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Retrograde type A dissection after endovascular stenting of the descending thoracic aorta. Is the risk real?

^a Arizona Heart Institute, Department of Cardiovascular and Endovascular Surgery, 2632 N. 20th Street, Phoenix, AZ 85006, United States
^b Bayhealth Medical Center, Department of Cardiac Surgery, Dover DE affiliated with University of Pennsylvania Health System, United States

Received 25 September 2007; received in revised form 14 March 2008; accepted 19 March 2008.

^_* Corresponding author. Tel.: +1 602 266 2200; fax: +1 602 604 5020. (Email: jkpodonu{at}yahoo.com).

Objective: Retrograde type A dissection during or after endoluminal graft repair of the descending thoracic aorta is a potentially lethal complication unique to thoracic endografting. Our aim is to increase its awareness and to review possible etiological factors. Methods: Two hundred and eighty-seven patients with different thoracic aortic pathologies were treated with endovascular prostheses over the last 6 years (February 2000 to March 2006) under a single-site protocol. A retrospective review was conducted to identify any retrograde aortic dissections by both chart and film review. Factors that may have contributed to its formation were also documented. This population was analyzed for the complication of retrograde aortic dissection as well as the factors related to its occurrence. Results: Seven patients (2.4%) with a gender distribution of three males and four females experienced a retrograde type A dissection within this sample at a median of 202 days. The mean age was 74 years (range 53–83). Aortic pathologies included aortic dissections (n = 6) and thoracic aortic aneurysm (n = 1). There were (n = 3) 43% retrograde type A dissections identified within the perioperative period. Balloon angioplasty was performed in 71.4% (n = 5). Two female patients (28.6%) had this event identified within their initial hospitalization with fatal consequences. Overall mortality was 57% (n = 4) with extension of dissection the primary cause of death n = 3 and open surgical repair (n = 1) after an extension of retrograde dissection. Conclusions: Female gender, use of stent-grafts for dissection and possible aggressive balloon angioplasty may play a role in the cause of retrograde type A dissection. A close surveillance program is recommended when using thoracic endografts outside the recommended device instructions for use.

Abbreviations: HTN = hypertension • N = number • MI = myocardial infarction • CVA = cerebrovascular accident • COPD = chronic obstructive lung disease • CABG = coronary artery bypass graft surgery • PTCA = percutaneous coronary angioplasty • POD = postoperative day • M = male • F = female

Key Words: Retrograde type A dissection • Endovascular stent-graft