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

Abstract

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 I 2 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.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study

“…The balloon dilation process following stent placement can also result in damage to the intima of the aorta, thereby exacerbating aortic inflammation and making it more susceptible to developing RTAD ( 10 ). Second, the choice of stent used during surgery is also an important contributing factor to the formation of RTAD ( 11 ). Typically, the selection of stent graft models is based on preoperative CTA and intraoperative imaging findings.…”

“…For asymptomatic RTAD patients, upon reviewing CTA during follow-up, we observed that a considerable number of patients exhibited varying degrees of aortic atherosclerosis. This suggests that potential aortic pathology is also a significant factor in RTAD ( 11 , 15 ).…”

“…Previous studies have indicated that aortic arch replacement with FET implantation is highly advantageous for patients with RTAD, especially those at high surgical risk. This not only reduces procedural complexity but also significantly shortens the overall surgical duration ( 6 , 11 , 16 , 17 ). However, due to the presence of TEVAR stents and the complex anatomy of the aortic arch, adopting this technique has become more challenging, inevitably leading to prolonged CPB and surgical duration.…”