Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair

Abstract

Objective: Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event.

Methods: A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables.

Results: The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥ 4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥ 4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥ 4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1).

Conclusions: rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥ 4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.

Figure 1

Preoperative computed tomography angiography (CTA) in patient undergoing thoracic endografting (TEVAR) for chronic Type B dissection with aneurysm who suffered postoperative retrograde ascending aortic dissection (rAAD). Note dilated ascending aorta measuring 4.5 cm (A); Normal transesophageal echocardiogram (TEE) at the completion of TEVAR procedure (B); CTA obtained after new onset chest pain and hypotension on postoperative day 6 revealing acute rAAD (C); Intraoperative TEE showing retrograde ascending aortic dissection at the time of open repair (D)

Figure 1

Preoperative computed tomography angiography (CTA) in patient undergoing thoracic endografting (TEVAR) for chronic Type B dissection with aneurysm who suffered postoperative retrograde ascending aortic dissection (rAAD). Note dilated ascending aorta measuring 4.5 cm (A); Normal transesophageal echocardiogram (TEE) at the completion of TEVAR procedure (B); CTA obtained after new onset chest pain and hypotension on postoperative day 6 revealing acute rAAD (C); Intraoperative TEE showing retrograde ascending aortic dissection at the time of open repair (D)

Figure 1

Preoperative computed tomography angiography (CTA) in patient undergoing thoracic endografting (TEVAR) for chronic Type B dissection with aneurysm who suffered postoperative retrograde ascending aortic dissection (rAAD). Note dilated ascending aorta measuring 4.5 cm (A); Normal transesophageal echocardiogram (TEE) at the completion of TEVAR procedure (B); CTA obtained after new onset chest pain and hypotension on postoperative day 6 revealing acute rAAD (C); Intraoperative TEE showing retrograde ascending aortic dissection at the time of open repair (D)

Figure 1

Preoperative computed tomography angiography (CTA) in patient undergoing thoracic endografting (TEVAR) for chronic Type B dissection with aneurysm who suffered postoperative retrograde ascending aortic dissection (rAAD). Note dilated ascending aorta measuring 4.5 cm (A); Normal transesophageal echocardiogram (TEE) at the completion of TEVAR procedure (B); CTA obtained after new onset chest pain and hypotension on postoperative day 6 revealing acute rAAD (C); Intraoperative TEE showing retrograde ascending aortic dissection at the time of open repair (D)