Total Arch and Descending Aorta Replacement for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Replacement for Complicated Type B Aortic Dissection.

Kazuyuki Ishibashi,Mamika Motokawa

doi:10.7759/cureus.5017

Abstract

Retrograde type A aortic dissection (RTAD) is a severe complication of thoracic endovascular aortic repair (TEVAR). In this regard, we present our unique surgical methods for total arch and descending aorta replacement for RTAD after TEVAR for complicated type B aortic dissection (TBAD). A 52-year-old man with a history of distal arch large aneurysm was diagnosed with TBAD. Because he had sustained chest pain and his aneurysm diameter was 67 mm, TEVAR was urgently performed. After a right axillary-left axillary artery bypass, a stent graft was deployed in the descending aorta via the right femoral artery. Coil embolization was performed in the left subclavian artery. After the condition of the stent graft was checked by angiography, no Type 1 endoleak and backflow from the re-entry was observed. However, seven days after the operation, he experienced chest pain suddenly.Computed tomography (CT) revealed forward blood flow in the descending aorta (type IA endoleak) and thrombosed aortic dissection in the ascending aorta. The distal arch diameter exceeded 70 mm. A decision was taken to immediately perform an operation. Total aortic arch and descending aorta replacement were performed through a median sternotomy with left 5th interspace thoracotomy. The operation was performed under deep hypothermic circulatory arrest, and selective antegrade cerebral perfusion was accomplished. As a result of the exploration of the aortic arch, it was found that the intimal injury by the bare stent caused RTAD. The patient was successfully extubated after the operation and was discharged without any complications. RTAD can present as an early complication after descending stent grafting because of aortic instability or due to the strength of bare stents. Aortic arch and descending aorta replacement after TEVAR via a clamshell incision can be safely performed if RTAD is diagnosed early.

Highlights

Thoracic endovascular aortic repair (TEVAR) has been increasingly performed for treating a complicated type B aortic dissection (TBAD)
We report a new method for the total arch and descending aorta replacement for retrograde type A aortic dissection (RTAD) after TEVAR for complicated TBAD using which we succeeded in the exclusion of the false lumen of the descending aorta
The results from the International Registry of Acute Aortic Dissection demonstrated that acute TBAD comprises approximately one-third of all aortic dissection cases and that approximately 25% of patients presenting with TBAD have complicated TBAD [13]

Summary

Introduction

Thoracic endovascular aortic repair (TEVAR) has been increasingly performed for treating a complicated type B aortic dissection (TBAD). Contrast-enhanced computed tomography (CT) showed that the proximal thoracic aorta diameter was 67 mm, and proximal entry was found distal to the left subclavian artery (LSA) (Figure 1). His chest pain progressively worsened despite an antihypertensive being administered. How to cite this article Ishibashi K, Motokawa M (June 27, 2019) Total Arch and Descending Aorta Replacement for Retrograde Type A Aortic Dissection After Endovascular Stent Graft Replacement for Complicated Type B Aortic Dissection. The Dacron graft was anastomosed with the stent graft and native descending aorta, and the distal side was anastomosed with a double-barrel technique because the major aortic branches had a false lumen origin. At the six-month follow-up, contrast-enhanced CT demonstrated that there was no problem at the anastomotic site and the false lumen at the descending aorta was completely thrombosed and shrunken (Figure 5)

Discussion

Findings

Conclusions

Disclosures