Caged Knickerbocker: A Novel Modification to Targeted False Lumen Management in Complex Aortic Dissection
David Blitzer, Gabriel Pereira, Charles Drucker, Khanjan Nagarsheth, John Karwowski, Bradley Taylor, Shahab Toursavadkohi
University of Maryland Medical Center, Baltimore, MD
INTRODUCTION: Targeted false lumen (FL) management has been described for particularly complex presentations of aortic dissection. These techniques share the common goal of redirecting flow into the true lumen (TL) while thrombosing the FL. The “Knickerbocker” technique (KB) is often referenced and includes dilating a focal portion of an oversized endograft in the TL resulting in purposeful rupture of the FL septum. Though effective, there is an increased risk of visceral propagation and malperfusion. The goals of this study were to describe a novel modification of the KB technique and present outcomes from our initial experience. The Caged KB (CKB) introduced here utilizes a smaller cuff that constrains the distal segment of the oversized endograft to control the FL rupture.
METHODS: A retrospective chart review was conducted at a tertiary academic center from 2019-2020. Patients were included if they had a history or current presentation of aortic dissection and underwent CKB repair. Data were collected to include demographics, indications for repair, technical success, perioperative outcomes, hospital course, mortality, and further aortic interventions.
RESULTS: Five patients were included in our evaluation. Four patients (80%) presented with chronic Type B aortic dissection (cTBAD) and concomitant aneurysmal degeneration of the thoracic aorta; one patient (20%) presented with an acute rupture secondary to cTBAD. Three patients (60%) had previous aortic repairs, two of which were for Type A Aortic Dissection that additionally required redo sternotomy and total arch replacement prior to CKB (Table 1). All patients presented with a patent for partially thrombosed FL. CKB was technically successful in all cases. Median operative time was 2:31 (Range: 1:19, 4:55) and there were no intraoperative complications such as aortic rupture, retrograde dissection, or visceral malperfusion. No major complications were identified in the immediate post-operative period. Median length of stay was 3.98 days (Range: 3.53, 11.09), and 4 (80%) patients were discharged home. Two (40%) patients required further aortic intervention due to aneurysmal degeneration (see patients 4 and 5, Table 1). For Patient 4, the CKB cuff was deployed proximal to the artery of Adamkiewicz and subsequent intervention required an interposition graft between the endograft and just proximal to celiac trunk. Patient 5 had a previous carotid-subclavian bypass and Zone 2 landing, in addition to a bovine arch. A small type IA endoleak was identified at the time of CKB and followed post-operatively until requiring elective repair with total arch replacement.
CONCLUSIONS: Achieving complete FL thrombosis is a considerable challenge when managing complex aortic dissections. Our data demonstrate technical feasibly and early successful outcomes with the CKB approach. Moving forward, future research should focus on discerning individual patients who will benefit from targeted FL management and compare outcomes between different approaches 
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