Regarding “Aortic rupture during STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique”

A recent Case report present a case of infra renal aortic rupture while using a compliant balloon to mold the true lumen inside previously placed bare metal stents during the STABILISE technique at the chronic stage of a type B aortic dissection.1Hsu Ashley C. DiBartolomeo Alexander D. Han Sukgu M. Fleischman Fernando Magee Gregory A. Aortic rupture during STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique.J Vasc Surg Cases Innov Tech. 2023; 9101338Google Scholar The author concluded that caution is advised for providers who wish to perform the STABILISE technique, and recommend using a semi-compliant balloon sized to the smallest total aortic diameter to mitigate the risk of rupture.1Hsu Ashley C. DiBartolomeo Alexander D. Han Sukgu M. Fleischman Fernando Magee Gregory A. Aortic rupture during STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique.J Vasc Surg Cases Innov Tech. 2023; 9101338Google Scholar We have several comments regarding this case report. Firstly, we commend the authors for presenting this complex and highly interesting case, which underscores the non-trivial nature of the STABILISE technique, used for the past ten years to more extensively remodel type B aortic dissections in the acute, subacute and even chronic stages, thereby improving both short- and long-term prognosis of this severe pathology.2Hofferberth S.C. Nixon I.K. Boston R.C. McLachlan C.S. Mossop P.J. Stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair: the STABILISE concept.J Thorac Cardiovasc Surg. 2014; 147: 1240-1245Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 3Melissano G. Bertoglio L. Rinaldi E. et al.Satisfactory short-term outcomes of the STABILISE technique for type B aortic dissection.J Vasc Surg. 2018; 68: 966-975Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 4Faure E.M. El Batti S. Sutter W. Bel A. Julia P. Achouh P. Alsac J.M. Stent-assisted balloon-induced intimal disruption and relamination of distal remaining aortic dissection after acute DeBakey type I repair.J Thorac Cardiovasc Surg. 2019; 157: 2159-2165Abstract Full Text Full Text PDF PubMed Google Scholar, 5Faure E.M. El Batti S. Sutter W. Bel A. Julia P. Achouh P. Alsac J.M. Stent-assisted balloon dilatation of chronic aortic dissection.J Thorac Cardiovasc Surg. 2021; 162: 1467-1473Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 6Faure E.M. El Batti S. Abou Rjeili M. Julia P. Alsac J.M. Mid-term outcomes of stent assisted balloon induced intimal disruption and relamination in aortic dissection repair (STABILISE) in acute type B aortic dissection.Eur J Vasc Endovasc Surg. 2018; 56: 209-215Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Additionaly, we inquire about the smallest total aortic diameter at the level of the abdominal aorta, as well as the size of the Tri-lobe balloon catheter (WL Gore & Associates) used. Indeed, the Tri-lobe balloon comes in two sizes, a small size for 16-32 mm vessels diameter and a large size for 26-42 mm vessels diameters. The use of an oversized balloon may increase the risk of aortic rupture. Next, as reported by the authors, it appears in Figure 2 that the balloon protrudes from the bare metal stent without deforming it, suggesting that the balloon is inflated in the false lumen, or at least outside the bare metal stent. This possibility is reinforced by the author's specification that the wire repeatedly pass through the interstices rather than through the middle of the bare metal stent, and there is no description of an angiographic control to ensure proper positioning of the balloon in the true lumen. Inflating the balloon outside the lumen of the bare stent may also increase the risk of aortic rupture. Finally, before performing the Tri-lobe inflation, the author describes that the introducer failed to advance into the aorta as it cought on the struts of the bare metal stent. This could have resulted in malpositioning of one of the stents as already reported and predisposed to rupture during balloon inflation. The use of semi-compliant balloons likely reduces the risk of aortic rupture during inflation, provided the balloon is not oversized, inflation is performed within the lumen of the bare metal stent, and there is no misplacement of the stent.