Management of complicated aortic dissection: natural history, translational research, simulation, bioconvergence, clinical evidence and literature review

Aortic remodeling by false lumen (FL) thrombosis is only achieved in around one-third of patients following thoracic endovascular aortic repair (TEVAR) for aortic dissection (AD), and FL patency is independently associated with poor long-term survival and aortic events. To address the pathological failure of aortic remodeling, it is necessary to understand the biomechanics of AD, in particular the variability in pressure between the true and false lumens and the effect of equalizing pressure on dissection repair. Implantation of aortic endografts has been associated with acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion. However, there is minimal insight in the cardiovascular community into aberrant cardiac remodeling after TEVAR, or fenestrated endovascular aortic repair (FEVAR), and branched endovascular aortic repair (BEVAR) of AD. During our endeavors to find the best solution for AD, we found that a 4-dimensional (4D) strategy, which takes account of time and cardiovascular hemodynamics, is crucial to ensure positive outcomes postintervention. The “4D strategy” with the shortening of the aortic metallic jacket and reduction of the number and stiffening of implanted devices through a staged hybrid single lumen reconstruction (TIGER) protocol offers the best solution until we have more compliant grafts. In this translational review, we provide an analytical overview for a combined approach to AD using abdominal aortic septotomy and proximal endografting by exploring the development of this technique from bench to bedside, followed by the discussion of the iterative clinical steps required for its optimization.