Retrograde aortic dissection after a stent graft repair of a type B dissection: how to improve the endovascular technique

Abstract

To date, endovascular repair of thoracic dissections is a reality, associated with acceptable morbidity and mortality. We present the case of a 72-year-old woman presenting a retrograde aortic dissection at the postoperative day 12, after an endovascular repair for a 60-mm thoracic dissecting aneurysm. Two years earlier, she had presented an uncomplicated thoracoabdominal type B aortic dissection between the isthmic aorta and the iliac bifurcation. Despite an acceptable blood pressure control, a 62-mm thoracic dissecting aneurysm was observed on the 24-month CT-scan. Due to a chronic obstructive pulmonary disease, we chose the endovascular approach to exclude the thoracic entry tear leading to the complete false lumen thrombosis around the endoprosthesis. However, the inferior part of the false lumen remained patent due to a second abdominal entry tear. The initial outcome was uneventful but the patient presented a sudden death syndrome twelve days after the endovascular repair. During the autopsy, we discovered an intrapericardial rupture of a retrograde dissection, starting at the level of the proximal bare spring of the endoprosthesis. We discuss some important technical details to improve the safety, and to reduce the risk of immediate or delayed complications.

Retrograde Type A Aortic Dissection After Endovascular Stent Graft Placement for Treatment of Type B Dissection

“…So far, most description of RTAD after stent grafting for type B dissection has been limited to isolated case reports [7][8][9][10][11][12][13] or studies evaluating the general effects and complications of endovascular therapy. 3,14 -32 Its incidence varied from 1.4% to 20%.…”

“…Balloon inflation also could cause injury on the wall, particularly when the stent graft is attached proximally on the already involved aorta. 7,41 During the early years in our center, balloon inflation was used on a regular basis to augment the fixation of the stent graft and to minimize endoleak until it resulted in terrible migration in several cases, which prompted us to investigate whether the instant mild type I endoleak was left without ballooning. Interestingly, spontaneous seal within 3 months was evidenced on follow-up CT in Ͼ90% of cases with slight type I endoleak, which had been detected in 17.6% of patients at the completion of the primary stent grating 4 such as patient 3 ( Figure 3).…”

Hybrid procedures combining conventional and thoracic endovascular aortic repair for thoracic aortic aneurysms

“…18,19 Furthermore, despite thrombosis of a false lumen in the thoracic region by TEVAR, the false lumen distal to the stent graft may fail to thrombose and can thus expand. 20,21 In our series, 8 of 11 patients with a double-barrel aortic dissection had a residual false lumen in the distal descendingabdominal aorta, and 3 had expansion.…”

Long-term results of second-stage thoracic endovascular aortic repair following total aortic arch replacement

“…11,12 Despite the fact that thrombosis of the false lumen in the thoracic region is achieved as a result of TEVAR, failure of thrombosis of the false lumen in the region distal to the stent graft and a tendency to enlarge has been reported. 13,14 In the present study, false lumens also persisted in the region between the distal descending aorta and the abdominal aorta in eight of nine patients with aortic dissection, and enlargement was seen in three of these cases.…”