Retrograde type A dissection following hybrid supra-aortic endovascular surgery in high-risk patients unfit for conventional open repair

J Cardiovasc Surg (Torino). 2018 Apr;59(2):243-251. doi: 10.23736/S0021-9509.16.08869-8. Epub 2015 Jul 29.

Abstract

Background: Hybrid procedures with combined open extra-anatomical supra-aortic bypasses and endovascular surgery are less invasive for patients with complex aortic arch pathology. The aim of this paper is to report patients who developed retrograde type A aortic dissection following initially successful hybrid endovascular treatment.

Methods: Retrospective review of prospectively collected computerized departmental database. All patients with supra-aortic hybrid endovascular surgery and post-procedure retrograde type A dissection were identified. Patient demographics, comorbid conditions, perioperative parameters, procedural details and post-operative complications were collected.

Results: From May 2005 to July 2014, 163 patients underwent thoracic aortic endovascular procedures at our institution. From the 46 patients who had supra-aortic hybrid endovascular repair, six patients (6/46, 13% of all supra-aortic hybrid cases, 3 males) developed retrograde type A aortic dissection. All were elective cases, with 3 chronic dissecting aneurysms and 3 atherosclerotic aneurysms. All had one-stage hybrid procedures: 2 patients had carotid-carotid bypass grafts, one had carotid-carotid-left subclavian bypass graft, and 3 had bypass grafts from ascending aorta to innominate artery and left carotid artery. Five patients had Cook Zenith thoracic stent-grafts (Cook Medical, Bloomington, IN, USA), and one had Medtronic Valiant stent-grafts (Medtronic Vascular Inc, Santa Rosa, CA, USA). The retrograde type A dissection occurred with sudden symptoms at day 5, 6, 10, 20, 105 and 128, respectively. There were 3 immediate fatalities and 2 patients treated conservatively deemed unfit for reintervention (one died of pneumonia at 9 months, and one remained alive at 7 months post-complication). One patient underwent successful emergency open surgery and survived.

Conclusions: Supra-aortic hybrid procedures in treating aortic arch pathology may be at risk of developing retrograde type A dissection. This post-operative complication inevitably have poor outcome, even with early diagnosis and prompt treatment.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aneurysm, Dissecting / diagnostic imaging
  • Aneurysm, Dissecting / mortality
  • Aneurysm, Dissecting / surgery*
  • Aorta, Thoracic / diagnostic imaging
  • Aorta, Thoracic / surgery*
  • Aortic Aneurysm, Thoracic / diagnostic imaging
  • Aortic Aneurysm, Thoracic / mortality
  • Aortic Aneurysm, Thoracic / surgery*
  • Aortography / methods
  • Blood Vessel Prosthesis
  • Blood Vessel Prosthesis Implantation / adverse effects*
  • Blood Vessel Prosthesis Implantation / instrumentation
  • Blood Vessel Prosthesis Implantation / mortality
  • Computed Tomography Angiography
  • Endovascular Procedures / adverse effects*
  • Endovascular Procedures / instrumentation
  • Endovascular Procedures / mortality
  • Female
  • Hong Kong
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications / diagnostic imaging
  • Postoperative Complications / etiology*
  • Postoperative Complications / mortality
  • Postoperative Complications / therapy
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Treatment Outcome