2.3.4. Stent graft–induced new entry (SINE)
Dong and colleagues defined SINE as a new tear in the aortic intima
induced by the TEVAR stent-graft post- intervention. Proximal SINE is
defined as a tear proximal to the stent-graft implanted, leading to RTAD
or proximal pseudoaneurysm [37]. Distal SINE (dSINE) occurs distal
to the stent-graft landing zone resulting in increased pressure in the
FL, leading to further expansion in its diameter [37]. The
occurrence of SINE has been frequently reported particularly following
TEVAR in un-TBAD [12, 21, 28], with a distal SINE being the most
commonly observed type [8, 12, 21, 38].
SINE is considered a dangerous complication of TEVAR, especially since
it is usually asymptomatic and incidentally discovered with routine
surveillance [39-41]. SINE can also lead to treatment failure as it
prevents FL thrombosis by re-establishing its perfusion and subsequently
hindering the favourable aortic remodelling [38].
Distal SINE is rarely observed immediately after TEVAR. However, longer
follow-up yielded a concerning incidence of 6.22%-26.5% with a mean
time for occurrence between 27.78-29.7 months post-procedure [31, 38,
42].
Predictors of dSINE were TEVAR in the chronic phase (OR: 2.6; 95%
31.22-5.68; P=.01), stent grafts with connecting bar (OR: 3.28; 95%CI
1.54-7.0; P<.0) and stent grafts size <165 mm
(OR:5.65; 95%CI 2.60-12.64; P<.01) [31]Furthermore, Jang
et al. [42] showed that distal oversizing is an independent
predictor of dSINE, and proposed accurate stent-graft size selection may
reduce the incidence of late dSINE. Medical management can be considered
as a treatment option for dSINE, provided that structural stability is
present. However, re-intervention is commonly indicated due to increased
FL diameter, rupture, pseudoaneurysm or malperfusion [31, 42, 43].
Reintervention with TEVAR in TBAD patients can improve long-term
survival. Nevertheless, recurrence rates of dSINE were high after TEVAR
reintervention. More tapered stent-grafts and improved techniques may
facilitate lower recurrence rates [43].