title: Surgical management of delayed retrograde type A aortic dissection following complete supra-aortic de-branching and stent-grafting of the transverse arch.
abstract: OBJECTIVE
  Hybrid endovascular procedures are rapidly evolving and have recently been adopted for high-risk patients deemed unsuitable for conventional aortic arch surgery. We describe here our initial experience with this technique, including the management of 2 patients who developed a retrograde type A aortic dissection post-de-branching.
  
  
  METHODS
  Between May 2010 and October 2012, 109 patients underwent conventional aortic arch repair at our institution. A further 9 high-risk patients with complex aortic arch pathology (median logistic EuroSCORE: 26, range: 11-41) were deemed unsuitable for conventional total aortic arch replacement and therefore underwent hybrid aortic arch repair. Complete supra-aortic de-branching, followed by endovascular stent-grafting (TEVAR) of the transverse arch and descending aorta, was performed in these high-risk patients.
  
  
  RESULTS
  In-hospital mortality was zero and no patient developed paraplegia/paraparesis due to spinal cord ischaemia. However, 2 patients (22%) developed retrograde type A aortic dissection on Days 10 and 12 post-TEVAR. Both patients had a dilated ascending aorta and received a stent graft containing bare metal springs at the proximal end. Emergency ascending aortic replacement was performed during moderate-to-mild hypothermia (28-34°C) and bilateral antegrade cerebral perfusion via cannulation of the de-branching prosthesis. A Hemashield prosthetic graft was anastomosed to the proximal stent graft in an elephant trunk technique. Both patients suffered from minor non-debilitating stroke, with 1 being discharged home and 1 transferred to a neurological rehabilitation centre 2 and 3 weeks after reoperation, respectively.
  
  
  CONCLUSIONS
  Retrograde type A aortic dissection after hybrid endovascular treatment of the aortic arch represents a new-most likely under-reported-pathology that may be successfully treated with open surgical repair. The use of stent grafts with protruding proximal bare springs and the implementation of oversizing and post-deployment ballooning should be avoided in patients undergoing hybrid arch procedures, particularly if the ascending aorta is dilated.
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Luehr
authors.forename: Christian D
authors.initials: CD
authors.lastname: Etz
authors.forename: Lukas
authors.initials: L
authors.lastname: Lehmkuhl
authors.forename: Andrej
authors.initials: A
authors.lastname: Schmidt
authors.forename: Martin
authors.initials: M
authors.lastname: Misfeld
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.forename: Friedrich-Wilhelm
authors.initials: FW
authors.lastname: Mohr
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000601:surgery*; D001013:Aorta, Thoracic / Q000473:pathology / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D009017:Morbidity; D015607:Stents
keywords: Aortic arch; Ascending aorta; Hybrid aortic repair; Proximal landing zone; Retrograde type A aortic dissection; Supra-aortic de-branching/re-routing; TEVAR