title: Retrograde type A dissection following hybrid supra-aortic endovascular surgery in high-risk patients unfit for conventional open repair.
abstract: BACKGROUND
  Hybrid procedures with combined open extra-anatomical supra-aortic bypasses and endovascular surgery are less invasive for patients with complex aortic arch pathology. The aim of this paper is to report patients who developed retrograde type A aortic dissection following initially successful hybrid endovascular treatment.
  
  
  METHODS
  Retrospective review of prospectively collected computerized departmental database. All patients with supra-aortic hybrid endovascular surgery and post-procedure retrograde type A dissection were identified. Patient demographics, comorbid conditions, perioperative parameters, procedural details and post-operative complications were collected.
  
  
  RESULTS
  From May 2005 to July 2014, 163 patients underwent thoracic aortic endovascular procedures at our institution. From the 46 patients who had supra-aortic hybrid endovascular repair, six patients (6/46, 13% of all supra-aortic hybrid cases, 3 males) developed retrograde type A aortic dissection. All were elective cases, with 3 chronic dissecting aneurysms and 3 atherosclerotic aneurysms. All had one-stage hybrid procedures: 2 patients had carotid-carotid bypass grafts, one had carotid-carotid-left subclavian bypass graft, and 3 had bypass grafts from ascending aorta to innominate artery and left carotid artery. Five patients had Cook Zenith thoracic stent-grafts (Cook Medical, Bloomington, IN, USA), and one had Medtronic Valiant stent-grafts (Medtronic Vascular Inc, Santa Rosa, CA, USA). The retrograde type A dissection occurred with sudden symptoms at day 5, 6, 10, 20, 105 and 128, respectively. There were 3 immediate fatalities and 2 patients treated conservatively deemed unfit for reintervention (one died of pneumonia at 9 months, and one remained alive at 7 months post-complication). One patient underwent successful emergency open surgery and survived.
  
  
  CONCLUSIONS
  Supra-aortic hybrid procedures in treating aortic arch pathology may be at risk of developing retrograde type A dissection. This post-operative complication inevitably have poor outcome, even with early diagnosis and prompt treatment.
authors.affiliation: Division of Vascular &amp; Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong, China.
authors.forename: Hon C
authors.initials: HC
authors.lastname: Yip
authors.affiliation: Division of Vascular &amp; Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong, China - ycchan88@ hkucc.hku.hk.
authors.forename: Yiu C
authors.initials: YC
authors.lastname: Chan
authors.affiliation: Division of Vascular &amp; Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong, China.
authors.forename: Kai X
authors.initials: KX
authors.lastname: Qing
authors.affiliation: Division of Vascular &amp; Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, Queen Mary Hospital, Hong Kong, China.
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Cheng
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D000072226:Computed Tomography Angiography; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006723:Hong Kong; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome