Distal stent-graft induced new entry after TEVAR or FET - insights into a new disease from EuREC

Background: To learn upon incidence and reasons for distal stent-graft induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and to develop prevention algorithms.

Methods: Analysis of an international multi-center registry (European Registry of Endovascular Aortic Repair Complications- EuREC), 69 dSINE patients out of 1430 TEVAR patients for type B aortic dissection (4,8 %) and 6 dSINE patients out of 100 patients after the FET procedure for aortic dissection (6 %) with secondary morphological comparison.

Results: The underlying aortic pathology was acute type B aortic dissection in 33 patients (44%), subacute and/ or chronic type B aortic dissection in 34 patients (45%), acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 patients (8%), acute type B intramural hematoma in 2 patients (3%). dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute/ chronic setting after TEVAR . After, the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR/ FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151days, 4 patients developed recurrence of dSINE (5%). Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen (TL) diameter, a more accentuated oval TL morphology and a higher degree of stent-graft oversizing in patients who have developed dSINE.

Conclusions: dSINE after TEVAR/ FET is not rare and occurs with similar incidence after acute and chronic aortic dissection- early and late. Avoiding oversizing in the acute and in the chronic setting as well as carefully selecting patients for TEVAR in post-dissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.