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Incidence, risk factors, and outcome of retrograde type A aortic dissection after TEVAR

A systematic review. English version

Retrograde Typ-A-Aortendissektion nach TEVAR: Inzidenz, Risikofaktoren und Outcome

Ein systematischer Review

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Abstract

Background

Retrograde type A aortic dissection after thoracic endovascular aortic repair (TEVAR) has recently been recognized as a new pathophysiological entity. Little is known about its incidence, risk factors, and outcome.

Methods

Electronic searches were performed in Medline until 8 November 2013. Relevant studies were identified. We looked for consecutive series reporting on incidence, risk factors, and outcome. Registries were excluded. Data were extracted and analyzed according to predefined outcome measures.

Results

Sixteen studies were identified for inclusion for qualitative and quantitative analyses. The incidence of retrograde type A aortic dissection after TEVAR was given in all 16 studies and was between 1.3 and 24 %. Incidence varied substantially with regard to the underlying aortic pathology treated as well as with regard to the application or non-application of supra-aortic transpositions prior to TEVAR. The strong association between acute aortic syndromes and retrograde type A aortic dissection was consistent in all other studies, being highest in the combination of an acute aortic syndrome and supra-aortic rerouting prior to TEVAR (24 %). Both proven and suspected pathophysiological mechanisms causing retrograde type A aortic dissection were consistent in all studies. The time interval between TEVAR and the occurrence of retrograde type A aortic dissection varied between immediate occurrence during the procedure and up to 7 years after treatment. Outcome varied according to the time of occurrence, being best in patients who were treated surgically where the diagnosis was made in hemodynamically stable conditions.

Conclusion

Retrograde type A aortic dissection after TEVAR is not rare in patients with the underlying pathology of type B aortic dissection, type B intramural hematoma as well as after total arch rerouting aimed for zone 0 landing zone deployment. Retrograde type A aortic dissection after TEVAR may occur early or late. Further studies are needed to clarify the pathophysiological mechanisms and to prevent this complication in the future.

Zusammenfassung

Hintergrund

Vor kurzem wurde die retrograde Typ-A-Aortendissektion nach TEVAR als neue pathophysiologische Entität anerkannt. Zu Inzidenz, Risikofaktoren und Outcome ist noch wenig bekannt.

Methoden

Bis zum 08.11.2013 wurde in der Datenbank Medline recherchiert, für die Fragestellung relevante Studien wurden identifiziert. Gesucht wurde nach Fallserien mit Dokumentation von Inzidenz, Risikofaktoren und Outcome. Nach vordefinierten Outcome-Kriterien wurden Daten extrahiert und analysiert.

Ergebnisse

Für die qualitativen und quantitativen Analysen wurden 16 Studien herangezogen. Die Inzidenz einer retrograden Typ-A-Aortendissektion nach TEVAR war in sämtlichen Studien angegeben, sie lag zwischen 1,3 und 24 %. Die Inzidenz war je nach zugrundeliegender aortaler Pathologie und je nach (Nicht-)Anwendung supraaortaler Transpositionen vor der Intervention sehr unterschiedlich. Die deutliche Assoziation zwischen akuten Aortensyndromen und retrograder Typ-A-Aortendissektion war konsistent in allen anderen Studien zu finden, am höchsten war sie bei der Kombination akutes Aortensyndrom und supraaortalem „Rerouting“ vor TEVAR (24 %). Nachgewiesene und angenommene pathophysiologische Mechanismen, die eine retrograde Typ-A-Aortendissektion verursachen, waren in sämtlichen Studien konsistent. Zwischen TEVAR und retrograder Typ-A-Aortendissektion lagen sehr verschiedene Zeitintervalle: zwischen sofortigem Eintreten schon während der Behandlung bis zu 7 Jahren postinterventionell. Das Outcome war je nach Zeitpunkt des Auftretens unterschiedlich: Am günstigsten war es bei chirurgisch behandelten Patienten wo die Diagnosestellung unter hämodynamisch stabilen Bedingungen erfolgt ist.

Fazit

Bei Patienten mit den zugrundeliegenden Pathologien Typ-B-Aortendissektion und/bzw. intramurales Typ-B-Hämatom, ferner nach komplettem Aortenbogenumbau, kommt es nicht selten nach TEVAR zu einer retrograden Typ-A-Aortendissektion. Sie kann früh oder spät TEVAR auftreten. Weitere Untersuchungen sind erforderlich, um die pathophysiologischen Mechanismen zu klären und dieser Komplikation künftig vorzubeugen.

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Compliance with ethical guidelines

Conflict of interest. M. Czerny, M. Rieger, and J. Schmidli state that there are no conflicts of interest. The accompanying manuscript does not include studies on humans or animals.

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Authors and Affiliations

  1. Department of Cardiovascular Surgery, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland

    M. Czerny MD, MBA & M. Rieger

  2. Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland

    J. Schmidli

  3. Universitäres Herzzentrum Freiburg-Bad Krozingen, Hugstetterstrasse 55, 79106, Freiburg, Germany

    M. Czerny MD, MBA

Authors
  1. M. Czerny MD, MBA
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  2. M. Rieger
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  3. J. Schmidli
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Corresponding author

Correspondence to M. Czerny MD, MBA.

Additional information

M. Czerny and M. Rieger contributed equally to this work. The German version of this article is published in Gefässchirurgie DOI 10.1007/s00772-014-1412-0

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Czerny, M., Rieger, M. & Schmidli, J. Incidence, risk factors, and outcome of retrograde type A aortic dissection after TEVAR. Gefässchirurgie 20 (Suppl 1), 45–50 (2015). https://doi.org/10.1007/s00772-014-1389-8

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