The Knickerbocker Technique for Endovascular Exclusion of False Lumen in Chronic Type B Aortic Dissection

Simple endovascular coverage of primary entry tear in chronic type B aortic dissection (CTBAD) is often unsuccessful in promoting false lumen (FL) thrombosis and aortic remodeling as it occurs with acute dissections. Aim of this video is to illustrate technical solutions used for effective endovascular treatment in a case of a residual CTBAD after acute type A aortic dissection. Critical issues addressed are (1) creation of a suitable landing zone for endografting at the time of the original open surgery for the acute Type A dissection, with the use of a branched open graft for revascularization and proximal rerouting of the innominate and the left common carotid arteries, (2) left subclavian (that presented chronic dissection involving the dominant vertebral artery) revascularization with carotid-subclavian by pass plus vertebral artery reimplantation, at the time of thoracic endografting, as the first step of residual CTBAD treatment, (3) secondary sealing of FL distal backflow by deploying in the distal thoracic true lumen an oversized, tapered stent graft, followed by controlled balloon rupture of the dissection membrane, the so-called knickerbocker technique. The ballooning maneuver dilated the endograft to full diameter at its midsection, permitting the graft to adhere to the outer aortic layer with a rapid expansion suggesting the dissection membrane had effectively ruptured.