Repair of retrograde ascending dissection after descending stent grafting

Abstract

Retrograde ascending dissection can present as an early or a late complication after descending stent grafting because of aortic instability or disease progression and has usually been associated with descending dissection or intramural hematoma. It is a life-threatening complication that can be managed safely with early recognition and rapid delivery of open or hybrid repair.

Retrograde Ascending Aortic Dissection After Thoracic Endovascular Aortic Repair for Distal Aortic Dissection or With Zone 0 Landing: Association, Risk Factors, and True Incidence

“…Endovascular repair of descending thoracic dissection and intramural hematoma did not seem to be specifically associated with rAAD in our study, whereas others have reported this association [1,4,15]. One of our patients had undergone TEVAR for acute symptomatic descending thoracic hematoma.…”

“…Patients with native ascending aorta and aortic arch are at risk for this complication, whereas patients with prior ascending aortic replacement, prior arch replacement, stage I traditional or frozen elephant trunk, or simultaneous ascending replacement are not. Many reports of various single-center series and TEVAR registry studies describe the incidence of rAAD by using as the denominator the total number of TEVARs performed at the institution or recorded in the registry, instead of limiting the denominator to patients who are at risk for rAAD [1,4,8,15]. Thus, the true incidence of rAAD may be underreported.…”

“…The timing of rAAD after open cardiac procedures, as well as after TEVAR, varies [1,2,4,5,8,[11][12][13]15]. Violation of the aortic intima by direct trauma from either open surgical instrumentation or percutaneous wire and catheter manipulation can cause immediate or late iatrogenic dissection.…”

“…The management of this devastating complication depends on the timing of dissection in relation to the index procedure [1,22]. Intraoperative or early postoperative recognition of a full rAAD indicates emergent repair, which can carry significant mortality [4,5,8].…”

“…Although its causes are multifactorial, rAAD has been associated with descending thoracic dissection, intramural hematoma, and endograft landing in zone 0 [1][2][3][4][5][6][7][8]. The reported incidence of 1% to 6.8% [1,4,5] may be an underestimate because the denominator used to calculate the incidence is usually the total number of TEVARs performed. To our knowledge, very few reports [2] clearly exclude from the denominator patients with previous aortic repairs that make the development of rAAD impossible, such as ascending or arch thoracic aortic replacement and stage I elephant trunk repair.…”