The PETTICOAT technique combines:
- Standard TEVAR (Thoracic Endovascular Aortic Repair) to seal the proximal entry tear.
- Distal bare-metal stent extension to expand the true lumen and promote false lumen collapse.
1. Key Components
| Component | Role |
|---|---|
| Proximal Covered Stent (TEVAR) | Seals primary entry tear, prevents retrograde flow into false lumen. |
| Distal Bare-Metal Stent | Expands true lumen, improves distal perfusion, reduces dynamic obstruction. |
| Optional Balloon Fenestration | Used if static obstruction persists (rarely needed with modern stents). |
2. Why is PETTICOAT Used?
Limitations of Standard TEVAR in TBAD
- TEVAR alone seals the proximal tear but may not fully expand the true lumen distally.
- Persistent false lumen flow → Risk of aneurysmal degeneration (20–40% at 5 years).
- Dynamic obstruction (true lumen collapse) → Malperfusion syndromes (renal, mesenteric, limb ischemia).
How PETTICOAT Helps
- Restores true lumen flow by mechanically expanding the compressed lumen.
- Promotes false lumen thrombosis by reducing pressure gradients.
- Reduces long-term aortic expansion (better remodeling than TEVAR alone).
3. Evidence Supporting PETTICOAT
| Study | Findings |
|---|---|
| STABLE Trial (2015) | PETTICOAT improved false lumen thrombosis (71% vs. 43% with TEVAR alone). |
| PETTICOAT Registry (2020) | Lower reintervention rates (12% vs. 30% with TEVAR alone). |
| 2023 ESC Guidelines | "Consider PETTICOAT for complicated TBAD with malperfusion." |
4. When is PETTICOAT Recommended?
Ideal Candidates
- Complicated TBAD (malperfusion, refractory pain, rapid expansion).
- Chronic TBAD with aneurysmal degeneration (>5.5 cm).
- Persistent false lumen flow after TEVAR.
Contraindications
- Ascending/arch dissection (Type A) → Requires open surgery.
- Severe iliac tortuosity (limits stent delivery).
5. Future Directions
- Bioabsorbable stents (temporary scaffolding to aid remodeling).
- Combination with biologic grafts to enhance aortic healing.
Conclusion
PETTICOAT represents a paradigm shift in TBAD management, offering better aortic remodeling than TEVAR alone. It is now a guideline-supported option for complex dissections.
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