Author + information
- Zhi Zheng,
- Chun Liu,
- Yihu Liu,
- Fubin Liu,
- Qiannan Guo,
- Haihao Wang and
- Youmin Pan
Acute Stanford type A aortic dissection is typically presented as antegrade dissection from a primary intimal tear in the proximal ascending aorta extending to the arch and the downstream distal aorta. However, it may also develop in a retrograde fashion with an intimal tear located in the descending aorta causing retrograde extension of aortic dissection into the ascending aorta, namely, retrograde type A aortic dissection (RTAAD). The optimal management of RTAAD is controversial. This was the first study to compare open surgery to thoracic endovascular aortic repair (TEVAR) in the treatment of RTAAD.
From January 2012 to June 2015, totally 573 patients of acute aortic dissection were admitted in our institute all diagnosed by computed tomographic angiography (CTA). Of them, 30 (5%) clinically stable RTAAD were evaluated. Before September 2013, open surgery (ascending aorta replacement and total arch replacement with stented elephant trunk implantation under cardiopulmonary bypass) was applied in RTAAD (open surgery group, 15 cases). Afterwards, TEVAR was introduced in clinically stable RTAAD (TEVAR group, 15 cases). Coated endovascular stent was implanted through femoral artery. The left subclavian artery (LSCA) was intentionally occluded in 7 patients, reconstructed through hybrid procedure in one, and remained uninfluenced in the rest 7 patients.
In TEVAR group, all procedures were technically successful, with complete coverage of the entry tear and complete thrombosis of the false lumen in the ascending aorta. No stroke, or paraplegia, or new intimal tear in the proximal ascending aorta, or endoleak, or stent immigration was observed during perioperative period and follow up. TEVAR resulted in complete thrombosis of the false lumen, reabsorption of the false lumen thrombus, and enlargement of the true lumen. The mean maximal area of the false lumen in the ascending aorta significantly decreased (874±161mm2 vs. 593±106 mm2, P<0.01) after TEVAR. At the distal edge of the stent graft, the mean whole area of the descending aorta remained stable (710±71mm2 vs. 704±67 mm2, P>0.05) after TEVAR.
In open surgery group, one postoperative death occurred due to multiple organ failure. Postoperative complications included respiratory failure requiring mechanical ventilation longer than 3 days in four cases, sever pneumonia in one, acute renal failure in one.
Postoperative morbidity rate (one case, 7%, vs. six cases, 26%, P<0.05) and perioperative death (0, 0% vs. one case, 7%) was significantly lower in TEVAR group when compared to open surgery group. The ICU time (1±0.3d vs. 3±1.3d, P<0.01) and hospitalization time (16±3d vs. 24±6d, P<0.01) was significantly shorter in TEVAR group than open surgery group.
TEVAR is a safe and effective technique in highly selected patients for the treatment of RTAAD. It is minimally invasive and ensures speedy patient recovery; however, further large-scale follow-up studies are required to verify its long-term efficacy.