When and how to replace the aortic arch for type A dissection.
Di Bartolomeo Roberto,Leone Alessandro,Di Marco Luca,Pacini Davide
Annals of cardiothoracic surgery
Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery and despite numerous innovations in medical and surgical management, early mortality remains high. The standard treatment of AAAD requires emergency surgery of the proximal aorta, preventing rupture and consequent cardiac tamponade. Resection of the primary intimal tear and repair of the aortic root and aortic valve are well-established surgical principles. However, the dissection in the aortic arch and descending untreated aorta remains. This injury is associated with the risk of subsequent false lumen dilatation potentially progressing to rupture, true lumen compression and distal malperfusion. Additionally, the dilatation of the aortic arch, the presence of a tear and retrograde dissection can all be considered indication for a total arch replacement in AAAD. In such cases a more aggressive strategy may be used, from the classic aortic arch operation to a single stage frozen elephant trunk (FET) technique or a two-stage approach such as the classical elephant trunk (ET) or the recent Lupiae technique. Although these are all feasible solutions, they are also complex and time demanding techniques requiring experience and expertise, with an in the length of cardiopulmonary bypass and both myocardial and visceral ischemia. Effective methods of cerebral, myocardial as well visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. Moreover, a correct assessment of the anatomy of the dissection, through the preoperative angio CT scan, in addition to the clinical condition of the patients, remain the decision points for the best arch repair strategy to use in AAAD.
Management of retrograde type A IMH with acute arch tear/type B dissection.
Nauta Foeke,de Beaufort Hector,Mussa Firas F,De Vincentiis Carlo,Omura Atsushi,Matsuda Hitoshi,Trimarchi Santi
Annals of cardiothoracic surgery
The incidence of intramural hematomas (IMH) in acute dissection (AD) patients varies between 6% and 30% in the literature, most frequently involving only the descending aorta (58%) than the arch or ascending aorta (42%). In this setting, IMH that initiate in the descending aorta, but extend into the arch or ascending aorta have been described, and referred to as a retrograde type A IMH. In these patients the risk of neurological or cardiac complications are high, and therefore an open surgical or hybrid approach has been proposed as the most appropriate. Nevertheless, the endovascular management of such lesions in surgically unfit patients for open surgery have been offered with acceptable outcomes, although the risk of landing in an unsuitable proximal landing zone is evident. In conclusion, retro-TAIMH is an acute aortic syndrome and should be managed as such. The recommended treatment strategy is open surgery for treating ascending or arch involvement, and TEVAR/medical, based on a complication-specific approach, for those with only descending localization. In those patients in whom retro-TAIMH is associated with an acute B dissection presenting with a proximal entry tear located into the descending aorta, a TEVAR represents an option treatment.
Thoracic endovascular aortic repair: A single center's 15-year experience.
Ziza Vincent,Canaud Ludovic,Molinari Nicolas,Branchereau Pascal,Marty-Ané Charles,Alric Pierre
The Journal of thoracic and cardiovascular surgery
OBJECTIVE:Specific complications of thoracic endovascular aortic repair (TEVAR) exist and long-term data are lacking. The purpose of this study was to evaluate our long-term TEVAR results. METHODS:This is a single-center retrospective study of 223 patients undergoing TEVAR from 1998 to 2013. Indication was aneurysm (45%), traumatic (26%), dissection (23%), and septic (6%). RESULTS:Patients' mean age was 62.7 ± 17.9 years, 84% of them had an American Society of Anesthesiologists score ≥3, and 42% had an aortic rupture. TEVAR was performed in zone 0 (n = 17), 1 (n = 17), or 2 (n = 59) in 42% of patients. Technical success rate was 96.4%. Overall 30-day mortality was 11.7% (elective aneurysm, 11.6%; emergent aneurysm, 34.3%; acute type B dissection, 14.8%; chronic dissection, 4.2%; septic, 8.3%; and traumatic, 1.7%). Major adverse events included stroke in 4.5%, spinal cord ischemia in 1.8%, and retrograde aortic dissection in 2.7%. Mean follow-up was 43.4 ± 38 months. Estimated aortic complications-free survivals at 12, 36, 60, and 120 months were (% ± standard error) 73% ± 3%, 64% ± 4%, 62% ± 4% and 57% ± 5%, respectively. Multivariate analysis showed that patients treated for a chronic aortic dissection had a significant risk of late reintervention (P = .001) CONCLUSIONS: Because of its simplicity and low morbimortality rate, TEVAR has become the first-line approach for thoracic aortic diseases. Mortality outcomes are related to aortic pathology, emergent status, and proximal landing zone. To improve long-term results, rigorous patient selection and follow-up, development of referral centers, and technologic evolution of materials have to be reached.
Endovascular Aortic Repair for Progressive Chronic Thoracoabdominal Aortic Dissections.
Mantese Vito,Kunhammed Shameem
Annals of vascular surgery
BACKGROUND:Ascending and thoracic aortic dissections progress into thoracoabdominal aneurysms 20-40% of the time, due to the initial aortic injury with associated weakness of the aortic wall. The increased firmness of the intimal flap usually results in a collapsed true lumen that does not spontaneously reexpand even with progressive dilatation of the aorta. In an effort to identify a safe and effective treatment path for this complex disease process, we present 4 cases illustrating successful sequential thoracic endovascular aortic repair (TEVAR) and fenestrated endovascular aortic repair (FEVAR). The treatment of these patients with endovascular techniques is less invasive than open conventional operations. However, multiple procedures are required using various complex novel techniques. METHODS:Institutional review board approval was obtained to identify 4 cases between January 2010 and May 2015 of patients with pretreatment hypertension, who initially presented with an aortic dissection. All patients subsequently developed a descending aortic aneurysm and were treated by TEVAR and FEVAR. Monthly and yearly outcomes were analyzed. RESULTS:All procedures concluded with branched visceral vessel patency and no type I endoleaks. One patient required extraction of the retrograde superior mesenteric artery stent placed during the acute phase for visceral reperfusion. Another patient developed acute thromboembolic occlusion of the right common femoral artery requiring emergent revascularization in the immediate postoperative period. CONCLUSIONS:Aortic dissection is the most common cause of death related to aortic pathology. Treatment of type B aortic dissections has traditionally been initially medical therapy unless complications develop. The treatment of subsequent complications has been associated with a high morbidity and mortality rate. However, the advent of evolving endovascular therapies has resulted in the reassessment of how these patients might be handled. This case series illustrates the treatment of expanding chronic thoracoabdominal aortic dissecting aneurysms with a total endovascular approach using various novel techniques.
Acute retrograde type A intramural hematoma treated with an endovascular approach.
Vo Anh T,Le Khoi M,Nguyen Trang T,Vu Thanh T,Vu Thien T,Nguyen Dinh H
Asian cardiovascular & thoracic annals
A 71-year-old woman was admitted with sudden onset of severe chest pain. Computed tomography demonstrated acute type A intramural hematoma with an entry tear in the first part of the descending aorta. The patient refused an operation. Endovascular repair was performed to prevent conversion to a typical dissection of the ascending aorta. At the 1-year follow-up, computed tomography showed total resolution of the intramural hematoma.
Repair of TEVAR-Associated Type A Dissection in the Elderly Is Possible With Reasonable Morbidity and Mortality.
Kornberger Angela,Petar Risteski,El Beyrouti Hazem,Khalil Mahmud,Burck Iris,Halloum Nancy,Beiras-Fernandez Andres,Vahl Christian-Friedrich
Vascular and endovascular surgery
BACKGROUND:Type A aortic dissection (AAD) is a devastating complication of thoracic endovascular repair (TEVAR). In elderly patients, surgery for AAD carries considerable morbidity and mortality. Repair of AAD after previous TEVAR is an even greater challenge as it usually requires the arch to be addressed and a preexisting stent graft to be included into the aortic repair. METHODS:A case series of 5 elderly patients who presented with acute AAD after previous TEVAR was reviewed. In 4 cases, there was retrograde AAD with involvement of the arch and stent graft. In 1 patient, intraoperative inspection showed no involvement of the arch. Three underwent ascending and subtotal arch replacement in moderate hypothermic circulatory arrest with selective cerebral perfusion. In 1 case, concomitant tricuspid valve repair was performed. The patient without involvement of the arch underwent emergent replacement of the ascending aorta in deep hypothermic circulatory arrest, and in the oldest, aged 88 years, surgery was limited to wrapping of the ascending aorta as an on-pump beating salvage procedure. RESULTS:Four (80%) of 5 patients survived and were discharged after an intensive care unit stay of 17.45 ± 15.98 days and a hospital stay of 26.0 ± 10.98 days. Mortality was 20%. All survivors were discharged with appropriate rehabilitation potential and without lasting neurological disabilities.
Stanford Type A Acute Retrograde Aortic Dissections: From Surgical to Endovascular Strategy?
Follis Fabrizio,Raffa Giuseppe M,D'Ancona Giuseppe,Amaducci Andrea,Follis Marco
Acute type A retrograde aortic dissection is characterized by a port of entry located in the descending aorta near the subclavian take-off, and is currently treated with surgery. Our experience with two patients who underwent a complicated postoperative course stimulated a review of the current literature and discussion of possible alternative strategies in light of recent advances in endovascular treatment.
Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single-Center Experience.
Chen Yen-Yu,Yen Hsu-Ting,Wu Chia-Chen,Huang David Kwan-Ru
Annals of vascular surgery
BACKGROUND:The aim of this study is to present our experience of thoracic endovascular aortic repair (TEVAR) for type A intramural hematoma (TAIMH) and retrograde thrombosed type A aortic dissection (rt-TAAD) with the entry tear in the descending aorta or the abdominal aorta and discuss the outcomes. METHODS:We retrospectively reviewed total 6 patients who underwent TEVAR for TAIMH (n = 2) or rt-TAAD (n = 4) in our hospital between September 2017 and July 2019. The mean age of the patients (5 men and 1 woman) was 74 ± 13 years, and the mean follow-up duration was 13 ± 7 months. RESULTS:TEVAR was successfully performed in the acute phase in all patients without relevant complications. After TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of the entire thoracic aorta were achieved in 4 patients. In the remaining 2 patients, one had residual thrombosed false lumen of the ascending aorta due to a new development of PAU at the distal aortic arch and another needed additional endovascular intervention for ascending aorta hematoma progression. Late aorta-related adverse event was observed in one patient, who needed open aortic repair. There was no death during follow-up. CONCLUSIONS:Tear-oriented endovascular aortic repair is a potential option in selected patients of TAIMH and rt-TAAD and has shown favorable immediate outcomes and aortic remodeling. However, the late aorta-related adverse event is not negligible, and their long-term outcome has not been fully clarified. More research is warranted.
[Clinical Experience of Endovascular Stent-graft Treatment for Stanford Type A Acute Aortic Dissection].
Uchida Tetsuro,Kuroda Yoshinori,Yamashita Atsushi,Hamasaki Azumi,Hirooka Shuto,Nakai Shingo,Kobayashi Kimihiro,Sadahiro Mitsuaki
Kyobu geka. The Japanese journal of thoracic surgery
BACKGROUNDS:Recently, thoracic endovascular aortic repair (TEVAR) is widely accepted and performed in patients with complicated and uncomplicated Stanford type B aortic dissection. However, TEVAR for Stanford type A aortic dissection is not commonly performed even in the endovascular era. This report describes patients who underwent TEVAR for Stanford type A dissection. PATIENTS:Since 2016, 5 patients underwent TEVAR for retrograde acute Stanford type A dissection. A covered stent-graft was placed in the descending aorta for primary entry coverage. An additional bare-stent was placed in the narrowed true lumen of the downstream aorta. A thrombosed false lumen was observed in 4 and a partially thrombosed lumen in 1 patient. No patient showed pericardial effusion, aortic insufficiency, or persistent back pain. Four of 5 patients were asymptomatic, and only 1 patient developed multiorgan malperfusion. Repetitive computed tomography (CT) was performed postoperatively. RESULTS:All patients underwent successful TEVAR without the need for additional intervention, and no operative mortality and morbidity were observed. The patient with multiorgan malperfusion recovered uneventfully without any complication. Follow-up CT revealed complete disappearance of the false lumen in the ascending aorta in all patients. CONCLUSIONS:Although TEVAR of the descending aorta was performed with acceptable mortality and morbidity rates in strictly selected patients with retrograde Stanford type A dissection, conceptual and technical issues remain unresolved in patients with ascending aortic stent-graft placement. Technological advances would lead to the development of innovative disease-specific endovascular devices and solutions in the future for TEVAR in patients with Stanford type A dissection.
Endovascular repair for retrograde type A aortic dissection with malperfusion.
Takahashi Shinya,Katayama Keijiro,Takasaki Taiichi,Sueda Taijiro
Asian cardiovascular & thoracic annals
An 81-year-old man became semiconscious and suffered back pain followed by chest pain. Computed tomography showed retrograde acute type A aortic dissection with entries in the proximal and middle descending aorta, and an occluded true lumen of the right carotid artery. Emergency endovascular repair was performed. Immediately after deploying a stent-graft, aortography showed recanalization of the right carotid artery and no blood flow in the false lumen of the ascending aorta and aortic arch. The postoperative course was uneventful. Computed tomography at 6 months after the procedure showed obliteration of the false lumen and a patent right carotid artery.
[Endovascular repair of primary retrograde Stanford type A aortic dissection].
Wu H W,Sun L,Li D M,Jing H,Xu B,Wang C T,Zhang L
Zhonghua wai ke za zhi [Chinese journal of surgery]
To summarize the short- and mid-term results on endovascular repair of primary retrograde Stanford type A aortic dissection with an entry tear in distal aortic arch or descending aorta. Between December 2009 and December 2014, 21 male patients of primary retrograde Stanford type A aortic dissection with a mean age of (52±9) years received endovascular repair in Department of Cardiothoracic Surgery, Jinling Hospital. Among the 21 cases, 17 patients were presented as ascending aortic intramural hematoma, 4 patients as active blood flow in false lumen and partial thrombosis, 8 patients as ulcer on descending aorta combined intramural hematoma in descending aorta, and 13 patients as typical dissection changes. All patients received endovascular stent-graft repair successfully, with 15 cases in acute phase and 6 cases in chronic phase. Cone stent was implanted in 13 cases, while straight stent in 8 cases, including 1 case of left common carotid-left subclavian artery bypass surgery and 1 case of restrictive bare-metal stent implantation. No perioperative stroke, paraplegia, stent fracture or displacement, limbs or abdominal organ ischemia or other severe complications occured, except for tracheotomy in 2 patients. Active blood flow in ascending aorta or aortic arch disappeared, and intramural hematoma started being absorbed on CT angiography images before discharge. All patients were alive during follow-up (6 to 72 months), and intramural hematoma in ascending aorta and aortic arch was absorbed thoroughly. Type Ⅰ endoleak and ulcer expansion were found in 1 patient, and type Ⅳ endoleak in distal stent was found in another one patient. Secondary ascending aortic dissection was found in 1 case two years later, which was cured by hybrid procedure with cardiopulmonary bypass. Endovascular repair of primary retrograde Stanford type A aortic dissection was safe and effective, which correlated with favorable short- and mid-term results.
[Emergent Thoracic Endovascular Aortic Repair and Subxiphoid Pericardiotomy for Retrograde Type A Acute Aortic Dissection with Cardiac Tamponade;Report of a Case].
Sunada Masatoshi,Suzuki Yusuke,Takano Takashi,Midorikawa Hirofumi,Kanno Megumu
Kyobu geka. The Japanese journal of thoracic surgery
Type A acute aortic dissection has a high rate of mortality. Emergent surgical repair is the gold standard treatment, but some patients cannot tolerate the open surgery. Here, we report an 82-year-old patient with a history of cerebral infarction and cerebral bleeding who presented with a depressed level of consciousness and who was in a state of shock. A computed tomography (CT) scan showed cardiac tamponade associated with retrograde type A aortic dissection(RAAD), with a primary entry tear at a distal site of the left subclavian artery. We therefore performed emergent primary entry closure with stent grafting using the Conformable Gore Tag device and emergent drainage of the cardiac tamponade with subxiphoid pericardiotomy. Postoperative CT scan showed complete closure of the primary entry tear and a completely thrombosed false lumen. Primary entry closure with stent grafting could be an effective option for RAAD that meets anatomical criteria.
Clinics in diagnostic imaging (182). Acute descending aortic dissection with aortic root retrograde extension.
Gifford John Nathan,Poh Angeline Choo Choo
Singapore medical journal
A 77-year-old man presented with acute-onset severe chest pain radiating to the back and elevated blood pressure. Multiphasic computed tomography of the aorta revealed an intimal tear in the descending thoracic aorta which extended both retrograde to the aortic root and antegrade to the infra-renal abdominal aorta. The initial impression, that the images showed a Stanford type B aortic dissection, was because the portion of the false lumen that extended beyond the aortic arch remained unopacified even on delayed phases, making it challenging to assess the extent of the dissection flap. Bedside transthoracic echocardiography revealed a pericardial effusion. Cardiac tamponade ensued and the patient passed away shortly after presentation. This case highlights the need for early and accurate imaging assessment of acute aortic dissection, including accurate identification of the site of intimal tear and the extent of the dissection flap.
True Lumen Stabilization to Overcome Malperfusion in Acute Type I Aortic Dissection.
Tsagakis Konstantinos,Jánosi Rolf A,Frey Ulrich H,Schlosser Thomas,Chiesa Roberto,Rassaf Tienush,Jakob Heinz
Seminars in thoracic and cardiovascular surgery
Acute type I aortic dissection (AD) complicated by true lumen (TL) collapse and malperfusion downstream is associated with devastating prognosis. The study reports an institutional mid-term experience with TL stabilization by uncovered stents to restore perfusion as a supplement to proximal thoracic aortic surgery. Between January 2007 and May 2017, 181 out of 270 acute type A AD patients were operated on type I AD. Eighteen uncovered stents (10%) were used to expand the aortic TL in presence of visceral and/or peripheral malperfusion. The procedures took place in a hybrid operating room and were combined with proximal aortic surgery. During follow-up (mean ± standard deviation 3.44 ± 2.1 years), the fate of AD was evaluated by computed tomography. Indication for TL stenting included visceral (44%) or peripheral malperfusion (11%) or both (45%). Stenting of aortic branches followed in 33%. All patients underwent proximal repair and were combined with frozen elephant trunk (67%) or retrograde descending aorta stent grafting (11%). Thirty-day mortality was 16.7%. Two-year survival was 71.8%. The false lumen around the uncovered stents remained patent in 89% and the aortic diameter increased 0.1 cm/y. No intimal rupture or occlusion of arteries occurred. In 1 patient, the stented aortic lumen was visualized after 6.3 years and neointima ingrowth covering the nitinol frame was found. In acute type I AD, combined endovascular-surgical procedures in a hybrid operation room setting can be used safely to resolve distal malperfusion. Encapsulation of uncovered stents within the intimal wall provides a stable fundament for endovascular techniques to close entry tears and false lumen.
Acute Type I aortic dissection: a propensity-matched comparison of elephant trunk and arch debranching repairs.
Ma Mingjia,Feng Xin,Wang Jing,Dong Yiming,Chen Taiqiang,Liu Ligang,Wei Xiang
Interactive cardiovascular and thoracic surgery
OBJECTIVES:Our goal was to compare the performance of the frozen elephant trunk (FET) and the hybrid aortic arch debranching procedures for acute Type I aortic dissection. METHODS:From January 2013 to December 2015, 168 patients with Type I aortic disease underwent ascending aorta and total aortic arch replacement with FET implantation (the FET group, n = 132) or arch debranching with 1-stage aortic arch exclusion using an endovascular stent in a retrograde manner (the debranching group, n = 36). A propensity score-matched subgroup of 26 pairs was identified. Perioperative data and mid-term follow-up results were assessed. RESULTS:In the FET and the debranching groups, the 30-day mortality rates were 14.4% and 5.6% (P = 0.254) and the incidence of stroke was 5.3% and 5.6% (P > 0.999). Cardiopulmonary bypass time was significantly shortened, and the circulatory arrest was exempted in the debranching group. Cardiopulmonary bypass time was identified as a predictor for 30-day mortality (P = 0.027, odds ratio 1.01). Body mass index ≥ 25 kg/m2 was associated with multiorgan dysfunction syndrome (P = 0.016, odds ratio 3.51). Surgical modality did not significantly affect early outcomes. The 3-year survival rate was 76.1% (95% confidence interval, 63.0-81.9%) in the FET group and 82.5% (95% confidence interval, 65.2-91.8%) in the debranching group (P = 0.330). CONCLUSIONS:The hybrid aortic arch procedure without circulatory arrest can be safely performed on patients with acute Type I aortic dissection. Irrespective of cost-effectiveness, arch debranching was a promising alternative for patients who were unfit for the FET procedure.
Descending aortic banding for re-rupture of retrograde aortic dissection after emergency thoracic endovascular aortic repair.
Hattori Shigeru,Noguchi Kenichiro,Gunji Yusuke,Nagatsuka Motoki,Yamabe Tsuyoshi,Ogino Hidemitsu,Katayama Ikuo
General thoracic and cardiovascular surgery
Conversion to open repair after thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection is rare, but inevitable. We present a case of an 86-year-old man with ruptured type B aortic dissection after TEVAR. He received a successful stent-graft implantation of the descending aorta without any type of endoleak. After the patient was transferred to the intensive care unit, he went into a shock state. Contrast-enhanced CT revealed a re-rupture of acute retrograde type B aortic dissection. The false lumen was patent and perforated to the left thorax. Left thoracotomy and descending aortic banding was performed. Descending aorta was encircled with a woven Dacron graft at the distal part of the rupture site to compress the patent false lumen. The bleeding was stopped, and the follow-up CT showed false lumen thrombosis. Descending aortic banding is one of the quick and effective open conversion techniques.
Acute retrograde type A aortic dissection: morphologic analysis and clinical implications.
DiMusto Paul D,Rademacher Brooks L,Philip Jennifer L,Akhter Shahab A,Goodavish Christopher B,De Oliveira Nilto C,Tang Paul C
The Journal of surgical research
BACKGROUND:This study compares the morphology and outcomes of acute retrograde type A dissections (RTADs) with acute antegrade type A dissections (ATADs), and acute type B dissections. MATERIALS AND METHODS:From 2000 to 2016, there were 12 acute RTADs, 96 ATADs, and 92 type B dissections with available imaging. Dissections were characterized using computerized tomography angiography images. We examined clinical features, tear characteristics, and various morphologic measurements. RESULTS:Compared with acute type B dissections, RTAD primary tears were more common in the distal arch (75% versus 43%, P = 0.04), and the false-to-true lumen contrast intensity ratio at the mid-descending thoracic aorta was lower (0.46 versus 0.71, P = 0.020). RTAD had less false lumen decompression because there were fewer aortic branch vessels distal to the subclavian that were perfused through the false lumen (0.40 versus 2.19, P < 0.001). Compared with ATAD, RTAD had less root involvement where root true-to-total lumen area ratio was higher (0.88 versus 0.76, P = 0.081). Furthermore, RTAD had a lower false-to-true lumen contrast intensity ratio at the root (0.25 versus 0.57, P < 0.05), ascending aorta (0.25 versus 0.72, P < 0.001), and proximal arch (0.39 versus 0.67, P < 0.05). RTAD were more likely to undergo aortic valve resuspension (100% versus 74%, P = 0.044). CONCLUSIONS:RTAD tends to occur when primary tears occur in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared with ATAD, RTAD has less root involvement, and successful aortic valve resuspension is more likely.
[Occurrence of New Entry after Thoracic Endovascular Aortic Repair for Retrograde Stanford Type A Aortic Dissection;Report of Two Cases].
Kitaura Junya,Komiya Tatsuhiko,Shimamoto Takeshi,Nonaka Michihito,Matsuo Takehiko
Kyobu geka. The Japanese journal of thoracic surgery
We report 2 cases of occurrence of new entry after thoracic endovascular aortic repair(TEVAR) for retrograde Stanford type A aortic dissection. Preoperative chest computed tomography (CT) demonstrated retrograde Stanford type A acute aortic dissection, and TEVAR was performed for entry closure. In the postoperative period, the aortic diameter was not dilated in either case and the false lumen of the ascending aorta disappeared in the case 2. In the chronic phase, however, Stanford type A acute aortic dissection occurred in both cases. TEVAR for acute aortic dissection to close the intimal tear might be a useful procedure, but it could cause a new aortic dissection. We should make a careful decision on surgical procedures in the retrograde Stanford type A aortic dissection.
Thoracic endovascular aortic repair for retrograde type A aortic dissection.
Higashigawa Takatoshi,Kato Noriyuki,Nakajima Ken,Chino Shuji,Hashimoto Takashi,Ouchi Takafumi,Tokui Toshiya,Maze Yasumi,Mizumoto Toru,Teranishi Satoshi,Yamamto Naoki,Ito Hisato,Sakuma Hajime
Journal of vascular surgery
OBJECTIVE:The efficacy of thoracic endovascular aortic repair (TEVAR) for retrograde type A aortic dissection (r-TAAD) with the entry tear in the descending aorta has not been clarified. METHODS:The medical records of 31 patients who underwent TEVAR for r-TAAD at three institutions between May 1997 and January 2016 were retrospectively reviewed. RESULTS:The mean age of the patients (30 men and 1 woman) was 64 ± 11 years. The entry tear was located in the descending thoracic aorta in all patients. Seven patients (23%) had dissection-related complications. The false lumen of the ascending aorta was patent in 13 patients (42%) and thrombosed in 18 (58%). The maximum diameter of the ascending aorta was 45 ± 4 mm. TEVAR was performed in the acute phase in 24 patients (77%) and in the subacute phase in 7 (23%). Only one patient (3%) died of aortic rupture within 30 days after TEVAR. Early aorta-related adverse events were observed in eight patients (26%), of whom five underwent additional interventions. The mean follow-up period was 99 ± 69 months. There were no late aorta-related deaths, although five patients died of other causes during follow-up. Overall survival rates at 1 year, 5 years, and 10 years were 97%, 93%, and 80%, respectively. Late aorta-related adverse events were observed in seven patients (23%), of whom five underwent additional interventions. Aorta-related event-free survival rates at 1 year, 5 years, and 10 years were 58%, 58%, and 51%, respectively. CONCLUSIONS:TEVAR for r-TAAD seems promising in terms of survival. However, the incidence of postoperative aorta-related adverse events is not negligible, so careful selection of patients is important. In addition, close follow-up is mandatory after TEVAR to avoid catastrophic consequences.
Importance of accurately locating the entry site for endovascular treatment of retrograde Type A acute aortic dissection.
Urbanski Paul P,Sodah Ayman,Matveeva Anna,Irimie Vadim,Wagner Matthias,Agaev Arzou,Schmitt Rainer
Interactive cardiovascular and thoracic surgery
OBJECTIVES:The aim of this study was to evaluate the diagnostic possibilities of accurately locating the entry site in acute retrograde Type A aortic dissection and the results of the corresponding endovascular treatments. METHODS:Among 100 patients who underwent surgery for the treatment of spontaneous acute Type A aortic dissection between 2012 and June 2017, all but 1 patient had preoperative computed tomographic angiography. A total of 8 retrograde extensions originated from the descending aorta, in which 6 of them were diagnosed correctly using radiological imaging. The surgical team was unable to properly diagnose the entry site using radiological imaging in only 1 patient, and no preoperative computed tomographic-angiographic scans were available for 1 other patient. In the latter case, the retrograde dissection was diagnosed intraoperatively and confirmed by postoperative computed tomographic angiography. RESULTS:In 5 patients, a tear-oriented endovascular repair was performed based on preoperative radiological findings. In the remaining 3 patients, conventional surgery of the proximal aorta was performed because of the clinical situation (e.g. aortic insufficiency, pericardial effusion) and/or diagnostic uncertainty. One patient subsequently underwent an endograft successfully. All patients survived surgery and were alive at the last follow-up; however, complete remodelling of the thoracic aorta was evident in only patients with endovascular repair. CONCLUSIONS:Tear-oriented endovascular repair of acute Type A aortic dissection originating from the descending aorta seems to be a valuable and durable therapeutic option. However, the determination of the entry site in the descending aorta is a prerequisite for this type of treatment. Therefore, the surgical team should consider a diagnostics based on modern, sophisticated radiological methods.
Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.
Chen Yanqing,Zhang Simeng,Liu Lei,Lu Qingsheng,Zhang Tianyi,Jing Zaiping
Journal of the American Heart Association
BACKGROUND:Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding the development of RTAD post-TEVAR. This systematic review aims to define the incidence, mortality, and potential risk factors of RTAD post-TEVAR. METHODS AND RESULTS:Multiple electronic searches were performed. Fifty publications with a total of 8969 patients were analyzed. Pooled estimates for incidence and mortality of RTAD were 2.5% (95% confidence interval [CI], 2.0-3.1) and 37.1% (95% CI, 23.7-51.6), respectively. Metaregression analysis evidenced that RTAD rate was associated with hypertension (=0.043), history of vascular surgery (=0.042), and American Surgical Association (=0.044). The relative risk of RTAD was 1.81 (95% CI, 1.04-3.14) for acute dissection (relative to chronic dissection) and 5.33 (95% CI, 2.70-10.51) for aortic dissection (relative to a degenerative aneurysm). Incidence of RTAD was significantly different in patients with proximal bare stent and nonbare stent endografts (relative risk [RR]=2.06; 95% CI, 1.22-3.50). RTAD occurrence rate in zone 0 was higher than other landing zones. CONCLUSIONS:The pooled RTAD rate after TEVAR was calculated at 2.5% with a high mortality rate (37.1%). Incidence of RTAD is significantly more frequent in patients treated for dissection than those with an aneurysm (especially for acute dissection), and when the proximal bare stent was used. Rate of RTAD after TEVAR varied significantly according to the proximal Ishimaru landing zone. The more-experienced centers tend to have lower RTAD incidences.
Two Cases of Endovascular Repair with the Stent Graft for Retrograde Type A Acute Aortic Dissection with Complications.
Masuda Takahiko,Hata Masaki,Yamaya Kazuhiro,Suzuki Tomoyuki,Terao Naoya
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia
Thoracic endovascular aortic repair (TEVAR) is used to treat retrograde type A acute aortic dissection (RTAAD). In case 1, a 52-year-old man, who was conservatively managed, reported worsening back pain. Emergency TEVAR was performed 7 days after onset. After deploying two GORE Conformable TAG (CTAG) in the descending aorta, his symptoms disappeared. In case 2, a 52-year-old man with progressive worsening resistant hypertension, renal dysfunction, and respiratory failure despite maximal medical therapy underwent TEVAR 8 days after onset. A CTAG was deployed from the left subclavian artery under rapid pacing, and two Zenith Dissection stents were placed, which resolved complications. In both cases, after 6 months, computed tomography (CT) scan showed complete resorption of the false lumen in the ascending aorta. TEVAR for RTAAD with complete thrombosis of false lumen in the ascending aorta can be an alternative to surgery when the primary tear is located in descending aorta.
Early- and mid-term aortic remodelling after the frozen elephant trunk technique for retrograde type A acute aortic dissection using the new Japanese J Graft open stent graft.
Yamane Yoshitaka,Uchida Naomichi,Mochizuki Shingo,Furukawa Tomokuni,Yamada Kazunori
Interactive cardiovascular and thoracic surgery
OBJECTIVES:We previously performed the frozen elephant trunk (FET) technique for acute type A aortic dissection to try to improve the long-term prognosis. In this study, we report the mid-term results of the FET technique for treating retrograde type A acute aortic dissection using a new device, the J Graft open stent graft (JOSG). METHODS:Between January 2008 and December 2015, 24 patients (mean age: 59.3 ± 13.9 years) underwent total arch replacement with the FET technique using the JOSG for retrograde type A acute aortic dissection. All patients had at least 1 year of follow-up imaging. RESULTS:The average outer diameter of the JOSG was 28 ± 2.8 mm (range: 25-35 mm). The average position of the distal edge of the JOSG was Th 6.6 ± 1.1. The cumulative survival rate at 1 year was 91.6%. Postoperative computed tomography 1 year after surgery showed that complete thrombosis was present in all patients at the level of the distal edge of the stent graft and the aortic valve. At the diaphragmatic level, complete thrombosis was seen in 14 (70%) patients, the false lumen was patent in most patients (90%) at the superior mesenteric artery level. CONCLUSIONS:The use of the FET technique with the JOSG for retrograde type A acute aortic dissection provides good outcomes. With the proper use of the JOSG, it is possible to expand the true lumen and eliminate antegrade false-lumen flow, resulting in good aortic remodelling. Furthermore, there should be obliteration of the false lumen from the stent graft to the aortic valve, and this might reduce long-term complications.
Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.
Zhang Simeng,Chen Yanqing,Lu Qingsheng
Current opinion in cardiology
PURPOSE OF REVIEW:Retrograde type A aortic dissection (RTAD) is a fatal complication after endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease. This review aims to elaborate this lethal complication, the potential risks of its incidence, and feasible approaches to lower the occurrence rate. RECENT FINDINGS:Many articles have shown lower incidence of RTAD in patients with thoracic aneurysm than those with aortic dissection. Also, acute aortic dissection seems to be more vulnerable when compared with chronic aortic dissection. Recent studies that focused on the risk of RTAD revealed that the mismatch of stent, the weakness of the aortic wall and intraoperative aortic injury played important roles in the development of RTAD. The mismatch of stent includes implanting the stent with the top bare spring, the location of landing zone, the oversizing of the stent on the proximal landing zone, and etc. Some centers presented some measures to lower the risks, such as increasing the oversizing of the stent, avoiding the aortic tortuosity, and locating in the healthy landing zone. SUMMARY:Ongoing research with improved technology and techniques continues to unravel new understanding and preventive measures of RTAD after endovascular treatment of aortic dissection and descending thoracic aneurysm disease. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to endovascular therapy of aortic diseases.