Repair of Late Retrograde Type A Aortic Dissection After TEVAR: Causes and Management

Abstract

One of the most feared complications of thoracic endovascular aortic repair (TEVAR) and hybrid arch repair is retrograde type A aortic dissection (RTAD). More than two-thirds of RTAD occurs in the immediate postoperative period and first postoperative month. In presentations beyond that point, progression of the native aortopathy must be considered. We report a late presentation of an RTAD seven months after hybrid repair of an aortic intramural hematoma with an ulcer-like projection, and review the causes and management of this TEVAR complication. doi: 10.1111/jocs.12698 (J Card Surg 2016;31:164-167) One of the most feared complications of thoracic endovascular aortic repair (TEVAR) and hybrid arch repair is retrograde type A aortic dissection (RTAD) that has a low incidence but high mortality. 1-5More than two-thirds of RTAD occurs in the immediate postoperative period and first postoperative month. 3 In presentations beyond that point, the progression of the native aortopathy must be considered. 6 We report an uncommon delayed presentation of an RTAD seven months after hybrid repair of an aortic intramural hematoma (IMH) with an ulcer-like projection (ULP), and review the causes and management of this TEVAR complication. PATIENT PROFILEA 71-year-old female was admitted with an acute type B IMH. A contrast-enhanced multidetector computed tomography (MDCT) showed a 14.8 Â 11 mm ULP in the outer curvature of the aortic arch distal to the origin of the left subclavian artery (LSA), and 15 mm of maximal thickness of the IMH (Fig. 1A and B). After one week of optimal medical management, the patient remained hypertensive, and a new MDCT scan demonstrated minimal resolution of the IMH and persistence of the ULP. The patient was scheduled for elective zone 2 TEVAR with concomitant LSA revascularization. A left common carotid artery (LCCA) to LSA bypass with a 6 mm standard-walled removable ringed GORE-TEX

Late complications after hybrid aortic arch repair

“…All RTADs developed in patients who had undergone hybrid repair for chronic dissection. Mosquera et al 11 reported a similar case of late RTAD at 7 months after hybrid arch repair for type B intramural hematoma. Therefore, careful follow-up for late RTAD seems to be more necessary in patients undergoing hybrid arch repair for dissection pathologies.…”

Open Conversion for Type A Ascending Aortic Dissection after Thoracic Endovascular Aortic Repair by the Chimney Graft Technique

“…To achieve reliable anastomosis in our patient, removing the proximal portion of the endograft including cutting the proximal parts of the bare metal stents with metal hooks was necessary to allow mobilization of the anastomotic site, closure the entry tear, and facilitate secure suturing because the ascending aorta was stiff and fixed within the chimney graft. 8 ) Although concerns have emerged regarding the risk of postoperative type 1a endoleak in patients with chimney grafts, this has not occurred during follow-up for 3 years. The main stent was a 40 mm Gore-TAG and it was tightly anastomosed to a 30 mm Dacron graft by tapering the proximal stent, probably leading to close adhesion to the aortic wall that prevented type 1 endoleak ( Fig.…”

Pulmonary artery dissection caused by extension of acute type B aortic dissection through the ductus arteriosus

“…Retrograde dissection from a type B aortic dissection usually involves the transverse arch and its branches and may also involve the ascending aorta following thoracic endovascular aortic repair . We present images of an acute dissection of the pulmonary artery (PA) caused by retrograde extension of an acute type B aortic dissection through a closed ductus arteriosus (DA).…”