Occlusion of the false lumen, management of aortic side branches

Complete thrombosis of the false lumen in chronic aortic dissection is essential to achieve positive aortic remodeling. However, persistent perfusion through aortic collaterals, dissected supra-aortic trunks (SAT), and renovisceral arteries often complicate this process. Our approach to treat chronic dissections integrates TEVAR and custom-made FBEVAR, often combined with supra-aortic trunk debranching or frozen elephant trunk (FET) procedures. Preemptive embolization of aortic side branches (intercostal, lumbar, mediastinal, bronchial, and mammary arteries) is a key strategy to prevent endoleaks and facilitate false lumen thrombosis. Based on preoperative imaging and anatomical considerations, endovascular access routes and embolization materials are carefully selected. A staged strategy targeting re-entry tears and aortic collaterals encourages progressive false lumen occlusion. False lumen embolization often includes false lumen endografts (FLE) implantation. Follow-up imaging is mandatory to plan iterative embolizations which are often required to achieve complete thrombosis. In this study, we comprehensively describe our approach to perform staged embolization, close postoperative surveillance, and an aggressive strategy targeting endoleaks that are critical to promote aortic remodeling and ensure long-term success.