Mid-Term Outcomes of the PETTICOAT-Snowshoe Technique for Preventing Distal Stent Graft–Induced New Entry in Double-Barrel Type B Aortic Dissection

OBJECTIVE To prevent distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) for double-barrel Stanford type B aortic dissection (TBAD), we adopted the PETTICOAT-Snowshoe technique. In this technique, a proximal stent graft is deployed, followed by the extension of a bare stent above the celiac artery and deployment of a second stent graft within the bare stent. This study aimed to evaluate its mid-term outcomes and feasibility in preventing distal SINE. METHODS This single-center retrospective study included patients who underwent the PETTICOAT-Snowshoe technique for double-barrel TBAD between October 2017 and July 2025. The primary endpoint was distal SINE. Secondary endpoints included aortic-related reintervention and mortality. Overall survival and freedom from aortic-related reintervention were estimated using the Kaplan-Meier method. RESULTS Sixty-three patients (median age, 61 years; 78% male) were analyzed, including acute (14%), subacute (30%), and chronic (56%) dissections. The median total length of covered stent grafts was 225 mm, and the median distal oversizing ratio was 30%. The median follow-up duration was 53 months. No distal SINE occurred during the follow-up. One patient (2%) died within 30 days due to retrograde type A dissection. Aortic-related reintervention was required in 11 patients (17%), and 8 patients (13%) died. The 5-year overall survival rate was 82.0 ± 5.9% (95% CI, 70.4-93.6%), while the freedom from aortic-related reintervention rate was 79.1 ± 6.0% (95% CI, 67.3-90.9%). The true lumen ratio improved from 26.0% preoperatively to 58.2% at 1 year and remained stable at 5 years. CONCLUSION The PETTICOAT-Snowshoe technique was associated with no distal SINE during the mid-term follow-up and may be a promising strategy for preventing distal SINE after TEVAR.