Antegrade stengraft Delivery in Acute Type-A Dissection: The Good, the Bad, and the Ugly

Objectives: We analyzed the midterm results of antegrade stentgraft delivery in the descending thoracic aorta in acute type-A dissection (AAD).

Methods: Outcomes were evaluated for 375 patients who underwent surgery for AAD between February 2000 and August 2019 (standard repair, SR, n = 337, 90%; standard repair + antegrade stentgraft delivery, SR + TEVAR, n = 38; 10%). A total of 89% (n = 33) of patients who received antegrade TEVAR had computed tomography postsurgery. Median follow-up time in the whole cohort was 21 months.

Results: Mean age at time point of AAD 59.5 years. 76% of patients were male. Indications for antegrade TEVAR were: entry/reentry of the dissection in the descending aorta in 50.0% (n = 19), true lumen compromise in 16% (n = 6) and malperfusion syndrome of lower extremities, and/or abdominal organs in 13% (n = 5). Chronic dissection or aneurysm of the descending aorta was present in 11% of patients (n = 4) and intramural hematoma in 5% (n = 2). The remaining 5% of patients (n = 2) had more than one indication for TEVAR of the descending aorta. Technical success of intraoperative TEVAR could be achieved in 95% (n = 36). Perforation of the descending aorta during stentgraft deployment occurred in one patient. In one case, additional placement of a second antegrade TEVAR due to inaccurate placement was necessary. Evaluation of hospital outcome did not reveal any significant differences between the two treatment groups. Out of 15 patients who suffered from preoperative malperfusion of abdominal organs or lower limbs, 13 were free from signs of postoperative malperfusion after TEVAR. Midterm survival was superior the SR group (p = 0.05).While 22 patients (67%) showed a good result in follow-up imaging. Nine patients (27%) suffered from a postoperative endoleaks (five type Ia and four type II), one patient (3%) from pseudoaneurysm and three patients (9%) from type-B dissections during follow-up and reintervention rate was of 8% (three patients).

Conclusion: Antegrade TEVAR in AAD is an easy applicable and helpful tool to improve antegrade distal downstream flow in order to regain/stabilize organ perfusion and/or to secure distal open anastomosis against bleeding from retrograde expansion of the dissection. However, careful indication of treatment or modifications of proximal sealing of the stentgraft are necessary due to a nonnegligible number of endoleaks. In order to evaluate impact of antegrade TEVAR on remodeling of the distal aorta longer follow-up times are needed for validation.