Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection

Conservative Treatment of Retrograde Aortic Dissection After Endovascular or Hybrid Repair of Descending Aorta Pathologies

BACKGROUND

Retrograde type A dissection (RTAD) represents a rare but possible lethal complication of thoracic endovascular aortic repair. Intervention is often recommended, but conservative management has been advocated in selected cases.

METHODS

We performed a systematic review of the literature through MedLine and Cochrane databases over the last 24 years to identify reported cases of RTAD managed conservatively. Primary endpoint was the overall and aortic-related mortality, the morbidity, and the need for intervention during follow-up. The underlining causes and indications for conservative management were also investigated. (Protocol on Prospero Centre for Reviews and Dissemination RD42024542966).

RESULTS

A total of 2,305 papers were identified, and 10 articles were included (20 cases). The reasons for conservative treatment were age (n = 8.40%) and/or haemodynamic stability(n = 16,80%) and/or unfitness for surgery(n = 12,60%). The causes of RTAD were fragile aortic wall in acute type B aortic dissection (TBAD) (n = 10, 50%), Marfan syndrome (n = 2, 10%), use of stents with proximal barbs or bare springs (n = 5, 25%), diameter of the ascending aorta>40 mm (n = 2, 10%), and intraoperative type IA endoleak (n = 2, 10%). Three patients (15%) were lost to follow-up immediately after discharge; one (5%) died in hospital from aortic rupture. At a mean follow-up of 33.5 months (range 9-60), the overall survival was 88.2% (n = 15/17) and aortic-related mortality was 10% (n = 2/20). No complications or interventions during the follow-up period were reported.

CONCLUSIONS

The mortality rate following RTAD is high, and surgery allows improvement in survival. Conservative management might represent a viable option for selected patients. However, the current evidence is poor and needs to be validated by further and more robust data before such a strategy could be suggested more widely.

Comparison of chimney technique and single-branched stent graft in a cohort of patients with type B aortic dissections: a retrospective cohort study

Background

Single-branched stent grafts and the chimney technique are widely used in the treatment of type B aortic dissection (TBAD). The main objective of this study was to compare the outcomes of single-branched stent grafts and the chimney technique in the treatment of TBAD.

Methods

From January 2019 to December 2021, the retrospective cohort study contained a cohort of 91 patients with TBAD undergoing thoracic endovascular aortic repair (TEVAR) using single-branched stent grafts and the chimney technique. Group A included 55 patients treated with single-branched covered stents, and Group B included 36 patients treated with the chimney technique. We compared the effects of the procedures on peri-/post-operative outcomes between the two groups. The primary endpoint is clinical death, and the secondary endpoints include the patency of branch stents, the incidence of cerebral infarction, false lumen thrombosis, and the proportion of paraplegia.

Results

For the baseline data, the two groups of patients show no differences in terms of age, gender, and associated symptoms. All procedures were successfully performed in both groups. The median follow-up period was 17.6 months (range, 10-34 months). During TEVAR, 5 (9.1%) type I endoleaks occurred in group A, and 11 (30.6%) occurred in group B (P<0.05). During follow-up, there were 2 cases (3.6%) of paraplegia and 1 case (1.8%) of cerebral infarction in Group A, while Group B had 1 case (2.8%) of paraplegia. Three patients in group B reported retrograde type A aortic dissection (RTAD), and 1 of them died (2.8%); however, there were no RTAD cases in group A. Complete thrombosis of the false lumen in the thoracic aorta was observed in 45.5% (25/55) of patients in group A and in 41.7% (15/36) in group B (P=0.72). No significant difference in the thrombosis-volume ratio in the whole false lumen was found during follow-up between group A (81.0%±2.9%) and group B (81.8%±2.6%; P=0.23).

Conclusions

Branched stent grafts can be used in cases with insufficient proximal landing zones and reduce the occurrence of type 1 endoleak compared to the chimney technique. This may help to prevent RTAD. Further research, including more cases and longer follow-up periods, is needed to substantiate these results.

The Rate of Postoperative Complications in Complicated Acute, and Subacute Type B Aortic Dissections after TEVAR vs. PETTICOAT Procedures: Systematic Review and Meta-Analysis

Background and Objectives: Provisional extension to induce complete attachment (PETTICOAT) is suggested as being associated with a lower incidence of aorta-related events and fewer reinterventions compared to thoracic endovascular aortic repair (TEVAR) in patients with complicated acute, and subacute type B aortic dissections. Materials and Methods: This article is a systematic review and meta-analysis following the PRISMA guidelines. The Medline, PubMed, Embase, and Cochrane databases were searched, starting on 21 February 2022 and ending on 22 June 2022, to identify studies that investigated the rate of postoperative complications in patients treated with the PETTICOAT compared to the TEVAR. A random effects meta-analysis was performed. Of 2350 studies, 5 studies involving 360 patients were included: 143 patients after the PETTICOAT procedure and 217 after the TEVAR. Results: The meta-analysis of all studies showed that the rate of secondary endovascular reinterventions was smaller in patients treated with the PETTICOAT (n = 3 studies; OR, 0.30; 95% CI, 0.10 to 0.94; p = 0.04). The results of other postoperative complications (30-day mortality, mortality during follow-up, paraplegia, stroke, and occurrence of endoleak) were lower in the PETTICOAT group but were not statistically significant. The rate of postoperative renal failure was lower in patients treated with the TEVAR (n = 4; OR, 1.08; 95% CI, 0.46 to 2.51; p = 0.86). Conclusion: This meta-analysis suggests that the PETTICOAT procedure is related to the lower rate of secondary endovascular reinterventions for complicated acute, and subacute type B aortic dissections.

Minimally Invasive Endovascular Repair for Nondissected Ascending Aortic Disease: A Systematic Review

Objective

The aim of this study is to evaluate the efficacy of endovascular treatment for nondissected diseases of the ascending aorta. Data Sources. PubMed, Embase, and SciELO. Review Methods. In this study, we conducted a search on the PubMed, Embase, and SciELO databases for all cases of ascending aortic endovascular repair included in the literature published between January 2007 and July 2023, excluding type A aortic dissection. We reviewed 56 case reports and 7 observational studies included in this study, assessing the techniques, equipment, procedural steps, and results. We summarized the age, complications, follow-up time, and access route.

Results

This study includes 63 articles reporting 105 patients (mean age: 64.96 ± 17.08 years) who received endovascular repair for nondissected ascending aortic disease. The types of disease include aneurysm (N = 16), pseudoaneurysm (N = 71), penetrating aortic ulcer (N = 10), intramural hematoma (N = 2), thrombosis (N = 2), iatrogenic coarctation (N = 1), and rupture of the aorta (N = 3). The success rate of surgery is 99.05% (104/105). Complications include endoleak (10.48%, 11/105), stroke (5.71%, 6/105), postoperative infection (1.91%, 2/105), acute renal failure (0.95%, 1/105), aortic rupture (0.95%, 1/105), thrombosis (0.95%, 1/105), and splenic infarction (0.95%, 1/105). Five patients required conversion to open surgery, two patients underwent endovascular reintervention, and four of these five patients underwent surgery due to endoleak. Early mortality was 2.86% (3/105).

Conclusion

While the viability and results of endovascular repair for the treatment of ascending aortic disease are acknowledged in some circumstances, further research is needed to determine the safety and effectiveness of endovascular treatment for ascending aortic disease.

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.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Development and validation of a nomogram to predict postoperative delirium in type B aortic dissection patients underwent thoracic endovascular aortic repair

Objective

Postoperative delirium (POD) is a common postoperative complication after cardiovascular surgery with adverse outcomes. No prediction tools are currently available for assessing POD in the type B aortic dissection (TBAD) population. The purposes of this study were to develop and validate a nomogram for predicting POD among TBAD patients who underwent thoracic endovascular aortic repair (TEVAR).

Methods

The retrospective cohort included 631 eligible TBAD patients who underwent TEVAR from January 2019 to July 2021. 434 patients included before 2021 were in the develop set; 197 others were in the independent validation set. Least absolute shrinkage and selection operator (LASSO) and logistic regression were applied to identify the most useful predictive variables for constructing the nomogram. Discrimination and the agreement of the model was assessed with the area under the receiver operating characteristic curve (AUC), Brier score and the Hosmer-Lemeshow goodness-of-fit test. The results were validated using a bootstrap resampling and the validation set.

Results

The incidence rate of POD observed in the development and validation cohort were 15.0% and 14.2%, respectively. Seven independent risk factors, including age ≥60 years, syncope or coma, postoperative blood transfusion, atelectasis, estimated glomerular filtration rate (eGFR) &lt;80 ml/min/1.73 m2, albumin &lt;30 g/L, and neutrophil to lymphocyte ratio, were included in the nomogram. The model showed a good discrimination with an AUC of 0.819 (95% CI, 0.762–0.876) in the developed set, and adjusted to 0.797 (95% CI, 0.735–0.849) and 0.791 (95% CI, 0.700–0.881) in the internal validation set and the external validation, respectively. Favorable calibration of the nomogram was confirmed in both the development and validation cohorts.

Conclusion

The nomogram based on seven readily available predictors has sufficient validity to identify POD risk in this population. This tool may facilitate targeted initiation of POD preventive intervention for healthcare providers.

Aortic-related Readmission after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-center Retrospective Study

OBJECTIVES

This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

METHODS

Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into two groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure.

RESULTS

A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were two major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (p=.93).

CONCLUSIONS

This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.

A Novel Vascular-Friendly Thoracic Stent Graft for Endovascular Repair of Acute Complicated Type B Aortic Dissection

Purpose: To evaluate the safety and efficacy of a novel vascular-friendly thoracic stent graft for patients with acute complicated type B aortic dissection (ac-TBAD).

Methods: A multicenter retrospective study was undertaken in which we prospectively collected data in consecutive ac-TBAD patients treated by thoracic endovascular aortic repair (TEVAR) with the Ankura Thoracic Stent. Complications, true lumen rate (TLR), and mortality were recorded. Follow-up computed tomography angiography (CTA) was performed at 1, 6, and 12 months postoperatively and yearly thereafter.

Results: Altogether, 63 patients with ac-TBAD in four medical centers were included. No deaths or serious complications occurred during the perioperative period. The mean follow-up time was 30.1 ± 18.9 months. All-cause mortality rate was 3.1% (n = 2). TEVAR-related mortality rate was 1.6% (n = 1) because of retrograde type A dissection (RTAD) at 6 months. The other death was caused by acute myocardial infarction (AMI) during the third postoperative month. A distal endoleak detected at 3 months in one patient (1.6%) was treated by reintervention. The use of this novel vascular-friendly thoracic stent graft in ac-TBAD postoperative patients significantly improved their TLR.

Conclusion: The novel vascular-friendly thoracic stent graft showed satisfactory results, with favorable stability of the aortic diameter during follow-up.

[Removal of ascending aortic dissection and residual blood flow after transcatheter isolation of descending aortic dissection]

Presented herein is a clinical case report concerning successful simultaneous surgical treatment of a female patient with a complication after transcatheter treatment for chronic dissection of the descending portion of the thoracic aorta. The woman was subjected to elective transcatheter isolation of chronic dissection of the descending thoracic aorta using a stent graft with complete coverage of the zone of the origin of the left subclavian artery. Repeat control imaging studies several months after the intervention revealed residual blood flow through the false channel, directed retrogradely from the distal edge of the stent graft to the left subclavian artery. Besides, the patient was also found to have local dissection of the distal part of the ascending aorta (zone 0). An operative intervention was performed: sternotomy, prosthetic repair of the ascending portion of the aorta and part of the aortic arch, as well as transposition of the left subclavian artery to the left common carotid artery. The control imaging studies confirmed radical removal of the false aneurysm of the ascending aorta and the presence of total thrombosis of the false channel at the level of the stent graft.

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND

A 46-year-old male underwent ascending aortic replacement, total arch replacement, and descending aortic stent implantation for Stanford type A aortic dissection in 2016. However, an intraoperative stent-graft was deployed in the false lumen inadvertently. This caused severe iatrogenic thoracic and abdominal aortic dissection, and the dissection involved many visceral arteries.

CASE SUMMARY

The patient had pain in the chest and back for 1 mo. A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection. The ascending aortic replacement, total arch replacement, and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior. An intraoperative stent-graft was deployed in the false lumen. Endovascular aneurysm repair was performed to address this intractable situation. An occluder was used to occlude the proximal end of the true lumen, and a covered stent was used to direct blood flow back to the true lumen. A three-dimensional printing technique was used in this operation to guide pre-fenestration. The computed tomography scan at the 1^stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired, with all visceral arteries remaining patent. The patient did not develop renal failure or neurological complications after surgery.

CONCLUSION

The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive. Our procedures provided a new solution for stent-graft deployed in the false lumen, and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.

Advantages of Transesophageal Echocardiography during Stent Grafting for Aortic Dissection: A Report of Three Cases

We report the cases of three patients who underwent thoracic endovascular aortic repair for type B aortic dissection in which transesophageal echocardiography (TEE) was used to guide the procedure in addition to fluoroscopy. TEE was found to be advantageous because it can visualize vascular structures along with the guidewire and devices. Furthermore, it provides real-time hemodynamic and hematological information without the need for contrast injection or radiation exposure. Although TEE assessment requires expertise, the efficient use of TEE appears to be helpful for further improving the outcomes of endovascular surgery for aortic dissection.