Retrograde Type A Dissection after Ascending Aorta Involved Endovascular Repair and Its Surgical Repair with Stented Elephant Trunk

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Aortic dissection with epileptic seizure: A case report

BACKGROUND

Aortic dissection (AoD) is a life-threatening disease. Its diversified clinical manifestations, especially the atypical ones, make it difficult to diagnose. The epileptic seizure is a neurological problem caused by various kinds of diseases, but AoD with epileptic seizure as the first symptom is rare.

CASE SUMMARY

A 53-year-old male patient suffered from loss of consciousness for 1 h and tonic-clonic convulsion for 2 min. The patient performed persistent hypomania and chest discomfort for 30 min after admission. He had a history of hypertension without regular antihypertensive drugs, and the results of his bilateral blood pressure varied greatly. Then the electroencephalogram showed the existence of epileptic waves. The thoracic aorta computed tomography angiography showed the appearance of AoD, and it originated at the lower part of the ascending aorta. Finally, the diagnosis was AoD (DeBakey, type I), acute aortic syndrome, hypertension (Grade 3), and secondary epileptic seizure. He was given symptomatic treatment to relieve symptoms and prevent complications. Thereafter, the medical therapy was effective but he refused our surgical advice.

CONCLUSION

The AoD symptoms are varied. When diagnosing the epileptic seizure etiologically, AoD is important to consider by clinical and imaging examinations.

Surgical Repair of Two Kinds of Type A Aortic Dissection After Thoracic Endovascular Aortic Repair

Background

Retrograde dissection is now recognized as an important complication following thoracic endovascular aortic repair (TEVAR). The purpose of this study is to describe two different situations of TAAD after TEVAR. We will introduce the surgical methods used to repair TAAD following TEVAR at our center, and evaluate its long-term prognosis.

Methods

Between January 2010 and October 2019, 50 patients who had previously received TEVAR treatment for TBAD were admitted to our center for repair of a type A aortic dissection. According to the patients’ CT angiographies and intra-operative findings, we identified two distinct groups: a retrograde group (stent-induced new aortic injury, with retrograde extension involving the ascending aorta) and an antegrade group (entry tear located in the aortic root, ascending aorta or the aortic arch, away from the edges of the stent grafts). The options for treatment of the proximal aorta were Bentall procedure (12/50, 24.0%) and ascending aorta replacement (38/50, 76.0%). All patients underwent total arch replacement (TAR) and frozen elephant trunk (FET) implantation. Survival over the follow-up period was evaluated with the Kaplan–Meier survival curve and the log-rank test.

Results

The median interval time from prior TEVAR to reoperation was 187 days (IQR: 30.0, 1375.0 days). 18.0% of TAAD after TEVAR did not have any obvious symptoms at the time of diagnosis, most of which were found on routine follow-up imaging. The patients in the retrograde group were younger than those in the antegrade group (44.0 ± 9.4 vs. 51.4 ± 10.5 years, P = 0.012). No significant differences in the incidence of post-operative complications or mortality were noted between the two groups. The mean follow-up time was 3 years. No late death or complications occurred after one year following surgery upon follow-up. The asymptomatic survival rate one year after surgery was 90.0%.

Conclusion

The TAR and FET technique was feasible and effective for complicated TAAD after TEVAR. The surgical success rate and long-term prognosis of patients undergoing the timely operation are satisfactory.

One-stop hybrid surgery for treatment of complex Stanford type B aortic dissection

OBJECTIVES

To compare the efficacy and prognosis of one-stop hybrid surgery using the elephant trunk procedure for treatment of complex Stanford type B aortic dissection.

METHODS

We retrospectively analyzed patients who underwent surgical treatment from January 2014 to July 2019. The patients were divided into those who underwent the elephant trunk procedure (n = 10) and those who underwent one-stop hybrid surgery (n = 10). The cardiopulmonary bypass time, mechanical ventilation time, length of hospital stay, and red blood cell usage were compared between the two groups. All patients' 3-month postoperative aortic computed tomography angiography (CTA) findings were also reviewed.

RESULTS

The cardiopulmonary bypass time, mechanical ventilation time, and length of hospital stay were significantly shorter and red blood cell usage was significantly lower in the one-stop hybridization group. The aortic cross-clamp time was not significantly different between the two groups. Aortic CTA review after hybrid surgery showed that the true lumen of the descending aorta was almost completely restored at 3 months.

CONCLUSION

One-stop hybrid surgery effectively alleviated the occlusion of the aortic dissection, prevented the need for additional surgery, and expanded the indications for covered-stent endovascular repair.

Laser fenestration of aortic arch stent grafts for endovascular treatment of retrograde type A dissection

OBJECTIVES

Retrograde type A dissection (RTAD) is a rare but life-threatening event following thoracic endovascular aortic repair (TEVAR), and its total endovascular treatment is a huge challenge. This research aimed to evaluate the safety, effectiveness, technical success, and medical outcomes of in situ laser fenestration of aortic arch stent grafts during TEVAR of RTAD.

METHODS

We retrospectively reviewed the clinical data of 15 patients with RTAD who received in situ laser fenestration of aortic arch stent grafts during TEVAR between Mar 2016 and Dec 2019. All patients were subjected to intraoperative extracorporeal brain perfusion. The preoperative, intraoperative and postoperative medical data were collected and analyzed.

RESULTS

The mean age of the 15 patients was 64 ± 8 years, 8 of whom were male. The immediate overall technical success rates, including aortic stent deployment were 100% and primary fenestration success was achieved in 13 (86.7%) patients. The mean postoperative length of stay was 10 ± 4 days. Stroke occurred in 1 case. No in-hospital/30-day death nor permanent paraplegia/paresis was observed. The mean follow-up time was 13 ± 5 months. Two type Ia endoleaks were found, but no late occlusion and migration of the supra-aortic branch arteries stents during the follow-up were observed.

CONCLUSIONS

The in situ laser fenestration of aortic arch stent grafts during TEVAR of RTAD is a potential total endovascular therapy of RTAD for patients unsuitable for direct surgical repair.

Surgical Outcomes of Stent-Related Type A Dissection Compared with Spontaneous Type A Dissection

Objective: Aortic endovascular stent implantation includes thoracic endovascular aortic repair (TEVAR), hybrid aortic repair (HAR), and ascending aorta stent implantation (AASI). In this study, we compared the surgical outcomes of stent-related type A dissection (SRTAD) compared with spontaneous type A dissection (STAD).

Methods: From July 2011 to July 2014, we identified 17 SRTAD patients received surgical repair in our institution. Propensity score-matching was used to identify 34 STAD patients as controls.

Results: Preoperative data of SRTAD group and STAD group had no statistical difference. Selective cerebral perfusion (SCP) time was longer in SRTAD group than in STAD group (P <0.05). SRTAD group had a longer cross-clamp time compared with STAD group (P <0.05). No intraoperative deaths in two groups. No differences in CPB time and concomitant procedures between two groups. In-hospital mortality was 11.76% (2 of 17) in SRTAD group and 2.9% (1 of 34) in STAD group (P <0.05). No differences were found in intensive care unit (ICU) time, ventilation, paraparesis, and other postoperative complications between SRTAD and STAD groups. No difference was found in survival rate between SRTAD and STAD groups in the postoperative 1-year follow-up.

Conclusions: SRTAD patients received surgical repair had a higher in-hospital mortality compared with STAD, but no differences were found in postoperative complications and mid-term outcomes.