Retrograde ascending Stanford B aortic dissection complicating a routine infrarenal endovascular aortic reconstruction

Retrograde type A aortic dissection during or after thoracic endovascular aortic repair: a single center 16-year experience

Objective

This article aims to investigate the incidence rate of retrograde type A aortic dissection (RTAD) and the risk factors of RTAD in relation to thoracic endovascular aortic repair (TEVAR).

Methods

Patients with thoracic aortic disease who underwent TEVAR at Henan Provincial People's Hospital from January 2004 to December 2019 were enrolled in the present research. The risk factors associated with RTAD following TEVAR using univariate and multiple logistic regression analyses.

Results

During the study period, A total of 1,688 TEVAR patients were included in this study, and of these, 1,592 cases were included in the type B aortic dissection (TBAD) group, and 96 cases were included in the non-TBAD group. There were 1,230 cases of aortic dissection and 362 cases of aortic intramural hematoma and/or penetrating ulcer in the TBAD group. The non-TBAD group included 68 cases of thoracic aortic aneurysm, 21 cases of thoracic aortic pseudoaneurysm, and seven cases of congenital aortic coarctation. The overall incidence rate of RTAD was 1.1% (18/1,688) in patients, all of which occurred in the TBAD group. The cohort comprised 18 RTAD patients with an average age of 56.78, consisting of 13 males and 5 females. Among them, 13 individuals exhibited hypertension. Ten instances happened within the TEVAR perioperative period, including two cases during the surgery, six cases occurred within three months, two cases occurred after one year, and the longest interval was 72 months following TEVAR. TEVAR was successfully implemented in 17 patients, while the operation technique was temporarily altered in one case. The new entry position for RTAD was identified as the proximal region of the stent graft (SG) in 13 patients, while in five cases, the entry site was more than 2 cm away from the proximal region of the SG. 17 cases were at the greater curvature of the aorta, and one case was at the lesser curvature. Multivariate logistic regression analysis revealed that the SG oversizing ratio is a relevant risk factor for RTAD. However, ascending aortic diameter, aortic arch type, SG type, and anchored region were not directly related to the occurrence of RTAD.

Conclusion

RTAD is a rare yet catastrophic complication. It could occur both during the procedure, early and late postoperative periods. Maintaining an appropriate SG oversizing ratio is crucial to minimize the risk of RTAD.

Acute Type B Aortic Dissection One Month After Fenestrated EVAR Procedure

Introduction

Acute aortic dissection after endovascular repair of an aortic aneurysm is a rare but serious condition, with potential complications that can result in the death of the patient.

Report

This is the case of a patient diagnosed with a type IV thoraco-abdominal aneurysm with involvement of both iliac arteries who underwent endovascular repair with a four fenestration device and a left iliac branch. One month after the procedure, the patient presented with a type B acute aortic dissection that extended from the left subclavian artery to the proximal stent of the fenestrated graft. This dissection was treated by thoracic endovascular aortic repair, and after a problematic post-operative period, the patient was discharged after 30 days.

Discussion

Occurrence of an acute aortic dissection after endovascular repair of an aortic aneurysm has rarely been reported in the literature. Development of these dissections has been related to factors such as excessive oversizing, use of devices with active fixation systems, or injuries during the procedure, although it is believed that the late onset would indicate that it was a de novo dissection. The presence of an aortic dissection can lead to the collapse and occlusion of the previous endograft and even to aortic rupture, and mortality in reported cases reaches 30%. The authors suggest that endovascular treatment should be considered in these patients.

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Aortic dissection in a patient with previous endovascular aneurysm repair is rare.

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Anatomic, device, and procedure factors could be the cause of this situation.

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Type B dissections could lead to collapse of the graft, sac growth, and rupture.

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Aggressive treatment must be considered to prevent serious complications.

Type B Aortic Dissection with Abdominal Aortic Aneurysm Rupture 1 Year after Endovascular Repair of Abdominal Aortic Aneurysm

We report a patient who developed a type B aortic dissection and ruptured his aneurysmal sac 1 year after endovascular abdominal aortic aneurysm repair (EVAR), despite standard follow-up. This 79-year-old man was presented to emergency room with acute abdominal pain and an acute lower limb ischemia. Computed tomography scan showed an acute type B aortic dissection feeding the aneurysmal sac of the EVAR. The aneurysm rupture occurred during imaging. Type B aortic dissection is a rare cause of aneurysmal rupture after EVAR. The first postoperative computed tomography scan should maybe include the arch and the descending thoracic aorta to rule out an iatrogenic dissection after EVAR.