The PETTICOAT-Snowshoe Technique Prevents Distal Stent Graft-Induced New Entry in Patients with Aortic Dissection

Distal stent graft-induced new entry (SINE) is a serious complication of thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD). The PETTICOAT-snowshoe technique was developed to prevent distal SINE for double-barrel TBAD. Initially, a proximal stent-graft (SG) is deployed, followed by the extension of a bare stent above the celiac artery and deployment of a second SG within the bare stent. This study examined whether the PETTICOAT-snowshoe technique prevents distal SINE.This was a single-center, retrospective study comparing 2 groups that underwent conventional standard TEVAR between January 2013 and September 2018 and TEVAR using the PETTICOAT-snowshoe technique after October 2018 for double-barrel TBAD.Twenty-seven patients (74% male) underwent standard TEVAR (group A), while another 27 (78% male) underwent the PETTICOAT-snowshoe technique (group B). TEVAR was performed in the chronic phase on 15 patients (55.6%) in group A and on 16 (59.2%) in group B. Aorta-related mortality occurred in 1 patient in group A (3.7%). Oversizing ratios at the distal edge of the SG diameter to the major axis of the true lumen were 25% ± 26% and 25% ± 21% in groups A and B, respectively. During the follow-up period, 5 patients (18.5%) in group A and none in group B (P = 0.02) developed distal SINE. 3 of 5 patients with distal SINE in group A were treated with additional TEVAR, one with thoracoabdominal aortic replacement, and one with conservative observation. The freedom from distal SINE rate was significantly higher in group B than in group A (P = 0.04).The PETTICOAT-snowshoe technique significantly prevented distal SINE during the mid-term period even with the same distal SG oversizing as conventional standard TEVAR.