusion.
19:48
First of all, usually the vessels that come off
19:51
the false lumen completely doesn't mean they're
19:53
malperfused. You see in the arterial phase of
19:57
the CT scan that they do not have a contrast
20:00
feeling so early as they do with the other vessels
20:03
that come off the true lumen, but that does not
20:05
mean that they have a relevant malperfusion that
20:08
compromises them. It just means they're getting
20:10
the blood a little bit later. Right. So that's
20:14
a radiologic effect, but it doesn't mean that
20:16
it's really an effect in terms of malperfusion.
20:19
If you think you have that and it's really an
20:21
effect that is causing malperfusion, you can
20:23
use other techniques like the fenestration of
20:26
the dissection membrane, which in the acute phase
20:29
is more trying to open up. There's always a re
20:33
-entry on those areas because as the membrane
20:35
takes off the wall, there is always a hole where
20:38
the origin of the vessel used to be. And you
20:40
can catheterize that, go with the wire from the
20:43
true lumen into the false lumen, and then take
20:45
a bigger balloon, a 12 -millimeter balloon in
20:48
this area, and open the hole. Open the tear.
20:50
Open the tear so you have more flow into the
20:53
false lumen, exactly that area, and have better
20:56
perfusion of the target vessel. But that's not
20:58
something that you very often do. Most people
21:01
that have tried it, I think I did in one case,
21:04
will have that do septotomies. have gone away
21:08
from doing septotomies to fight assisted septotomies
21:11
in the acute phase because that could be running
21:14
into big problems. Thank you for that. Let's
21:17
talk a little bit about septotomy. Do you do
21:20
septotomies? What do you think about them? What's
21:22
your take? So we've done septotomies. It's not
21:26
a technique that we have embraced completely
21:29
in terms of using it very, very frequently. We
21:34
are very selective users of this technique. I
21:36
think we have used it in cases where we had a
21:40
very challenging true -false, true -false dissection
21:45
membrane in a chronic dissection where we wanted
21:47
to open up the visual segment. to make our catheterization
21:51
easier. I think the dissection membrane should
21:54
not be looked at as our enemy always. In quite
21:58
a few cases and situations, Having a dissection
22:01
membrane that stabilizes the stent graft in one
22:05
side of a big aorta is not bad at all because
22:09
it can help you move to fenestrations instead
22:12
of branches, which we know is better for a lot
22:15
of patients. For that, it's not something I regularly
22:18
do. Having said that, there are some situations
22:20
where you can definitely avoid a bigger operation.
22:25
By doing a septotomy, if you have a good landing
22:28
zone above the celiac trunk and you can do a
22:31
septotomy there and bring a standard TVAR down
22:34
to the celiac trunk, then you could avoid a false
22:38
luminal occluder, for example. But that's something
22:40
that is, in my experience or in the cases that
22:43
I get to see, not that common. However, we have
22:47
used that technique, for example, in a rupture
22:49
where we saw that we needed a way to completely
22:52
seal and that was a good way to get. the seal
22:54
at the level of the distal thoracic aorta. We
22:57
don't routinely use it. We use it in selected
23:00
scenarios where we want to get more room in the
23:03
paravisceral aorta for a branch of the fenestrations,
23:06
but not routinely. I'd like to ask a little bit
23:09
more about how to handle the false lumen and
23:13
flow. So there's ongoing debate about how aggressively
23:16
we should aim to stop flow in the false lumen.
23:19
In your opinion, how important is it to complete
23:23
false lumen flow cessation. And how do you choose
23:26
between the options embolization, candy plug,
23:29
extensive FIVAR -BIVAR repair to achieve distal
23:33
landing zone in non -dissected levels? Again,
23:36
an issue where we work a lot without evidence.
23:39
We know that it makes little sense to put a stent
23:43
graft into true lumen and redirect flow. even
23:47
if you have a bigger tear if you have huge tears
23:50
right below your stent graft because you're still
23:53
gonna have a very very relevant flow back in
23:55
the false lump so if you're doing that to protect
23:59
against aneurysm degeneration it only has limited
24:03
effect if you don't go down to the cilia to start
24:06
then we wait in most of the cases so when we
24:09
decide to to address the false lumen. I would
24:12
say we're not very aggressive into a false lumen
24:15
occluder in the very early phase when we do a
24:18
protective procedure to enhance remodeling. We
24:22
are quite aggressive when we already have a nano
24:24
-resin because in this case of course it doesn't
24:27
just help to put a true lumen tent graft. but
24:30
you also need to address the false lumen in order
24:32
to exclude backflow and therefore exclude the
24:35
aneurysm because you are dealing with an aneurysm.
24:37
So for that, however, you do need to have some
24:41
kind of a small portion segment of the aorta
24:44
above the celiac trunk. where you can put your
24:46
false lumen occluder. We don't do embolizations
24:49
in most of the cases because it is something
24:52
that we know that it's not enough. It's not enough
24:55
to just throw bands of endotrache in the false
24:58
lumen. And the last and most reliable way to
25:02
go is to, of course, do a fenestrate or branch
25:05
repair, which is, however, the next step of invasiveness
25:08
in these kind of procedures. Thanks for talking
25:11
about that. And how about the choice of target
25:14
vessel bridging stent? How do you decide between
25:16
balloon expandable and self -expanding stents?
25:18
And what factors most influence your choice?
25:21
So balloon expandable stents are for us the standard,
25:24
usually also... covered in order to be able to
25:27
go again through those stent grafts without fearing
25:31
that you are going through the struts. You want
25:33
something that will have radial force and will
25:35
push the membrane to the wall and self expanding
25:39
stents are in our practice usually reserved for
25:42
more distal pathologies where you want to reinforce
25:45
the the true lumen in a dissected vessel where
25:50
Just opening up the proximal tear was not enough
25:53
and you have the feeling there are more tears
25:55
down the vessel and you still have relevant malperfusion
25:58
along the branch. Okay, wire handling and access.
26:03
Let's move on to that. One of the trickiest aspects
26:05
is working in the false lumen and doing so safely.
26:09
So how does the wire behave differently there
26:11
and what tips do you have for safely navigating
26:14
it? Well, that is definitely a fact. Navigating
26:19
between true and false luminance is one of the
26:21
most critical aspects of managing dissections.
26:25
Understanding images is a critical aspect in
26:28
managing dissections and getting prepared for
26:31
treating a dissection is probably the most important
26:34
thing. Which means that when you go into a dissection
26:37
case, you need to be... very well prepared in
26:41
terms of having a good idea of which vessels
26:45
go off the false lumen, which vessels go off
26:48
the true lumen, which points you have an entry
26:52
and a re -entry, so you know how your wires and
26:57
catheters are going to behave. Usually what we
26:59
do is we try to get access from a vessel that
27:03
is for sure in the true lumen and is not dissected,
27:06
so a femoral artery that is not dissected. If
27:09
the femoral artery, for example, is dissected,
27:12
we try to understand where is it dissected and
27:15
how we can get access to the true or false lumen.
27:17
Most commonly the femoral artery is not dissected
27:20
if the dissection stops at the level of the internal
27:23
iliac artery and at that level you in more than
27:27
90 % of the cases I would say that the internal
27:29
iliac artery goes off the true lumen which is
27:32
very interesting and this is the first indicator
27:35
of whether you will make it to the true lumen
27:37
or not so shooting an angiography in the respective
27:41
projection right at that level and trying to
27:44
catheterize the internal iliac artery will help
27:46
you get into the true lumen and then you navigate
27:49
up not using your wire but using a pigtail catheter
27:54
that will prevent you, after you know you're
27:56
in the true lumen on the lower part, that will
27:59
prevent you to cross again from a smaller re
28:02
-entry from the true to the false lumen. So instead
28:05
of moving up your wire, you move up with your
28:08
catheter. And then you shoot the repetitive angiographies
28:13
along the way to make sure that you don't lose
28:17
your way across the aorta. You should again have
28:21
your preparation worksheet where you know which
28:24
vessels go off which loom. Having said that,
28:27
this is your good way of doing things. IVOS has
28:29
changed our practice in the last years. So intravascular
28:33
ultrasound is a very, very useful tool in difficult
28:37
situations especially, but also routinely. It
28:40
helps you figure out whether you are in the true
28:43
or the false loom. These are a few of the tips,
28:45
but I think important is also to have all the
28:47
extremities prepared, prepped and ready to go
28:50
for, because sometimes you cannot get the access
28:52
from below. You have to get the access from above
28:55
and then try to navigate from the other direction.
28:59
Thank you for that. And I'm glad you talked about
29:02
IVOS. What is the role of IVOS in your procedures?
29:04
Are you using this to make a decisive difference?
29:07
We are using IVOS very often in our dissections.
29:11
I think there are different ways of how to use
29:13
it and there are a lot of arguments. For me,
29:16
the most important help is to make sure you are
29:18
in the true lumen first. If you have any doubts
29:21
that this might be the true or the false lumen,
29:24
it is more important when you have... bigger
29:27
re -entries down the road where you can really
29:30
easily pass from true to false lumen and you
29:32
don't know on that segment whether you are in
29:34
the true or the false lumen. What I don't use
29:37
the IVOS for is oversizing the proximal part
29:40
because there you don't have perpendicular positioning
29:43
of probe of the IVOS to really claim that you
29:46
can do measurements. You can do that in the straight
29:49
part of the descending order sometimes especially
29:51
in the dissections. What I really like using
29:54
the IVOS for After I have done my TVAR is also
29:58
to make sure that I don't have a true lumen collapse
30:01
afterwards, which is sometimes the case because
30:05
it's so dynamic, the dissection membrane, that
30:08
you still have massive collapses in the diastole
30:11
and the systole. This is something that could
30:13
be very difficult to see angiographically. And
30:16
one last use that I have for the IVOS is to make
30:18
sure I don't have a retrograde type A dissection.
30:21
So you suggest using IVUS in the beginning to
30:24
make sure that your path is not true, false,
30:26
true, and also at the end to control what you've
30:30
done after placing the T -virus. So before we
30:33
talked about using wires in the false lumen,
30:35
and if I can summarize, if I've understood correctly,
30:38
you're saying please know your scans, know what's
30:41
true and false, where your origins are coming
30:43
off. Go up with a catheter and do an early and
30:47
frequent angiograms. You know, sometimes we know
30:52
that we're in the false lumen and we're trying
30:53
to get to the true lumen or we're actually going
30:55
to put a candy plug in and we're in the true
30:57
lumen and trying to get into the false lumen.
30:59
And you do an angiogram before and you can anticipate
31:02
where the opening might be. You know, you're
31:04
scanned, but you don't really know. And when
31:07
you're moving your wire, you're trying to catheterize
31:09
into the false lumen. What tricks can you use
31:12
in how the wire moves to see, oh, I think we've
31:16
moved from the true to the false lumen or is
31:18
it all just gut feeling? Well, I mean, usually
31:23
what you see is a different course than the ones
31:25
you had before. Okay, so the path is different.
31:29
You know just what the path is when you're in
31:31
the true lumen, and after you have done some
31:34
efforts to find that entry from the true to the
31:37
false, you suddenly see that the wire is not
31:40
at the same path it was before, but it takes
31:43
a new path. So that's what I usually understand
31:47
as it takes a different course or it behaves
31:51
differently. Otherwise, it's usually big enough
31:54
always to have an easy course. And it's not like
31:58
in the peripheral vessels where you can tell
32:00
whether you're in the true lumen or sub -intimal.
32:03
In the aorta, the wire doesn't really behave
32:06
differently, but you can see that now it goes
32:09
another way. And what about stiff wires in the
32:11
false lumen? Is it always a no -go or in chronic
32:13
dissections it's okay in an acute or inflammatory
32:16
phase this is a no -go? Do you think it's okay
32:19
to use stiff wires in the false lumen if you
32:21
need to? Well, you have to if you need to stand.
32:24
No, in the false lumen. Well, we also use that
32:27
as well when we do a candy plug, for example.
32:30
So that's not something we are afraid of. And
32:33
also when we do the maneuver of opening up a
32:36
tear with a balloon, we also use stiffer wire
32:39
which goes from the force to the true lumen or
32:42
vice versa. I wouldn't say that usage of stiffer
32:49
wires in the false loom per se is a risk. Definitely
32:52
making sure that these wires are always under
32:55
control and you don't press them against the
32:57
outer wall or the wall is something we always
33:00
try to be. cautious about but that's a general
33:03
rule i would always keep for anywhere in the
33:06
aortic system let's talk about the future and
33:09
planning for the future post -dissection aneurysms
33:12
are often associated with higher re -intervention
33:15
rates compared with degenerative aneurysms in
33:18
your experience what are the main drivers of
33:20
these re -interventions and what strategies can
33:23
help to improve durability and long -term outcomes
33:26
well that of course addresses more the chronic
33:29
dissections I would say dissection of the target
33:32
vessels and the fact that the distal landing
33:35
zone is not very secure as it is in other degenerative
33:39
aneurysms is another important factor. And of
33:42
course, the fact that these patients have usually
33:44
big lumbar arteries that are patent is increasing
33:48
the chance of endoleaks that also contribute
33:51
to the secondary intervention in these patients.
33:55
Do you ever leave skips? between your stents
33:58
or gaps or intentionally in stent coverage and
34:02
what are the principles behind that decision?
34:04
Is that a total no -go or there's cases where
34:06
you've done that? So you mean we do a T -var
34:10
and then E -var just to try? We don't like doing
34:13
that very much, to be honest, in the sense that
34:18
you run a big risk of putting an E -var in a
34:22
dissected order. You pretty much use the dissection
34:27
membrane and that can lead to collapse in the
34:31
worst case. if you have if you have a persistent
34:34
pressure on the on the false lumen and you have
34:37
that graft in the true lumen um you mean collapse
34:41
of the graph and and these are something that
34:45
that doesn't make sense in my opinion to to do
34:48
unless you have a secure landing zone from the
34:52
top to the bottom. But say we had covered an
34:54
entry gap at the top with a T -var and so many
34:57
years later the patient develops infravenously
34:59
an aneurysm of the dissection. Then to place
35:03
an EVAR and leave the thoracobdominal area is
35:07
not ever thought of? Well, again, I think that's
35:12
the big challenge in these cases is you put something
35:16
where you still leave the side straight open.
35:21
in this case, not the back door, but the side
35:23
street, and that will still perfuse the aneurysm
35:27
below. So I don't see very much the point in
35:30
doing that. But I know some people have been
35:33
doing it with the idea that they treat with that
35:36
the true lumen collapse of the infrarenal aorta.
35:39
We don't usually do that and try to go for total
35:42
solutions from top to bottom. You prefer to go
35:45
to do the thoracobdominal part. Before doing
35:49
the EVAR, then coming back and having to do the
35:52
thoracobdominal area when you already have an
35:55
EVAR in place. Okay, let's talk about some closing
36:00
reflections. If you were to give a top three
36:04
tips for vascular surgeons tackling complex aortic
36:07
dissections, what would they be? I think the
36:10
single most important thing is be well prepared
36:14
and have studied the anatomy up front. Know your
36:17
CT scan, know your patient, of course, and how
36:20
you will navigate through this order, the entrance
36:23
and the re -entrance down the road. And the second
36:27
important thing is deal with the problem you
36:29
are facing and don't try to make things beautiful,
36:33
but deal with what you're dealing with. Get in,
36:36
get it done and get out. You don't have to heal
36:40
the patient of his aortic dissections and you
36:43
will not do it. If you try to do too much, sometimes
36:46
you get into more trouble than you should. And
36:49
third is keep your patients close, keep them
36:52
in surveillance and make sure that you take the
36:56
right decision at the right moment. Giving some
36:58
time in between is not usually something that
37:02
is always bad. We don't have to do everything
37:05
the first go around. It's okay to wait and come
37:07
back. Yes. I see. Now looking ahead, are there
37:10
any innovations in devices, wires or imaging
37:13
that you think will significantly change aortic
37:16
dissection management in the next five to ten
37:18
years? What's coming? I would have to play the
37:21
lottery if I knew that. My guess would be that
37:26
there is a big discussion about compliance stents,
37:29
stents that are changing the hemodynamics of
37:33
the vascular tree less than the ones we're using
37:36
now. And that's something that might make a big
37:39
deal. Having solutions that will help us treat
37:43
a dissection without placing a stent graft are
37:47
being discussed. studies and trying to see whether
37:51
that works or not and just closing the entries
37:54
without really treating everything. I think this
37:57
is a very challenging topic. If should it work,
38:00
it would be interesting. Closing the entry tear.
38:04
Yeah, I think that's something that has been
38:06
that some people look into. And of course, these
38:10
techniques of doing the septotomy in a secure
38:14
way could be seen differently in a few years
38:17
if we have more more specific devices for that.
38:21
In general, I think the treatment of dissections,
38:24
however, will largely remain closely associated
38:29
with StenGraph developments, where we also see
38:33
constant improvement of our devices incorporating
38:36
supra -arctic vessels. And from there, I think
38:39
that's what will still be what we will mostly
38:42
do. Thank you. Professor Tsilimparis, thank you
38:47
so much for sharing your insights, technical
38:49
pearls and personal experiences. Aortic dissection
38:52
is a challenging field, but episodes like this
38:54
give our listeners practical guidance that they
38:56
can carry into their own practice. Thanks to
38:59
you all for listening to the ESVS podcasts. Don't
39:01
forget to share this episode with your colleagues
39:03
and subscribe for more discussions on the cutting
39:05
edge of vascular surgery. Goodbye for now. Bye
39:08
-bye.