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The Journal of Cardiovascular Surgery 2018 April;59(2):243-51

DOI: 10.23736/S0021-9509.16.08869-8


language: English

Retrograde type A dissection following hybrid supra-aortic endovascular surgery in high-risk patients unfit for conventional open repair

Hon C. YIP, Yiu C. CHAN , Kai X. QING, Stephen W. CHENG

Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong, China


BACKGROUND: Hybrid procedures with combined open extra-anatomical supra-aortic bypasses and endovascular surgery are less invasive for patients with complex aortic arch pathology. The aim of this paper is to report patients who developed retrograde type A aortic dissection following initially successful hybrid endovascular treatment.
METHODS: Retrospective review of prospectively collected computerized departmental database. All patients with supra-aortic hybrid endovascular surgery and post-procedure retrograde type A dissection were identified. Patient demographics, comorbid conditions, perioperative parameters, procedural details and post-operative complications were collected.
RESULTS: From May 2005 to July 2014, 163 patients underwent thoracic aortic endovascular procedures at our institution. From the 46 patients who had supra-aortic hybrid endovascular repair, six patients (6/46, 13% of all supra-aortic hybrid cases, 3 males) developed retrograde type A aortic dissection. All were elective cases, with 3 chronic dissecting aneurysms and 3 atherosclerotic aneurysms. All had one-stage hybrid procedures: 2 patients had carotid-carotid bypass grafts, one had carotid-carotid-left subclavian bypass graft, and 3 had bypass grafts from ascending aorta to innominate artery and left carotid artery. Five patients had Cook Zenith thoracic stent-grafts (Cook Medical, Bloomington, IN, USA), and one had Medtronic Valiant stent-grafts (Medtronic Vascular Inc, Santa Rosa, CA, USA). The retrograde type A dissection occurred with sudden symptoms at day 5, 6, 10, 20, 105 and 128, respectively. There were 3 immediate fatalities and 2 patients treated conservatively deemed unfit for reintervention (one died of pneumonia at 9 months, and one remained alive at 7 months post-complication). One patient underwent successful emergency open surgery and survived.
CONCLUSIONS: Supra-aortic hybrid procedures in treating aortic arch pathology may be at risk of developing retrograde type A dissection. This post-operative complication inevitably have poor outcome, even with early diagnosis and prompt treatment.

KEY WORDS: Coronary artery bypass - Stents - Thoracic aortic aneurysm - Hematoma - Dissection - Sternotomy

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