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Failure to achieve intramural hematoma-free proximal seal zone in TEVAR increases risk for retrograde dissection
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Patients who underwent thoracic endovascular aortic repair for complicated type B aortic dissections and did not achieve 2 cm of intramural hematoma-free proximal seal zone had an increased risk for retrograde type A dissection, according to a study published in the Journal of Vascular Surgery.
Eric C. Kuo, MD, resident physician in the division of vascular surgery and endovascular therapy at University of Southern California in Los Angeles, and colleagues performed a retrospective review of 71 patients (mean age, 59 years; 73% men) who underwent TEVAR for type B aortic dissections from May 2006 to June 2016.
CT images were taken to identify the extent of the dissection, primary entry tear, the involvement of intramural hematoma of the proximal seal zone and the distances between arch branches.
Patients were then categorized as having either the proximal extent of the seal zone in an intramural hematoma-free aorta (group A; n = 26; mean age, 58 years; 92% men) or a proximal seal zone that did not incorporate any intramural hematoma-free aorta (group B; n = 45; mean age, 59 years; 62% men).
CT scans were performed to assess aortic remodeling during a mean follow-up of 14 months. The primary outcome of interest was the development of a retrograde type A dissection. Other clinical outcomes of interest were reinterventions, morbidities and death.
Some of the indications for TEVAR in this study included aneurysm, malperfusion, rupture, persistent pain and uncontrolled hypertension.
During follow-up, 8.5% of patients achieved a proximal seal zone of 2 cm in an intramural hematoma-free aorta. To create this, 43.7% of patients would require coverage of all three arch branch vessels, according to a review of arch anatomy.
After TEVAR, one patient suddenly died and two patients had retrograde type A dissections that were confirmed in imaging and required open repairs. All three of these patients were in group B.
No patients who had a proximal seal zone in a healthy aortic segment had retrograde type A dissections.
At 24 months, freedom from aorta-related mortality was 97.4% and overall survival was 93%.
Both groups had similar rates of aortic remodeling such as false lumen regression, true lumen expansion and false lumen thrombosis.
“The convenience of sealing entirely within [intramural hematoma] should be carefully considered in the context of potentially higher risk of [retrograde type A dissection], especially during the acute phase,” Kuo and colleagues wrote. “Furthermore, the risks of [retrograde type A dissection] after TEVAR must be considered against the indication for intervention, especially when the disease-free proximal seal zone is difficult to achieve.” – by Darlene Dobkowski
Disclosures: The authors report no relevant financial disclosures.
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