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Patients developing retrograde acute type A dissection after TEVAR for
complicated type B dissection display higher morbidity and mortality
than in spontanous acute type A dissection.1 The kind
of optimal therapy remains obscure and both open versus interventional
angiographic repair may be considered. In cases of pericardial tamponade
open surgery may solve the problem. We present a case of successful open
surgical repair including total replacement of the aortic valve, root,
ascending aorta and arch until zone 2. In this particular instance, the
distal open anastomosis was accomplished by cutting off the un-covered
stent portion protruding into zone 0, and by suturing a vascular
prosthesis to the dissected distal aortic arch including the covered
stent part into the stitches.
Case presentation: At the time of acute complicated type-B dissection,
urgent debranching by a left carotideo-subclavian bypass and zone 2
TEVAR using two Cook™ stentgrafts (one tapered 40-36 mm, one straight 36
mm) were performed. Procedural success was documented by CT scan showing
false lumen thrombosis and the patient discharged without any complaints
thereafter. Three weeks later the patient presented to the hospital with
severe chest pain and a CT scan was immediately obtained. Acute
retrograde type A dissection was diagnosed involving the aortic root,
the ascending aorta and the arch. (Figure 1) Rapidly, the patient
developed high-grade aortic insufficiency and pericardial tamponade and
was immediately sent for surgery.
A valve-replacing full root replacement using a stentless all-biological
graft (BioIntegral™ 25 mm) and an ascending and total arch replacement
(Hemashield™ vascular graft 28 mm) were performed. Two supra-aortic arch
vessels were reimplanted together (brachiocephalic trunk, left common
carotid) using a common island technique. Distal open anastomosis was
accomplished in zone 2 after resecting the bare metal ends of the stent
graft using scissors. By a double 3-0 prolene running suture the Dacron
graft was connected to the distal arch including the covered portion of
the stent. The drawing illustrates the suturing technique (Figure 2).
After an uneventful course the patient was discharged and recovered
fully. Postoperative CT imaging one week, 6 and 11 months after surgery
shows a stable procedural success. (Figure 3) Follow-up echocardiography
showed a regular valve function. Meanwhile, the patient has returned to
work and resumed driving motorcycle.
Discussion: Retrograde type A dissection after TEVAR occurs at 2.5% and
frequency is higher in patients following TEVAR for type B dissection
compared to aneurysm repair.1 Mortality remains a
major issue, with values ranging from 37 to 50%. 2When bail-out re-do TEVAR in the arch is not feasible, open repair
becomes necessary. No recommendations with respect to anastomotic
technique in the arch have been made so far, but it can principally
either include removal of the TEVAR stent graft from the native aorta or
its preservation within. In cases with bare metal ends extending to the
proximal arch, an anastomotic suture problem exists. In the present
case, cutting off the bare metal ends and including the covered stent
part into the suture line resulted in excellent hemostasis. Follow-up in
similar cases and scientific reporting is desirable.
Patient consent: The patient gave written consent to publication of
clinical case details and images.
Figure legend:
Figure 1: CT showing the thrombosed false lumen*, the acute retrograde
type A dissection** and the aortic root (AR). Angulation: LAO 64°.
Figure 2: Scheme of anastomotic suturing technique.
Figure 3: Postoperative CT scan 11 months after surgery showing the
anastomosis* and aortic root (AR). Angulation: LAO 58°.
1. Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde Type A
Aortic Dissection After Thoracic Endovascular Aortic Repair: A
Systematic Review and Meta-Analysis. J Am Heart Assoc. 2017;6(9).
2. Yammine H, Briggs CS, Stanley GA, et al. Retrograde type A dissection
after thoracic endovascular aortic repair for type B aortic dissection.J Vasc Surg. 2019;69(1):24-33.