Factors favoring retrograde aortic dissection after endovascular aortic arch repair

Abstract

Objective To assess factors predisposing patients to retrograde type A aortic dissection (RTAD) who have undergone hybrid aortic arch repair. Methods From 2001 to 2013, 32 patients underwent hybrid aortic arch repair in our department: 19 in zone 1 and 13 in zone 0. Among these patients, 6 experienced RTAD (18.7%): 3 in zone 0 (23%), 3 in zone 1 (15.8%). Preoperative computed tomography scans of these 32 patients were evaluated. A morphologic assessment of the aortic arch, ascending aorta, and aortic root was performed. Other potential risk factors were investigated. Binary logistic regression was performed to test for possible associations with RTAD. Results Five patients were successfully converted to open repair. Patients who had RTAD were similar to those who did not, across pertinent variables, including age, type of device, diameter of the ascending aorta, and presence of a bicuspid aortic valve (all P >.1). Incidence of RTAD was observed to be higher among women (P =.034), patients with stent-graft oversizing>10% (P =.018), and patients treated with a stent-graft of diameter >42 mm (P =.01). Aortic morphology analysis showed that an indexed aortic diameter of>20 mm/m2 (P =.003); aortic root morphology, specifically loss of the sinotubular junction (P =.004); and presence of an aortic arch malformation (P =.03) were correlated with risk of RTAD. Two patients in the zone-0 group with severe angulation (>120°) between the ascending and the transverse aorta suffered RTAD. Conclusions The occurrence of RTAD after hybrid aortic arch repair is common. To prevent this complication, preoperative screening of the aortic arch, ascending aorta, and aortic root morphology is critical.