Fenestrated/branched aortic endovascular repair of chronic dissections managed after previous PETTICOAT.

Background: Previous PETTICOAT stents, applied in type B aortic dissections, may complicate subsequent fenestrated/branched endovascular aortic repair. This study presents the technical and clinical outcomes of f/bEVAR in chronic type A and B aortic dissections previously managed with PETTICOAT.

Methods: This case series included patients from two aortic centers, with chronic dissections managed with f/bEVAR for thoracoabdominal aneurysms following PETTICOAT. The PROCESS guidelines were followed. Technical parameters and clinical outcomes were assessed.

Results: Eight male patients were included (63 [54-74] years). Two were managed for type I, five for type II and one for type V thoracoabdominal aneurysms. Six custom-made (two fenestrated, three branched and one combined) and two off-the-shelf branched endografts were used. Technical success was 100%. Adjunctive target vessel related procedures were performed in six cases, including pre-catheterization of stenotic renal arteries due to overlapping PETTICOAT stents, dissection flap fenestration for target vessel catheterization, in-situ fenestration after accidental celiac artery occlusion, and ballon-assisted bridging stent advancement through the PETTICOAT stent-struts. Balloon-expandable or self-expanding covered stents reinforced with balloon-expandable bare metal stents were used. No death occurred within 30 days. Two early reinterventions were performed: one relining renal bridging stent compression between the PETTICOAT stent-struts and one renal branch coiling due to bleeding. Median follow-up was 21 months. No death, reintervention or target vessel instability was detected.

Conclusions: According to the described experience, f/bEVAR may be successfully applied in patients with previous PETTICOAT by experienced hands. However, technical challenges, needing immediate intra-operative or early post-operative management, are frequent.