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Vo UG, Ma R, Hockley J, Jansen S. Emergency Endovascular Repair of Thoracic Aorta Via a Percutaneous Popliteal Approach Following an Iatrogenic Injury. Vasc Endovascular Surg 2024; 58:396-398. [PMID: 37947778 DOI: 10.1177/15385744231215567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Iatrogenic arterial injuries are rare but well-recognised complications of spinal surgery. This paper presents a case of an iatrogenic arterial injury during a total en bloc spondylectomy resulting in significant haemorrhage and the patient's haemodynamic instability. The devastating complication was successfully treated with an emergency thoracic endovascular aortic repair via a percutaneous popliteal approach, while the patient remained in prone position. The patient had an uneventful recovery with no subsequent arterial injury or pseudoaneurysm to the access vessel.
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Affiliation(s)
- Uyen G Vo
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Robert Ma
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Joseph Hockley
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
- Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Nedlands, Australia
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2
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Kelly H, Herman D, Loo K, Narangoli A, Watson E, Berlant C, Huerta M, Labak CM, Zhou X. Recognition of Significantly Delayed Spinal Cord Ischemia Following Thoracic Endovascular Aortic Repair: A Case Report and Review of the Literature. Cureus 2024; 16:e51522. [PMID: 38304669 PMCID: PMC10831204 DOI: 10.7759/cureus.51522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 02/03/2024] Open
Abstract
Spinal cord ischemia (SCI) is an uncommon but serious complication of thoracic endovascular aortic repair (TEVAR). SCI after TEVAR is thought to result from decreased segmental blood supply to an important network of collateral blood flow in the spinal cord. Little is known about the prevalence and optimal treatment of SCI that occurs beyond the periprocedural period. We report a case of delayed SCI in a 67-year-old patient who underwent TEVAR. The patient presented almost two years after TEVAR with acute paraplegia preceded by pre-syncope. The delayed SCI was likely triggered by pre-syncope, a thrombosed endoleak shown on imaging, and the patient's vascular risk factors. Treatments included cerebrospinal fluid (CSF) drainage, mean arterial pressure (MAP) augmentation, and a naloxone infusion, which resulted in moderate recovery in lower extremity motor function. This case highlights the tenuous nature of spinal cord perfusion after TEVAR and that prompt recognition and early treatment of SCI are critical in preventing the progression from ischemia to infarction.
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Affiliation(s)
- Hannah Kelly
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Danielle Herman
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Kiana Loo
- Neurology, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Adeeb Narangoli
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Emily Watson
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Corey Berlant
- Emergency Medicine, University Hospitals St. John Medical Center, Westlake, USA
| | - Mina Huerta
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Collin M Labak
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Xiaofei Zhou
- Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, USA
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3
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Fenech I, Ferriggi A, Abela M. A Rare Case of Profound Sinus Bradycardia in a Patient With Descending Aortic Dissection. Cureus 2023; 15:e49291. [PMID: 38143677 PMCID: PMC10748454 DOI: 10.7759/cureus.49291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
A 34-year-old uncontrolled hypertensive male presented with chest pain radiating to the back. Despite severe pain, he was persistently bradycardic at 38 beats per minute. The workup at the emergency department confirmed the presence of an acute Stanford B aortic dissection. Stanford B dissections are not usually associated with bradycardia. It is Stanford A dissections that are mostly linked with bradycardia because Stanford A dissections can cause concomitant coronary artery extension and involvement of the atrioventricular node. This case demonstrates that sinus bradycardia can exist in the acute setting of any painful aortic dissection, even though it might not necessarily involve the coronary arteries.
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Affiliation(s)
| | | | - Mark Abela
- Cardiology, Mater Dei Hospital, Msida, MLT
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4
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Liu YC, Sun YT, Yao YT. Anesthesia management of patients undergoing thoracic endovascular aortic repair: A retrospective analysis of single center. Medicine (Baltimore) 2023; 102:e34508. [PMID: 37565902 PMCID: PMC10419515 DOI: 10.1097/md.0000000000034508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) is a new alternative surgical treatment for aortic pathologies, which is more minimally invasive. The aim of current study was to summarize the single-center experience of general anesthesia for patients undergoing TEVAR. In adult patients undergoing surgery for congenital heart disease, the strategy of "fast-track" anesthesia with early extubation in theater is associated with a shorter intensive care unit (ICU) stay, and lower health-care-related costs. Fast-track anesthesia has not been assessed in patients under TEVAR. Adult patients who received general anesthesia for TEVAR in our center from January 2020 to December 2020 were included. Baseline characteristics, airway management, anesthetic techniques and major complications were collected. A total of 204 (171 male, mean age 58.1 ± 11.5 years) patients met inclusion criteria for this study. The distribution of pathologies included 29 descending thoracic aneurysms, 87 type B dissections, and 88 intramural hematoma/perforating aortic ulcer. Etomidate was the induction agent in 190 (93.1%) patients, compared with propofol in 16 (7.8%). Cisatracurium was the muscle relaxant in 201 (98.5%), compared with rocuronium in 3 (1.5%). Midazolam (benzodiazepines) was given to 124 (60.8%) patients during anesthesia induction. General anesthesia was maintained with sevoflurane in 85.3% (174) patients, dexmedetomidine in 201 (98.5%) and propofol in 204 (100%). Postoperative length of stay (LOS) in the hospital was 6.0 (5.0-7.8) days. LOS in the ICU was 23.0 (20.0-27.8) hours. Overall neurologic event rate was 2.0% (n = 4) (spinal cord ischemia 1.5% [n = 3]; stroke 0.5% [n = 1]). After matching, patients who received "fast-track" anesthesia had a shorter LOS in ICUs (21.0 [18.0-24.0] vs 24.0 [20.0-44.0] hours; P = .005), and a shorter postoperative LOS in hospital (5.0 [4.0-7.0] vs 6.0 [5.0-8.0] days; P = .001). There were no in-hospital deaths. Fast-track anesthesia is feasible and safe in patients underwent TEVAR. This management strategy is associated with shorter LOS of ICU and total postoperative hospital stays. An early extubation strategy should be implemented for hemodynamically stable patients.
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Affiliation(s)
- Ying-chun Liu
- Department of Anesthesiology, Dongying People’s Hospital, Shandong, China
- Department of Anesthesiology, Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yan-ting Sun
- Department of Anesthesiology, Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Anesthesiology, Baoji High-Tech Hospital, Shaanxi, China
| | - Yun-tai Yao
- Department of Anesthesiology, Anesthesia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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5
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Halbert S, Nagy C, Antevil J, Sarin S, Trachiotis G. Endovascular Repair of Zone 0 Ascending Aortic Pseudoaneurysm: A Case Report. Aorta (Stamford) 2023; 11:152-155. [PMID: 38503308 PMCID: PMC11038720 DOI: 10.1055/s-0043-1777436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/08/2023] [Indexed: 03/21/2024]
Abstract
Although open surgery is standard of care for ascending aortic pathology, endovascular approaches can be viable options. We report the case of a 77-year-old man with a 5.7-cm ascending aorta penetrating ulcer. Given his age and clinical profile, the patient underwent Zone 0 thoracic endovascular aortic repair.
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Affiliation(s)
- Sarah Halbert
- Division of Cardiothoracic Surgery, Heart Center, Veterans Affairs Medical Center, Washington, District of Columbia
- Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Christian Nagy
- Division of Cardiothoracic Surgery, Heart Center, Veterans Affairs Medical Center, Washington, District of Columbia
- Department of Cardiology, George Washington University School of Medicine and Health Sciences and Veterans Affairs Medical Center, Washington, District of Columbia
| | - Jared Antevil
- Division of Cardiothoracic Surgery, Heart Center, Veterans Affairs Medical Center, Washington, District of Columbia
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Shawn Sarin
- Division of Cardiothoracic Surgery, Heart Center, Veterans Affairs Medical Center, Washington, District of Columbia
- Department of Radiology, Interventional Radiology, George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
| | - Gregory Trachiotis
- Division of Cardiothoracic Surgery, Heart Center, Veterans Affairs Medical Center, Washington, District of Columbia
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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6
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Rudra P, Cardoso R, Echevarria S, Kaya B, Abdullah R, Baskara Salian R, Bhindar SZ, Zerin A, Patel T, Abdin Z, Al-Tawil M. Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Traumatic Aortic Injury: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e41078. [PMID: 37519486 PMCID: PMC10375940 DOI: 10.7759/cureus.41078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Blunt aortic injury is the second most prevalent cause of patient fatalities post-trauma, closely following head injuries as the leading cause. In recent years, thoracic endovascular aortic repair (TEVAR) has evidently improved survival rates and reduced complications in patients suffering from blunt traumatic aortic injury (BTAI) in comparison to open surgery and non-operative management. It is difficult to characterize the appropriate criteria for the timing of TEVAR, whether early or delayed for BTAI, considering the discrepancies related to timing. Electronic databases, including PubMed, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase, were searched through April 2023. The primary outcomes were short-term mortality and hospital and intensive care unit (ICU) stays. Time to TEVAR, acute respiratory distress syndrome, sepsis, deep vein thrombosis, delayed stroke, and renal failure were also evaluated. We included a total of seven studies, comprising 4177 patients who met the inclusion criteria. Short-term mortality was significantly higher in the early TEVAR group (RR: 1.86; 95% confidence interval (CI); (1.26-2.74); p<0.001; I2=33%). In contrast, the ICU length of stay was significantly shorter in the early group (mean difference: -2.82 days; 95% CI; (-4.09 - -1.56); p<0.0001; I2=55%). There was no significant difference between both groups in the presenting profile or postoperative complications. Patients undergoing delayed TEVAR had markedly lower mortality rates but a longer ICU stay. The need for future studies with more robust designs is imperative to investigate the factors influencing the timing of repair and the associated outcomes.
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Affiliation(s)
- Pranathi Rudra
- Internal Medicine, Gandhi Medical College, Secunderabad, IND
| | - Rayner Cardoso
- Medical School, All India Institue of Medical Sciences, Jodhpur, IND
| | | | - Berfin Kaya
- Obstetrics and Gynaecology, Faculty of Medicine, Izmir Kâtip Celebi University, Izmir, TUR
| | - Ramal Abdullah
- Medical School, Foundation University Medical College, Foundation University School of Health Sciences (FUSH), Islamabad, PAK
| | | | - Shah Zaib Bhindar
- Orthopaedic Surgery, Ghurki Trust and Teaching Hospital, Lahore, PAK
| | - Annu Zerin
- Internal Medicine, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Tirath Patel
- Medical School, American University of Antigua, St. John's, ATG
| | - Zain Abdin
- Critical Care Medicine, IMG Helping Hands, Albuquerque, USA
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7
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Ali-Hasan-Al-Saegh S, Halloum N, Scali S, Kriege M, Abualia M, Stamenovic D, Bashar Izzat M, Bohan P, Kloeckner R, Oezkur M, Dorweiler B, Treede H, El Beyrouti H. A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection. Medicine (Baltimore) 2023; 102:e32944. [PMID: 37058052 PMCID: PMC10101253 DOI: 10.1097/md.0000000000032944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/23/2023] [Indexed: 04/15/2023] Open
Abstract
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.
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Affiliation(s)
- Sadeq Ali-Hasan-Al-Saegh
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Nancy Halloum
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Salvatore Scali
- Division Vascular Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Marc Kriege
- Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mohannad Abualia
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Davor Stamenovic
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | | | - Roman Kloeckner
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Mehmet Oezkur
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Bernhard Dorweiler
- Department of Vascular Surgery, Faculty of Medicine, University of Cologne, Koln, Germany
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Hazem El Beyrouti
- Department of Cardiac and Vascular Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
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Bordes SJ, Vefali B, Montorfano L, Bongiorno P, Grove M. Evaluation and Management of Complications of Endovascular Aneurysm Repair of the Thoracic Aorta. Cureus 2023; 15:e36930. [PMID: 37131556 PMCID: PMC10148752 DOI: 10.7759/cureus.36930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/04/2023] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) has become the standard of care for descending thoracic aortic pathology as the procedure has a historically low rate of reintervention and a high rate of success. However, TEVAR can be associated with complications such as endoleak, upper extremity limb ischemia, cerebrovascular ischemia, spinal cord ischemia, and post-implantation syndrome. An 80-year-old man with a history of complex thoracic aortic aneurysms underwent repair of a large thoracic aneurysm with a frozen elephant trunk procedure in 2019 at an outside institution. The proximal aortic graft extended to the arch and the innominate and left carotid artery were implanted into the distal portion of the graft. The endograft, extending from the proximal graft to the descending thoracic aorta, was fenestrated to maintain left subclavian artery flow. In an attempt to gain a seal at the fenestration, a Viabahn graft (Gore, Flagstaff, AZ, USA) was inserted. A type III endoleak was identified postoperatively at the fenestration, and a second Viabahn graft was required to gain a seal during the initial hospitalization. In 2020, an endoleak persisted at the fenestration on follow-up imaging, but the aneurysmal sac was stable. No intervention was recommended. The patient later presented to our institution with three days of chest pain. A type III endoleak at the level of the subclavian fenestration persisted with significant enlargement of the aneurysm sac. The patient underwent an urgent repair of the endoleak. This consisted of covering the fenestration with an endograft and left carotid to subclavian bypass. Subsequently, the patient developed a transient ischemic attack (TIA) due to kinking and extrinsic compression by the large aneurysm sac of the proximal left common carotid artery, requiring a right carotid to left carotid-axillary graft bypass. This report with a literature review discusses TEVAR complications and outlines methods to approach them. TEVAR complications and their management should be firmly understood to improve overall treatment outcomes.
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Affiliation(s)
- Stephen J Bordes
- Surgery, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Baris Vefali
- Cardiology, St. Michael Medical Center, Newark, USA
| | - Lisandro Montorfano
- Surgery, Vanderbilt University Medical Center, Nashville, USA
- Surgery, Cleveland Clinic Florida, Weston, USA
| | | | - Mark Grove
- Vascular Surgery, Cleveland Clinic Florida, Weston, USA
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Martin Czerny, Maximilian Kreibich, Tim Berger, Stoyan Kondov, Matthias Siepe, Friedhelm Beyersdorf, Bartosz Rylski. Type 1 Endoleak: Management following Thoracic Endovascular Aortic Repair. Aorta (Stamford) 2022; 10. [PMID: 36521809 DOI: 10.1055/s-0042-1756665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The best treatment option for type IA endoleak after thoracic endovascular aortic repair (TEVAR) is its avoidance by understanding the underlying disease process, having/creating adequate landing zones, as well as respecting anatomy in combination with knowledge of the capabilities and limitations of the TEVAR device used.
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10
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Ellauzi H, Arora H, Elefteriades JA, Zaffar MA, Ellauzi R, Popescu WM. Cerebrospinal Fluid Drainage for Prevention of Spinal Cord Ischemia in Thoracic Endovascular Aortic Surgery-Pros and Cons. Aorta (Stamford) 2022; 10:290-297. [PMID: 36539146 PMCID: PMC9767776 DOI: 10.1055/s-0042-1757792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/14/2022] [Indexed: 06/17/2023]
Abstract
Thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI) which exerts a devastating impact on patient's quality of life and life expectancy. Although routine prophylactic cerebrospinal fluid (CSF) drainage is not unequivocally supported by current data, several studies have demonstrated favorable outcomes. Patients at high risk for SCI following TEVAR likely will benefit from prophylactic CSF drains. However, the intervention is not risk free, and thorough risk/benefit analysis should be individualized to each patient.
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Affiliation(s)
- Hesham Ellauzi
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
- Department of Surgery, Istishari Hospital, Amman, Jordan
| | - Harendra Arora
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John A. Elefteriades
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad A. Zaffar
- Aortic Institute at Yale New-Haven, Department of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Rama Ellauzi
- Department of Surgery, Istishari Hospital, Amman, Jordan
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.
| | - Wanda M. Popescu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
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11
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Li RD, Chia MC, Eskandari MK. Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke. Ann Vasc Surg 2022; 87:205-212. [PMID: 35835381 PMCID: PMC9901212 DOI: 10.1016/j.avsg.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. METHODS The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression. RESULTS Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P = 0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79 years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79 years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention). CONCLUSIONS Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.
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Affiliation(s)
- Ruojia Debbie Li
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Matthew C Chia
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Mark K Eskandari
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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12
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Abstract
Mycotic thoracic aortic aneurysm (MTAA) is an aneurysm of the aorta caused by infection of the vessel tissue through microbial inoculation of the diseased aortic endothelium. It is most commonly caused by bacteria. Rarely, it can be caused by fungi. However, viral aortic aneurysm has never been reported. Depending on the area and time period investigated, the infections organism discovered may vary significantly. Little is known about the natural history of MTAA due to its rarity. It is not known if they follow the same pattern as other TAAs. However, it is unclear whether MTAA follows a similar clinical course. The combination of clinical presentation, laboratory results, and radiographic results are used to make the diagnosis of MTAA. Treatment of MTAA is complex since patients frequently present at a late stage, frequently with fulminant sepsis, as well as concomitant complications such as aneurysm rupture. While medical treatment, including antibiotics, is recommended, surgery is still the mainstay of management. Surgery to treat MTAA is complicated and carries a high risk of morbidity and mortality and includes both open repairs and endovascular ones. In this review, we explore the etiology, pathogenesis, clinical presentations, diagnostic modalities as well as treatment management available for MTAA.
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13
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Nazari S. Early Repair of Aortic Wall Structural Defect by "Net" Endoprosthesis to Arrest the Aneurysm without Interference with Aortic Branch Vessel Perfusion. Aorta (Stamford) 2022; 10:95-103. [PMID: 36318930 PMCID: PMC9626036 DOI: 10.1055/s-0042-1748842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Current treatments of aortic aneurysm include surgical or endovascular, respectively, anatomical or functional, substitution of the aneurysm tract; however, with these methods, perfusion of at least some collateral branches cannot be fully restored, leading to the risk of paraplegia. We present a novel endovascular “net” prosthesis to strengthen the aortic wall while preserving perfusion of collateral branches. This consists of a polyester mesh “net”-layered conduit in a variable cylindrical shape, which is personalized based on patient computed tomography scan images, and is defined by circular crossing spirals of a thin nitinol wire. The prosthetic conduit, shrunk by compressing the nitinol spirals, can be inserted into the vascular lumen and expanded in situ. Then, the insertion control device can be fully removed. Thus, the, “net” prosthesis, positioned inside the aorta in stable contact with the intimal wall for 2 to 5 months, is colonized by neointima and spontaneously moved deeper into the aortic wall in contact with the media, thus being ideally able to stabilize aortic diameter without interference with collateral branch blood perfusion. This new, (ideally) paraplegia-free procedure is aimed at curing the aortic wall structural defect, thus arresting the aneurysm from further progression. This contrasts with current treatments, indicated by aneurysm dimensions for their implied complication risk, which are actually for prophylaxis of impending rupture or dissection rather than fortification of the natural aorta. Moreover, this new approach can be used alongside open surgical procedures (personalized external aortic root support) as well as a frozen “net” elephant trunk technique, for full aortic stabilization.
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Affiliation(s)
- Stefano Nazari
- Department of Research, Fondazione Alexis Carrel, Basiglio (MI), Italy,Address for correspondence Stefano Nazari, MD Via Marconi Res Parco 152, 20080 Basiglio (MI)Italy
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Ma L, Liu L, Yan S, Yan J. Bentall procedure for retrograde type A dissection after endovascular repair in type A aortic dissection: A case report. Medicine (Baltimore) 2022; 101:e29615. [PMID: 35945792 PMCID: PMC9351882 DOI: 10.1097/md.0000000000029615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE The management of retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type A aortic dissection (TAAD) has rarely been reported. We report the management of RTAD after TEVAR with in situ fenestration for TAAD. PATIENT CONCERNS A 59-year-old man with TAAD had undergone TEVAR with in situ fenestration 4 months prior to presenting to our emergency room complaining of acute chest and back pain. Computed tomography angiography showed RTAD starting from the proximal endograft and extending to the aortic root. DIAGNOSIS The patient was diagnosed with RTAD. INTERVENTIONS We performed only the Bentall procedure, and the patient did not require total arch replacement. We removed the bare spring of the proximal endograft and anastomosed the prosthetic graft with the endograft and the native ascending aortic wall. OUTCOMES The postoperative course was uneventful, and the patient remained asymptomatic for 3 years after surgery. Computed tomography angiography at the 3-year follow-up showed no perivalvular or anastomotic leakage. LESSONS RTAD after TEVAR for TAAD was safely and effectively treated by anastomosing the prosthetic graft with the endograft and the native ascending aortic wall instead of total arch replacement.
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Affiliation(s)
- Li Ma
- Department of Anesthesiology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing, China
- Department of Cardiovascular Surgery, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, China
| | - Long Liu
- Department of Cardiovascular Surgery, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, China
| | - Sheng Yan
- Department of Cardiovascular Surgery, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, China
| | - Jun Yan
- Department of Cardiovascular Surgery, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, China
- *Correspondence: Jun Yan, Department of Cardiovascular, Taiyuan Central Hospital of Shanxi Medical University, No. 5 Dong San Dao Xiang, Jiefang Road, Taiyuan, Shanxi 030009, China (e-mail: )
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Guerra A, Feinglass JM, Chia MC, Vavra AK. Characterizing endovascular aortic intervention outcomes for nonruptured aortic aneurysms by physician specialty. Surgery 2022; 171:762-769. [PMID: 35090735 PMCID: PMC8885887 DOI: 10.1016/j.surg.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evaluate patient outcomes after endovascular aortic interventions performed for nonruptured aortic aneurysms by physician specialties. METHODS Endovascular aortic repair (EVAR), fenestrated or branched repair (F-BEVAR), and thoracic endovascular aortic repair (TEVAR) procedures were obtained from the Illinois Hospital Association Comparative Health Care and Hospital Data Reporting Services database from 2016 to 2019. Logistic and Poisson regression were used to determine outcomes by patient, physician, and hospital characteristics. RESULTS A total of 4,935 procedures, 3,666 (74.3%) EVAR, 567 (11.5%) F-BEVAR, and 702 (14.2%) TEVAR were performed by vascular surgeons, interventional radiologists, interventional cardiologists, and cardiac surgeons. Vascular surgeons performed interventions equally between hospital types while interventional radiologists primarily performed interventions in teaching hospitals (68.1%) and interventional cardiologists and cardiac surgeons typically performed interventions in community hospitals (91.8% and 82.1%, respectively; P < .001). No differences in inpatient mortality were noted between specialties. Patients treated by interventional radiologists had increased odds of staying in the hospital ≥8 days (odd ration [OR] 1.95, 95% confidence interval [CI] 1.19-3.19) and patients treated by interventional cardiologists had lower odds of being admitted to the intensive care unit [ICU] (OR 0.42, 95% CI 0.18-0.95). CONCLUSION Differences in practice patterns among specialties performing endovascular aortic aneurysm repair for nonruptured aneurysms suggest opportunities for collaboration to optimize quality of care.
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Affiliation(s)
- Andres Guerra
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department, Chicago, IL.
| | - Joe M Feinglass
- Northwestern Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics
| | - Matthew C Chia
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department
| | - Ashley K Vavra
- Northwestern Feinberg School of Medicine, Division of Vascular Surgery, Surgery Department
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Queiroz AB, Lopes JB, Santos VP, Cruz PBAF, Fidelis RJR, Filho JSA, Passos LCS. Physician-Modified Endovascular Grafts for Zone-2 Thoracic Endovascular Aortic Repair. Aorta (Stamford) 2022; 10:13-19. [PMID: 35640582 PMCID: PMC9179216 DOI: 10.1055/s-0042-1742696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/02/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study aims to describe our technique and early experience with physician-modified endovascular grafts (PMEGs) for aortic arch diseases in zone 2. We used a total endovascular technique based on a single fenestrated endograft to preserve left subclavian artery (LSA) patency. METHODS From December 2019 to August 2020, six consecutive patients with a variety of thoracic aortic diseases were treated with handmade fenestrated thoracic aortic grafts: four aortic dissections, one penetrating aortic ulcer, and one intramural hematoma. The planning, endograft modification, surgical technique, and follow-up of the patients were described. We evaluated immediate technical success and after 30 days, the LSA patency, Type-1 endoleak, and postoperative complications. RESULTS Thoracic endovascular aortic repair (TEVAR) was performed for zone 2 in all cases. Immediate technical success, defined as successful alignment of the LSA with a covered stent and no Type-1 endoleak, was achieved in all cases. Patients had a 30-day follow-up computed tomography, which demonstrated LSA patency and no Type-I endoleaks. To date, no strokes, left arm ischemia, paraplegia, or conversions to open surgery have been reported; one patient operated for acute Type B dissection died during the early follow-up. CONCLUSION TEVAR for zone 2 with a PMEG to maintain LSA patency achieved technical success and early durability. It is expected that with longer follow-up and a larger number of cases, these results will be confirmed.
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Affiliation(s)
- André B. Queiroz
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - Jackson B. Lopes
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
| | - Vanessa P. Santos
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - Pedro B. A. F. Cruz
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
| | - Ronald J. R. Fidelis
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - José S. Araújo Filho
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
- Division of Vascular Surgery, Universidade Federal da Bahia, Hospital Universitário Professor Edgar Santos, Salvador-Bahia, Brazil
| | - Luiz C. S. Passos
- Centro de Doenças da Aorta - CDA, Division of Vascular and Endovascular Surgery, Cardiac Surgery, Cardiology and Anesthesia, Universidade Federal da Bahia, Hospital Ana Nery, Salvador-Bahia, Brazil
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Pruitt EY, Scali ST, Arnaoutakis DJ, Back MR, Arnaoutakis GJ, Martin TD, Beaver TM, Huber TS, Upchurch GR. Complicated acute type B aortic dissection: update on management and results. J Cardiovasc Surg (Torino) 2020; 61:697-707. [PMID: 32964895 PMCID: PMC7796970 DOI: 10.23736/s0021-9509.20.11555-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of thoracic endovascular aortic repair (TEVAR) has evolved and is now firmly established as a mainstay of therapy for acute complicated type B aortic dissection (acTBAD). However, several important issues remain unresolved including the optimal timing, sizing, graft selection, coverage length and utilization of adjunctive therapies to address false lumen perfusion. Therefore, the purpose of this study was to provide a contemporary perspective on the management and results for TEVAR of acTBAD. METHODS All TEVAR patients (N.=159) with acTBAD from a single high-volume, academic medical center were analyzed. Comparative results across time-dependent cohorts (2005-2009 [N.=43] vs. 2010-2014 [N.=56] vs. 2015-2020 [N.=60]) are presented. RESULTS 30-day mortality was 13%(N.=21) with a trend towards improvement over time (2005-2009, 18% vs. 2010-2020, 12%; P=0.1). Similarly, incidence of postoperative complications also declined: 2005-2009, 70% vs. 2010-2020, 36%(P-trend=0.08). One and 2-year freedom from aorta-related reintervention was 78±7% and 73±9% and did not differ across cohorts (log-rank P=0.5). Respective one and 5-year survival was 75±3% and 64±7%, but significantly improved with time (log-rank P<0.001). The corresponding one and five-year freedom from aorta-related mortality was 82±4% and 78±7% but did not change during the study interval (log-rank P=0.3). CONCLUSIONS Outcomes for TEVAR of acTBAD continue to improve over time. This time-dependent analysis delineates how results have changed due to increasing experience, technologic evolution, and maturation of the peer reviewed evidence. These results along with the evidence-based review provided herein, provide an update on the management and results of TEVAR of acTBAD while highlighting specific controversies unique to the management of this challenging clinical problem.
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Affiliation(s)
- Eric Y Pruitt
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA -
| | - Dean J Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - Tomas D Martin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
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Harmon TS, Ghannam A, Meyer TE, Concepcion C, Pirris J, Matteo J. Covered or Not, Here I Come: Stanford Type B Aortic Dissection Repair With a Covered and Uncovered Stent Hybrid Technique. Cureus 2020; 12:e11729. [PMID: 33391956 PMCID: PMC7772157 DOI: 10.7759/cureus.11729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The complications resulting from aortic dissections are often devastating. Historically, when a Stanford B aortic dissection extended into the visceral abdominal aorta, only surgical management was considered to limit visceral organ malperfusion. Complications of surgical management for Stanford B aortic dissections are as high as 50%. The inherently high complication and mortality rate for any acute aortic dissection, in addition to the complication rates resulting from surgical management, have demonstrated poor outcomes. This is especially true when aortic dissections involve the visceral segment, where thoracic endovascular aortic repair (TEVAR) becomes limited or contraindicated. In the last two decades, various approaches for TEVAR have improved in both endograft design and interventional technique. The current literature demonstrates improved outcomes for patients that receive TEVAR for Stanford B aortic dissections, including those that involve the visceral segment. Despite favorable prognostic advancement in TEVAR, the proven management complexity of Stanford B aortic dissections continue to reflect the pitfalls of the endovascular devices that are currently available. We describe a covered and uncovered stent hybrid technique in patients with complicated Stanford B aortic dissections involving the visceral segment, considering these deficiencies. Hundred percent technical success was demonstrated in the short and mid-term surveillance periods.
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Affiliation(s)
- Taylor S Harmon
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Alexander Ghannam
- Cardiothoracic Surgery, University of Florida College of Medicine, Jacksonville, USA
| | - Travis E Meyer
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | | | - John Pirris
- Cardiothoracic Surgery, University of Florida College of Medicine, Jacksonville, USA
| | - Jerry Matteo
- Radiology, University of Florida College of Medicine, Jacksonville, USA
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Chen HD, He F, Qian XM. Treatment experience of thoracic aortic aneurysm recurrence after multiple surgeries for Marfan syndrome: A case report. Medicine (Baltimore) 2019; 98:e17391. [PMID: 31577745 PMCID: PMC6783246 DOI: 10.1097/md.0000000000017391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
RATIONALE Marfan syndrome (MFS), an autosomal dominant hereditary disease, often results in structural and functional abnormalities of the aortic wall. Because of residual aortic aneurysm or aortic dissection, patients with MFS usually need repeat operations after the first operation. PATIENT CONCERNS A patient diagnosed with MFS who had undergone 2 surgeries because of abdominal aortic dissection aneurysm and Stanford A type aortic dissection at different times. DIAGNOSES MFS. INTERVENTIONS Due to aneurysmal dilatation of the residual descending aorta, we performed the third surgery for him through using 2 artificial stent grafts to fix and package the area of the remaining vessel in our hospital. OUTCOMES The result was good, and the patient was discharged successfully. LESSONS Using artificial material to repair and wrap the area of the residual vessel during the first surgery can provide an anchor area for future endovascular stent implantation and also offer a possibility for stent implantation in patients with MFS.
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Ishibashi K, Motokawa M. Total Arch and Descending Aorta Replacement for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Replacement for Complicated Type B Aortic Dissection. Cureus 2019; 11:e5017. [PMID: 31497447 PMCID: PMC6716760 DOI: 10.7759/cureus.5017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Retrograde type A aortic dissection (RTAD) is a severe complication of thoracic endovascular aortic repair (TEVAR). In this regard, we present our unique surgical methods for total arch and descending aorta replacement for RTAD after TEVAR for complicated type B aortic dissection (TBAD). A 52-year-old man with a history of distal arch large aneurysm was diagnosed with TBAD. Because he had sustained chest pain and his aneurysm diameter was 67 mm, TEVAR was urgently performed. After a right axillary-left axillary artery bypass, a stent graft was deployed in the descending aorta via the right femoral artery. Coil embolization was performed in the left subclavian artery. After the condition of the stent graft was checked by angiography, no Type 1 endoleak and backflow from the re-entry was observed. However, seven days after the operation, he experienced chest pain suddenly. Computed tomography (CT) revealed forward blood flow in the descending aorta (type IA endoleak) and thrombosed aortic dissection in the ascending aorta. The distal arch diameter exceeded 70 mm. A decision was taken to immediately perform an operation. Total aortic arch and descending aorta replacement were performed through a median sternotomy with left 5th interspace thoracotomy. The operation was performed under deep hypothermic circulatory arrest, and selective antegrade cerebral perfusion was accomplished. As a result of the exploration of the aortic arch, it was found that the intimal injury by the bare stent caused RTAD. The patient was successfully extubated after the operation and was discharged without any complications. RTAD can present as an early complication after descending stent grafting because of aortic instability or due to the strength of bare stents. Aortic arch and descending aorta replacement after TEVAR via a clamshell incision can be safely performed if RTAD is diagnosed early.
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