\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}
\usepackage{CJKutf8}



\usepackage{float}








\begin{document}

\title{Evaluation of flow dynamics in dSINE (distal Stent graft-Induced New
Entry) using 4D flow MRI}



\author[1]{Kenji Sakakibara}%
\author[2]{Hiroyuki Nakajima}%
\author[1]{Yudai Hagihara}%
\author[1]{Chie Nakamura}%
\author[1]{Daichi Shikata}%
\author[1]{Yuki Takesue}%
\author[1]{Satoru Shiraiwa}%
\author[1]{Yoshihiro Honda}%
\author[1]{Shigeaki Kaga}%
\author[1]{Masahiro Hamasaki}%
\author[2]{Hisashi Johno}%
\affil[1]{University of Yamanashi}%
\affil[2]{University of Yamanashi Faculty of Medicine}%


\vspace{-1em}



  
  \date{June 16, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


Evaluation of flow dynamics in dSINE (distal Stent graft-induced New
Entry) using 4D flow MRI

Kenji Sakakibara\textsuperscript{1)}, Hiroyuki
Nakajima\textsuperscript{1)}, Yudai Hagihara\textsuperscript{1)}, Chie
Nakamura\textsuperscript{1)}, Daichi Shikata\textsuperscript{1)}, Yuki
Takesue\textsuperscript{1)}, Satoru
Shiraiwa\textsuperscript{1)},Yoshihiro
Honda\textsuperscript{1)},Shigeaki Kaga\textsuperscript{1)}

Masahiro Hamasaki\textsuperscript{2)}, Hisashi Johno\textsuperscript{2)}

1) Department of Surgery (II), Faculty of Medicine, University of
Yamanashi

2) Department of Radiology, Faculty of Medicine, University of Yamanashi

\textbf{Corresponding author:~~Kenji Sakakibara, M.D.}

Department of Surgery(II), Faculty of Medicine, University of Yamanashi

1110 Shimokato, Chuo City, Yamanashi, 409-3898 Japan

Tel:~~+81-55-273-9682, Fax:~~+81-55-273-6767

E-mail:~~kenjis@yamanashi.ac.jp

Keywords:~dSINE, 4D flow MRI\emph{,}

\textbf{AUTHOR CONTRIBUTIONS}

All authors were involved in reviewing the final draft of the
manuscript. All authors have made a significant contribution to
preparing the case report.

\textbf{CONFLICT OF INTEREST:} The authors declare no conflicts of
interest.

\textbf{CONSENT:} The patient has given written informed consent for the
publication of this case report

\textbf{DATA AVAILABILITY STATEMENT}

All data regarding this case has been reported in the manuscript. Please
contact the corresponding author if you are interested in any further
information.

\textbf{Abstract:}

In cases of distal stent graft-induced new entry (dSINE), analysis using
4D flow MRI revealed accelerated flow into the false lumen and observed
wall shear stress (WSS) elevation, prompting a decision for false lumen
expansion. Thoracic endovascular aortic repair (TEVAR) was performed,
resulting in rethrombosis of the false lumen.

\textbf{Key Clinical Message}

In cases of distal stent graft-induced new entry (dSINE), analysis using
4D flow MRI revealed accelerated flow into the false lumen and observed
wall shear stress (WSS) elevation, prompting a decision for false lumen
expansion. Thoracic endovascular aortic repair (TEVAR) was performed,
resulting in rethrombosis of the false lumen.

\textbf{Introduction:}

Total Arch Replacement (TAR) using a Frozen Elephant Trunk (FET) is
performed for chronic type B aortic dissection, with reported successful
thrombosis of the false lumen. However, when distal stent graft-induced
new entry (dSINE) occurs in the postoperative period, the blood flow
within the false lumen remains unclear. In this study, 4D flow MRI was
employed for blood flow evaluation in dSINE cases, providing actual
measurements of flow velocity and direction, unlike contrast-enhanced CT
simulations. Accelerated flow from the true lumen to the false lumen was
confirmed, along with an increase in WSS within the false lumen,
predicting future enlargement. Consequently, TEVAR was performed for
dSINE, resulting in favorable rethrombosis of the false lumen.

\textbf{Case:}

A male in his 60s experienced acute type A aortic dissection in 2015 and
underwent Bentall`s\begin{CJK}{UTF8}{gbsn}　\end{CJK}\selectlanguage{english}operation. In 2020, contrast-enhanced CT revealed
an open false lumen from the distal arch to the abdominal aorta with an
enlarged false lumen, leading to total arch replacement with FET.
Postoperatively, thrombosis of the false lumen progressed, and the
diameter of the distal arch decreased (Fig 1(A)). In 2023, the patient
presented with chest and back pain. Contrast-enhanced CT showed blood
flow in the previously thrombosed false lumen and an enlargement of the
false lumen diameter (Fig. 1(B)(C)). 4D Flow MRI revealed accelerated
flow from the true lumen to the false lumen at the distal end of the FET
(Fig. 2(A)(B)), along with an increase in wall shear stress at the site
where the flow from the true lumen to the false lumen reached (Fig. 2(C
)). These findings led to the decision that the false lumen diameter
would further enlarge.

The strategy was to perform TEVAR for new entry closure. Aortic
angiography showed high-velocity blood flow from the true lumen to the
false lumen at the distal end of the stent graft (Fig. 3(A)(B)). TEVAR
was performed for dSINE, resulting in the disappearance of blood flow
into the false lumen, and the surgery was concluded (Fig. 3C).
Postoperative CT showed thrombosis of the false lumen and a reduction in
its diameter (Fig. 3D). After 6 months, the false lumen was thrombosed,
and its diameter continued to shrink.

\textbf{Discussion:}

Chronic aortic dissection poses a risk of aortic diameter enlargement
and rupture in the chronic phase. Therefore, imaging diagnosis with CT
to monitor the aneurysmal diameter is strongly recommended. Reports on
the prognosis of chronic aortic dissection have suggested that cases
with an open false lumen have a poorer life prognosis than cases with a
closed false lumen, indicating a potential link between blood flow
within the false lumen and the enlargement or rupture of the aortic
aneurysm in the chronic phase.\textsuperscript{1)} Treatment with FET
for total arch replacement has been reported to achieve good thrombosis
of the false lumen in chronic aortic dissection. When performing total
arch replacement, FET, compared to the conventional Elephant Trunk (ET)
method for distal anastomosis, facilitates a more central anastomosis in
the proximal portion of the arch, making peripheral anastomosis easier
and reducing blood loss. Additionally, the insertion of a reinforced FET
with a stent graft allows for the expectation of thrombotic occlusion
and subsequent disappearance of the false lumen in the descending
thoracic aorta during the chronic phase. However, complications such as
dSINE may occur in the chronic phase as a result of FET. dSINE is the
new entry of the stent graft's distal end, leading to the generation of
new blood flow from the true lumen to the false lumen, causing
enlargement of the false lumen. After the FET procedure, dSINE occurred
in 6.5\% of patients in the chronic setting\textsuperscript{2)}.
Excessive oversizing of the stent graft relative to the true lumen and
the spring-back force of the stent graft contribute to SINE formation.
Generally, dSINE is asymptomatic and incidentally discovered during
regular follow-up CT scans. However, approximately 5\% of cases present
with symptomatic chest or back pain. \textsuperscript{3)}Typical CT
images show the distal part of the stent graft inserted into the true
lumen detaching from the intima of the aorta, protruding into the false
lumen, and resuming blood flow into the false lumen or enlargement of
the false lumen.

4D Flow MRI is a non-invasive imaging technique that expands 2D
phase-contrast MRI in three dimensions. It allows for the direct
measurement of blood flow, including flow from the true lumen to the
false lumen, and wall shear stress (WSS) within the aorta in cases of
aortic dissection. In this study, 4D Flow MRI was used for the first
time to analyze blood flow in a case of dSINE. The analysis of aortic
dissection with 4D MRI indicates that if accelerated blood flow and
localized increases in WSS are observed in the remaining dissected area
from the true lumen to the false lumen, factors contributing to remote
enlargement are likely.\textsuperscript{4)}

In the case of dSINE, as in cases of chronic open false lumen aortic
dissection, accelerated blood flow from the true lumen to the false
lumen was observed, suggesting further enlargement. Thus, TEVAR was
chosen\textsuperscript{56)}, and good thrombosis of the false lumen was
achieved. However, regular follow-up with CT imaging is necessary due to
the risk of arterial expansion and re-dissection.

\textbf{Conclusion:}

In contrast to blood flow simulations using CT, we conducted blood flow
analysis of dSINE cases using measurable 4D Flow MRI. In this case, 4D
Flow MRI revealed accelerated blood flow into the newly formed false
lumen and an increase in WSS, indicating factors contributing to the
enlargement of the false lumen.

\textbf{AUTHOR CONTRIBUTIONS}

\textbf{KS:} ~Writing, reviewing, and editing.~\textbf{HN:}
~Supervision\textbf{, CN, DS, YT, SS, YH:} directly and substantively
managed this patient, collected data, and drafted and revised this
manuscript. \textbf{SK:} Supervision.\textbf{MH, HJ:} Image analysis
using 4D flow MRI.

All authors were involved in reviewing the final draft of the
manuscript. All authors have made a significant contribution to
preparing the case report.

\textbf{ACKNOWLEDGMENTS}

None.

\textbf{CONFLICT OF INTEREST}

The authors declare no conflicts of interest.

\textbf{CONSENT}

The patient has given written informed consent for the publication of
this case report

\textbf{DATA AVAILABILITY STATEMENT}

All data regarding this case has been reported in the manuscript. Please
contact the corresponding author if you are interested in any further
information.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji
  S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki
  Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S,
  Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y,
  Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T,
  Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T,
  Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita
  Y, Ono M, Ueda Y; Japanese Circulation Society, the Japanese Society
  for Cardiovascular Surgery, the Japanese Association for Thoracic
  Surgery and the Japanese Society for Vascular Surgery Joint Working
  Group. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment
  of Aortic Aneurysm and Aortic Dissection. Circ J. 2023 Sep
  25;87(10):1410-1621.
\item
  Czerny M, Eggebrecht H, Rousseau H, Mouroz PR, Janosi RA, Lescan M,
  Schlensak C, B\selectlanguage{ngerman}öckler D, Ante M, Weijde EV, Heijmen R, Eckstein HH,
  Reutersberg B, Trimarchi S, Schmidli J, Wyss T, Frey R, Makaloski V,
  Brunkwall J, Mylonas S, Szeberin Z, Klocker J, Gottardi R, Schusterova
  I, Morlock J, Berger T, Beyersdorf F, Rylski B. Distal Stent
  Graft-Induced New Entry After TEVAR or FET: Insights Into a New
  Disease From EuREC. Ann Thorac Surg. 2020 Nov;110(5):1494-1500.
\item
  Shimamura K, Miyagawa S Incidence, Mechanism and Prevention of Stent
  Graft-induced New Entry Tear (SINE) after TEVAR for Aortic Dissection.
  Jpn J Vasc Surg 2022; 31: 363--368
\item
  Takei Y, Itatani K, Miyazaki S, Shibasaki I, Fukuda H.
  Four-dimensional flow magnetic resonance imaging analysis before and
  after thoracic endovascular aortic repair of chronic type B aortic
  dissection. Interact Cardiovasc Thorac Surg. 2019 Mar 1;28(3):413-420.
\item
  Kreibich M, Berger T, Rylski B, Chen Z, Beyersdorf F, Siepe M, Czerny
  M. Aortic reinterventions after the frozen elephant trunk procedure. J
  Thorac Cardiovasc Surg. 2020 Feb;159(2):392-399.e1. doi:
  10.1016/j.jtcvs.2019.02.069.
\item
  Furutachi A, Takamatsu M, Nogami E, Hamada K, Yunoki J, Itoh M,
  Kamohara K. Early and mid-term outcomes of total arch replacement with
  the frozen elephant trunk technique for type A acute aortic
  dissection. Interact Cardiovasc Thorac Surg. 2019 Nov 1;29(5):753-760.
\end{enumerate}

\textbf{Figure legends}

Fig 1. (A) 3D-CT revealed an open false with an enlarged false lumen,
leading to total arch replacement with FET. (B) 3D CT (C)
contrast-enhanced CT showed blood flow in the previously thrombosed
false lumen and an enlargement of the false lumen diameter (Fig.
1(B)(C)).

Fig2 4D Flow MRI revealed accelerated flow from the true lumen to the
false lumen at the distal end of the Frozen Elephant Trunk (A)axial
image (B))3D-view, (C) An increase in wall shear stress at the site
where the flow from the true lumen to the false lumen is reached.

Fig, 3 (A) (B) Aortic angiography showed high-velocity blood flow from
the true lumen to the false lumen at the distal end of the stent graft.
(C) TEVAR was performed for dSINE, resulting in the disappearance of
blood flow into the false lumen, and the surgery was concluded (D)
Postoperative CT showed thrombosis of the false lumen and a reduction in
its diameter (Fig. 3D).

\textbf{Additional files}

Additional file 1 --- 4DflowMRI.wmv This video corresponds to Figure 2.

Additional file 2 --- angio.wmv This videocorresponds to Figure 3.

.

\textbf{Hosted file}

\verb`\selectlanguage{english}4\selectlanguage{english}DMRI\begin{CJK}{UTF8}{gbsn}論文.\end{CJK}\selectlanguage{english}pptx`  available at \url{https://authorea.com/users/509459/articles/826602-evaluation-of-flow-dynamics-in-dsine-distal-stent-graft-induced-new-entry-using-4d-flow-mri}

\selectlanguage{english}
\FloatBarrier
\end{document}

