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Repair of retrograde ascending dissection after descending stent grafting.
J Thorac Cardiovasc Surg 2014; 147(1):151-4JT

Abstract

OBJECTIVE

Retrograde dissection is now recognized as an important complication after thoracic endovascular aortic repair (TEVAR), but its treatment is poorly understood. Our objectives were to investigate the risks, describe the repair methods, and assess the outcomes of this complication.

METHODS

From 2000 to 2012, 766 patients underwent TEVAR. Of these patients, 14 (1.8%), plus 1 who had undergone TEVAR elsewhere (n = 15), developed retrograde dissection after stent grafting. They had undergone TEVAR for distal aortic dissection in 7, intramural hematoma in 5, aneurysm in 2, and transection in 1. Their mean age was 65 ± 9 years. At the initial TEVAR, the left subclavian artery was covered in 9, the mean stent graft diameter was 34 ± 2 mm, and >1 device was used in 8 patients. The site of entry tear was at the greater curvature in 11 and lesser curvature in 4. One patient ruptured and died 12 days after TEVAR and never made it to the operating room. The other 14 underwent proximal aortic repair. The median interval between TEVAR and repair of retrograde dissection was 6 months; 3 patients presented within 1 month. The repair techniques included reverse frozen elephant trunk in 5, total arch repair in 4, ascending or hemiarch repair in 4, and ascending TEVAR in 1. Concomitant procedures included aortic valve repair in 4, replacement in 2, root remodeling in 1, and coronary bypass in 1.

RESULTS

No operative mortality occurred. One patient underwent reoperation for bleeding. Two required a tracheostomy for respiratory failure. However, no renal failure, stroke, or spinal injury occurred. At a median follow-up of 26 months, 4 aortic reoperations had occurred: 1 distal stent graft extension for type 1b endoleak, 2 hybrid thoracoabdominal completion repairs for growth of residual distal disease, and 1 emergency TEVAR for aortobronchial fistula. The latter patient died of septic complications, and 3 other late noncardiac deaths occurred.

CONCLUSIONS

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.

Authors+Show Affiliations

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

24139893

Citation

Idrees, Jay, et al. "Repair of Retrograde Ascending Dissection After Descending Stent Grafting." The Journal of Thoracic and Cardiovascular Surgery, vol. 147, no. 1, 2014, pp. 151-4.
Idrees J, Arafat A, Johnston DR, et al. Repair of retrograde ascending dissection after descending stent grafting. J Thorac Cardiovasc Surg. 2014;147(1):151-4.
Idrees, J., Arafat, A., Johnston, D. R., Svensson, L. G., & Roselli, E. E. (2014). Repair of retrograde ascending dissection after descending stent grafting. The Journal of Thoracic and Cardiovascular Surgery, 147(1), pp. 151-4. doi:10.1016/j.jtcvs.2013.08.075.
Idrees J, et al. Repair of Retrograde Ascending Dissection After Descending Stent Grafting. J Thorac Cardiovasc Surg. 2014;147(1):151-4. PubMed PMID: 24139893.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Repair of retrograde ascending dissection after descending stent grafting. AU - Idrees,Jay, AU - Arafat,Amr, AU - Johnston,Douglas R, AU - Svensson,Lars G, AU - Roselli,Eric E, Y1 - 2013/10/18/ PY - 2013/06/27/received PY - 2013/08/06/revised PY - 2013/08/21/accepted PY - 2013/10/22/entrez PY - 2013/10/22/pubmed PY - 2014/2/14/medline KW - 26 KW - 26.1 KW - RAD KW - TEVAR KW - retrograde ascending dissection KW - thoracic endovascular aortic repair SP - 151 EP - 4 JF - The Journal of thoracic and cardiovascular surgery JO - J. Thorac. Cardiovasc. Surg. VL - 147 IS - 1 N2 - OBJECTIVE: Retrograde dissection is now recognized as an important complication after thoracic endovascular aortic repair (TEVAR), but its treatment is poorly understood. Our objectives were to investigate the risks, describe the repair methods, and assess the outcomes of this complication. METHODS: From 2000 to 2012, 766 patients underwent TEVAR. Of these patients, 14 (1.8%), plus 1 who had undergone TEVAR elsewhere (n = 15), developed retrograde dissection after stent grafting. They had undergone TEVAR for distal aortic dissection in 7, intramural hematoma in 5, aneurysm in 2, and transection in 1. Their mean age was 65 ± 9 years. At the initial TEVAR, the left subclavian artery was covered in 9, the mean stent graft diameter was 34 ± 2 mm, and >1 device was used in 8 patients. The site of entry tear was at the greater curvature in 11 and lesser curvature in 4. One patient ruptured and died 12 days after TEVAR and never made it to the operating room. The other 14 underwent proximal aortic repair. The median interval between TEVAR and repair of retrograde dissection was 6 months; 3 patients presented within 1 month. The repair techniques included reverse frozen elephant trunk in 5, total arch repair in 4, ascending or hemiarch repair in 4, and ascending TEVAR in 1. Concomitant procedures included aortic valve repair in 4, replacement in 2, root remodeling in 1, and coronary bypass in 1. RESULTS: No operative mortality occurred. One patient underwent reoperation for bleeding. Two required a tracheostomy for respiratory failure. However, no renal failure, stroke, or spinal injury occurred. At a median follow-up of 26 months, 4 aortic reoperations had occurred: 1 distal stent graft extension for type 1b endoleak, 2 hybrid thoracoabdominal completion repairs for growth of residual distal disease, and 1 emergency TEVAR for aortobronchial fistula. The latter patient died of septic complications, and 3 other late noncardiac deaths occurred. CONCLUSIONS: 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. SN - 1097-685X UR - https://www.unboundmedicine.com/medline/citation/24139893/Repair_of_retrograde_ascending_dissection_after_descending_stent_grafting_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0022-5223(13)01072-6 DB - PRIME DP - Unbound Medicine ER -