Abstract 4274: Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent-Graft Placement- Insights from the European Registry on EVAR Complications (EUREC)

Abstract

Background: Thoracic endovascular aortic repair (TEVAR) is increasingly applied in the treatment of aortic dissections and aneurysms. Single center reports have addressed retrograde ascending aortic dissection (rAAD) as a potentially lethal complication unique to TEVAR. We used data from a European multi-center registry to determine possible etiological factors and outcomes of this dreadful complication. Methods: So far 15 European sites and 1 Chinese center are contributing to the European Registry on EVAR Complications (EUREC) which is an open, independent, ongoing multi-center registry. Between 01/1998 and 05/2008 these centers performed a total of 3074 TEVAR procedures. Results: 33 rAAD cases (56.3±11.6 yrs, 20 males) were reported (incidence 1.1%). Indications for TEVAR were: acute type B dissection (n=17), chronic dissection (n=10), thoracic aneurysm (n=4), and aortic ulcer (n=1). 20 procedures were performed as emergency TEVAR. Stent-grafts with proximal bare springs were used in 26/33 (79%) cases. Additional balloon inflations were performed in 6 (18%) cases. rAAD occurred intraoperatively (n=5, 15%), during the index hospitalization (n=7, 21%), and during follow-up (n=21, 64%). 9 (27%) patients were asymptomatic, the remaining patients presented with acute chest pain (n=11, 33%), syncope (n=10, 30%), or sudden death (n=5, 15%). Emergency or elective surgical repair was performed in 19 and 4 patients, respectively. Conservative therapy was chosen in the remaining 10 patients. Outcome was fatal in 14/33 (42%) patients. The most probable cause of rAAD as reported by the investigators was stent-graft induced in 58%, procedure related in 9%, and underlying undiagnosed aortic disease in 15% of patients. In 16/33 patients direct evidence of stent-graft induced rAAD was obtained by surgery or necropsy. Conclusion: Although the incidence of rAAD was low (1.1%) in the present EUREC analysis, it was associated with significant mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone rAAD. As suspected, the majority of rAAD cases was associated with the use of proximal bare spring stent-grafts and in almost half of the patients direct evidence of stent-graft induced injury was obtained from surgery or necropsy.