Retrograde Type A Dissection after Ascending Aorta Involved Endovascular Repair and Its Surgical Repair with Stented Elephant Trunk

Background: Retrograde type A dissection (RTAD) is a serious complication after ascending aorta involved endovascular repair (AAIER). We here report our surgical approach to this serious complication. Methods: From July 2011 to July 2014, 8 RTADs after AAIER patients received surgical repair in our institution. Data of these RTAD patients were retrospectively collected for further analysis. All patients received urgent surgical repair based on the stented elephant trunk technique. We took 2 different ways to handle the previous stent during operation. In patients who had a prior hybrid aortic repair, we removed the proximal part of the stent while the distal part was left in place. In patients who had prior ascending aorta stent implantation (AASI), the stent was totally removed. Results: The mean age of the patients was 57.6 +/- 11.9 years. Regarding the index intervention, 2 patients received hybrid aortic repair and 6 patients received AASI. In patients who received AASI, 1 patient underwent simultaneous thoracic endovascular aortic repair (TEVAR) and another patient received simultaneous chimney technique in innominate artery and left common carotid artery combined with bypass from left subclavian artery to left common carotid artery to cure the type I endoleak induced by the previous implanted TEVAR stent. All patients received a new elephant trunk implantation during surgical repair. The mean cardiopulmonary bypass, selective cerebral perfusion, and aortic cross-clamp time were 172.1 +/- 13.3, 40.8 +/- 4.2, and 121.8 +/- 11.4 min, respectively. The mean intensive care unit time was 7.8 +/- 3.4 days. Two patients (25.0%) experienced transient neurologic dysfunction and recovered completely before discharge. In-hospital death rate was 12.5% (1 of 8). The mean follow-up time was 17.1 +/- 9.5 months. No late deaths or complications occurred during follow-up. Conclusions: AAIER especially AASI used in aortic dissection treatment should be seriously considered since RTAD might occur. Our study indicated that surgical repair with stented elephant trunk was feasible and according to the cause of RTAD, different surgical strategies should be taken to manage the stent.