Retrograde Type A Dissection after TEVAR for Type B Aortic Dissection
Halim Yammine, Charles S. Briggs, Gregory A. Stanley, Jocelyn K. Ballast, William E. Anderson, Tzvi Nussbaum, John R. Frederick, Frank R. Arko, III
Carolinas Medical Center, Charlotte, NC
BACKGROUND: The purpose of this study was to evaluate clinical, anatomical, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular repair (TEVAR) for type B aortic dissection (TBAD).
METHODS: Between January 2012 and January 2017, 186 patients underwent TEVAR for TBAD at a multidisciplinary aortic center. Patients who developed RTAD after TEVAR (n=15) were compared with those who did not (noRTAD: n=171). Primary outcomes were survival and need for reintervention.
RESULTS: The incidence of RTAD in our sample was 8% (n=15). Kaplan Meier estimates found that noRTAD had better survival (p=.04). Survival rates at 30 days, 1 year, 3 years, and 5 years were 93%, 60%, 60%, and 53% for RTAD and 94%, 87%, 80%, 80% for noRTAD. In the RTAD group, 1 RTAD was diagnosed intraoperatively, 5 were diagnosed within 30 days of the index procedure, 6 were diagnosed within 1 year, and 3 were diagnosed after 1 year. Reintervention for RTAD was undertaken in 10 out of 15 patients, with a 50% survival rate for those who underwent reintervention. A higher percentage of RTAD patients had the presence of IMH (p=.03). Patients who developed RTAD presented more frequently with renal ischemia (p=.04). A significantly greater number of RTAD patients (93% RTAD, 64% noRTAD, p=.02) had a proximal landing zone in zone 2 or 1. Patients who had RTAD had stent grafts placed in the visceral and renal arteries for complicated dissections, and this approached significance (p=.05). Only 3 RTAD patients had a type 2 arch (20%), compared with 53 noRTAD (31%, p=0.6), but in comparing type 2 arch with type 1 or 3, there was no statistical significance (p=.6). We did not find any correlations between development of a RTAD with ratio of descending to ascending diameters, aortic sizing, graft size, or bare metal struts at proximal attachment zone. We found no statistically significant differences between the RTAD and noRTAD groups in terms of demographics, genetic disease, comorbidities, or previous repairs.
CONCLUSIONS: The development of a RTAD after TEVAR for TBAD does not appear to be correlated with any easily identifiable demographic feature, but appears to be correlated with proximal landing zones in zone 1 and 2. Furthermore, the presence of IMH, as well as more complicated presentation with renal ischemia was significantly more frequent in patients with RTAD. TBAD patients should be followed long-term, as type A dissections in our patients occurred even after 1 year.
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