A graft inversion technique for retrograde type A aortic dissection after thoracic endovascular repair for type B aortic dissection

Abstract

BackgroundRetrograde type A aortic dissection (RTAD) is a rare but life-threatening complication after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). A graft inversion technique was applied to distal anastomosis in total arch replacement for this complicated dissection. We reviewed our results of the processing for this serious complication. The aim is to evaluate the feasibility of this technology.MethodsFrom January 2013 to December 2017, 20 patients (80% male, mean age 50.9 ± 9.5 years) with retrograde type A aortic dissection after thoracic endovascular aortic repair for type B aortic dissection were scheduled for surgical treatment at our center. All patients underwent an ascending aorta and total aortic arch replacement procedure. The 20 patients were divided into two groups, 1 group involved 9 patients underwent surgery using stepwise technique; the graft inversion technique was performed in the other group containing the remaining 11 patients. The postoperative variables, including cardiopulmonary bypass time, the circulatory arrest time, the aortic cross clamp time, were analyzed. Meanwhile we also analyzed the postoperative mortality and complications to evaluate the early and mid-term outcomes of surgical treatment for RTAD after TEVAR.ResultsIn-hospital mortality was 10% (2 of 20 patients). No patient developed postoperative paraplegia, renal failure, stroke, or distal anastomotic bleeding. Two patients developed renal insufficiency, one developed neurologic insufficiency, and one developed pulmonary infection, all of which were managed accordingly. Cardiopulmonary bypass (CPB) time, and circulatory arrest time were significantly shorter in the graft inversion group than in the stepwise group (165.8 ± 37.9 min versus 206.1 ± 46.8 min, p<0.05; 34.5 ± 5.6 min versus 42.4 ± 9.5 min, p<0.05, respectively). The 18 survivors had a mean follow-up of 25.8 ± 18.2 months, and all patients remained alive and well.ConclusionGraft inversion can enable a secure distal anastomosis under good surgical exposure, resulting in reduced durations of CPB, and circulatory arrest for RTAD after TEVAR. Surgical treatment could be a safe alternative for treatment of this patients.Electronic supplementary materialThe online version of this article (10.1186/s13019-019-0851-9) contains supplementary material, which is available to authorized users.

Surgical Treatment of Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair

“…19,20) In our study, the RTAD group did not increase the incidence of postoperative major adverse events compared with the no-RTAD group. Hu, et al 25) reported a graft inversion technique for distal anastomosis of RTAD. Compared with the traditional anastomosis technique, the inversion technique is beneficial to the exposure of the surgical field and can shorten the time of CPB.…”

Bentall procedure for retrograde type A dissection after endovascular repair in type A aortic dissection: A case report

“…Lu et al [4] reported that the incidence of RTAD in TAAD was nearly 15%, while it was 1.3% to 8% in TBAD. [6,7] Several factors may contribute to these findings. First, the ascending aorta is subjected to high velocities and consequent shear stresses under pulsatile movements during the cardiac and respiratory cycles.…”

“…This can lead to proximal leakage and rupture from repeated friction between the endograft and aortic wall. [4,6] Second, an increased radial force due to the curvature of the aortic arch and stent oversizing may injure the aortic wall. Third, blood pressure and heart rate instability can also increase the incidence of TAAD compared to TBAD; this is why TEVAR cannot be regularly used in the treatment of acute TAAD.…”

“…[7][8][9] In the management of existing endografts, the appearance of a new tear in the fragile aortic wall during endograft removal must be considered, so in most cases, these endografts are left in place, and the frozen elephant trunk technique is omitted; however, the bare spring of the proximal endograft would be removed to create an appropriate distal plane. [6,7,10] However, the surgical management of RTAD after TEVAR for TAAD has seldom been reported. [11][12][13] In contrast to RTAD in TBAD, RTAD in TAAD requires the resolution of aortic arch and endograft lesions if total arch replacement is performed.…”

“…[7–9] In the management of existing endografts, the appearance of a new tear in the fragile aortic wall during endograft removal must be considered, so in most cases, these endografts are left in place, and the frozen elephant trunk technique is omitted; however, the bare spring of the proximal endograft would be removed to create an appropriate distal plane. [6,7,10]…”