Retrograde Aortic Dissection During Thoracic Endovascular Aortic Repair: How to Prevent and Treat

Today, thoracic endovascular aortic repair (TEVAR) is the recommended treatment for descending thoracic aortic aneurysm, complicated type B aortic dissection (cTBAD), and traumatic aortic injury, when anatomically suitable.[1Isselbacher E.M. Preventza O. Black 3rd JH Augoustides J.G. Beck A.W. Bolen M.A. et al.2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.Circulation. 2022 Dec 13; 146: e334-e482Crossref PubMed Scopus (379) Google Scholar] Its use in uncomplicated TBAD is increasing. As with any emerging technology and treatment, new complications arise. Retrograde type A aortic dissection (RTAD) is a catastrophic and life-threatening complication. The incidence of RTAD is 2-5% of all patients undergoing TEVAR.[2Canaud L. Ozdemir B.A. Patterson B.O. Holt P.J.E. Loftus I.M. Thompson M.M. Retrograde aortic dissection after thoracic endovascular aortic repair.Ann Surg. 2014 Aug; 260: 389-395Crossref PubMed Scopus (190) Google Scholar, 3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar, 4Williams J.B. Andersen N.D. Bhattacharya S.D. Scheer E. Piccini J.P. McCann R.L. Hughes G.C. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair.J Vasc Surg. 2012 May; 55: 1255-1262Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 5Wang L. Zhao Y. Zhang W. Shu X. Wang E. Guo D. et al.Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair: Incidence, Time Trends and Risk Factors.Semin Thorac Cardiovasc Surg. 2021 Autumn; 33: 639-653Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 6Shalhub S. Eagle K.A. Asch F.M. LeMaire S.A. Milewicz D.M. GenTAC Investigators for the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) Consortium. Endovascular thoracic aortic repair in confirmed or suspected genetically triggered thoracic aortic dissection.J Vasc Surg. 2018 Aug; 68: 364-371Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] To minimize the incidence of RTAD and improve the outcomes when it occurs, it is essential first to understand what are the risk factors for developing it, how to avoid them, and what are the best ways to manage RTAD when it occurs. The occurrence of RTAD after TEVAR is associated with several key risk factors, as elucidated in the literature. Some of those factors are patient- or tissue-related. One significant factor is the underlying disease process itself that required the TEVAR. According to the literature, patients treated for TBAD are more prone to the occurrence of RTAD, even when landing in a "seemingly healthy" aorta. Most likely, the inflammation and disease process extends beyond the visible pathological segments of the aorta.[7Eggebrecht H. Thompson M. Rousseau H. Czerny M. Lönn L. Mehta R.H. et al.Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.Circulation. 2009 Sep 15; 120: S276-S281Crossref PubMed Scopus (315) Google Scholar, 8Cochennec F. Tresson P. Cross J. Desgranges P. Allaire E. Becquemin J.P. Hybrid repair of aortic arch dissections.J Vasc Surg. 2013 Jun; 57: 1560-1567Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 9Carrel T.P. Czerny M. Commentary: Retrograde Type A Aortic Dissection After TEVAR for Type B Aortic Dissection - On the Verge to Oblivion?.Semin Thorac Cardiovasc Surg. 2021 Autumn; 33: 654-655Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] Other conditions, such as hereditary thoracic aortic diseases or bicuspid aortic valves, also significantly increase the risk for RTAD, with incidences reported as high as 25%.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar,6Shalhub S. Eagle K.A. Asch F.M. LeMaire S.A. Milewicz D.M. GenTAC Investigators for the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) Consortium. Endovascular thoracic aortic repair in confirmed or suspected genetically triggered thoracic aortic dissection.J Vasc Surg. 2018 Aug; 68: 364-371Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar] Aortic diameter is another critical factor, with an ascending aorta diameter exceeding 40 mm identified as a risk factor for RTAD after TEVAR. A few factors are related to the technical aspects of performing TEVAR. The proximalization of the landing zone beyond zone 2 increases the risk for RTAD, most likely due to the mismatch between the elastic ascending aorta and the rigid stent graft. The design of the proximal edge of the stent graft has also been a topic of debate. Few studies have demonstrated that proximal bare stent (PBS) had a higher incidence of RTAD to ones without PBS.[5Wang L. Zhao Y. Zhang W. Shu X. Wang E. Guo D. et al.Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair: Incidence, Time Trends and Risk Factors.Semin Thorac Cardiovasc Surg. 2021 Autumn; 33: 639-653Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,11An Z. Song Z. Tang H. Han L. Xu Z. Retrograde Type A Dissection after Thoracic Endovascular Aortic Repair: Surgical Strategy and Literature Review.Heart Lung Circ. 2018 May; 27: 629-634Abstract Full Text Full Text PDF Scopus (0) Google Scholar]. The metal tip of the PBS can damage the aortic intima, thereby, promoting dissection development.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar,11An Z. Song Z. Tang H. Han L. Xu Z. Retrograde Type A Dissection after Thoracic Endovascular Aortic Repair: Surgical Strategy and Literature Review.Heart Lung Circ. 2018 May; 27: 629-634Abstract Full Text Full Text PDF Scopus (0) Google Scholar] Another identified risk factor is the oversizing of stents by more than 20%.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar,12Beck A.W. Wang G. Lombardi J.V. White R. Fillinger M.F. Kern J.A. et al.Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection post-approval project.J Vasc Surg. 2022 May; 75: 1539-1551Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] This practice increases the radial force on the aortic wall, making it more susceptible to dissection. Applying balloon dilation after stent implantation, while reinforcing stent attachment, can also elevate tension on the aortic wall, particularly in cases of acute aortic dissection, posing a risk for RTAD.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar] Iatrogenic aortic dissection induced by catheters during surgical procedures is also recognized as a risk factor. Injuries to the aortic wall, especially when guidewires and catheters are improperly handled, may lead to the formation of a tear, contributing to RTAD.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar,11An Z. Song Z. Tang H. Han L. Xu Z. Retrograde Type A Dissection after Thoracic Endovascular Aortic Repair: Surgical Strategy and Literature Review.Heart Lung Circ. 2018 May; 27: 629-634Abstract Full Text Full Text PDF Scopus (0) Google Scholar,12Beck A.W. Wang G. Lombardi J.V. White R. Fillinger M.F. Kern J.A. et al.Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection post-approval project.J Vasc Surg. 2022 May; 75: 1539-1551Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] The presence of endoleak, a common TEVAR complication, can elevate the risk of RTAD by maintaining blood flow in the false lumen.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar,10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar,12Beck A.W. Wang G. Lombardi J.V. White R. Fillinger M.F. Kern J.A. et al.Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection post-approval project.J Vasc Surg. 2022 May; 75: 1539-1551Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,]] Uncontrolled hypertension post-TEVAR is also associated with an increased risk of RTAD, as it generates longitudinal and transverse shear stress on the aorta, contributing to dissection expansion.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar] Understanding and addressing these diverse risk factors are imperative in developing comprehensive strategies aimed at preventing RTAD after TEVAR and, thereby, enhancing the safety and success of the procedure.[10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar] Keeping the above-mentioned risk factors in mind, preventing RTAD after TEVAR necessitates a multifaceted strategy, encompassing both patient selection and procedural techniques. A judicious approach to patient evaluation and selection is crucial, involving a thorough assessment for underlying conditions, such as HTAD, bicuspid aortic valve malformation, or aortic diameter exceeding 40 mm.[4Williams J.B. Andersen N.D. Bhattacharya S.D. Scheer E. Piccini J.P. McCann R.L. Hughes G.C. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair.J Vasc Surg. 2012 May; 55: 1255-1262Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar,5Wang L. Zhao Y. Zhang W. Shu X. Wang E. Guo D. et al.Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair: Incidence, Time Trends and Risk Factors.Semin Thorac Cardiovasc Surg. 2021 Autumn; 33: 639-653Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,12Beck A.W. Wang G. Lombardi J.V. White R. Fillinger M.F. Kern J.A. et al.Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection post-approval project.J Vasc Surg. 2022 May; 75: 1539-1551Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar] In cTBAD, TEVAR might be necessary as a lifesaving event in this high-risk population, and might not be avoidable. Therefore, awareness to this possible complication is essential, and utilizing imaging, such as intravascular ultrasound (IVUS) or echocardiography (ECHO), at the end of the procedure in such populations is helpful for an early diagnosis and management of RTAD. In terms of procedural techniques, selecting an appropriate stent is pivotal, with factors such as diameter and length carefully considered. Oversizing the stent by more than 10-20% should be avoided to prevent an increase in radial force on the aortic wall, which could lead to dissection. The choice of stent design is also critical, with covered stents being preferred over PBS, which has been linked to RTAD.[3Chen Y. Zhang S. Liu L. Lu Q. Zhang T. Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.J Am Heart Assoc. 2017 Sep 22; 6e004649Crossref Scopus (156) Google Scholar,5Wang L. Zhao Y. Zhang W. Shu X. Wang E. Guo D. et al.Retrograde Type A Aortic Dissection after Thoracic Endovascular Aortic Repair: Incidence, Time Trends and Risk Factors.Semin Thorac Cardiovasc Surg. 2021 Autumn; 33: 639-653Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar] Balloon dilation after stent implantation should be approached cautiously, and avoided when possible, particularly in cases of acute aortic dissection.[14Cheng Z. Shi J. Pe C. Guo Y. Typical Retrograde Type A Dissection After Previous Type B Dissection.Heart Surg Forum. 2021 Jun 26; 24: E589-E592Crossref Google Scholar] Minimizing aortic wall injury during the procedure is imperative in avoiding iatrogenic aortic dissection induced by catheters, which emphasizes the need for proper handling of guidewires and catheters. Postoperative care and monitoring play a significant role in preventing RTAD. Management of preexisting hypertension is paramount, as it is important to ensure adequate hypertension control after TEVAR. This might require an admission to an intensive care unit and continuing an anti-impulse therapy while transitioning the patient to an adequate oral regimen. Implementing a structured follow-up plan for patients post TEVAR is essential, given that RTAD can occur at various intervals after the procedure. Educating patients about potential symptoms, such as new-onset chest pain, and encouraging prompt reporting of symptoms are key components of postoperative care. Regular imaging surveillance, including computed tomography angiography, during follow-up is crucial for detecting signs of RTAD or related complications.[10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar,15Charlton-Ouw K.M. Sandhu H.K. Leake S.S. Miller CC 3rd Afifi R.O. Azizzadeh A. et al.New type A dissection after acute type B aortic dissection.J Vasc Surg. 2018 Jan; 67: 85-92Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,16Khoynezhad A. White R.A. Pathogenesis and management of retrograde type A aortic dissection after thoracic endovascular aortic repair.Ann Vasc Surg. 2013 Nov; 27: 1201-1206Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar] RTAD treatment following TEVAR involves surgical interventions aimed at managing the complications associated with this condition. Various surgical strategies have been employed, and outcomes reported in the literature highlight the effectiveness of these approaches. Postoperative mortality ranges from 4.2-11.1%.[17Estrera A.L. Shah P. Lee T.Y. Irani A.D. Safi H.J. Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique.Vascular. 2009 Mar-Apr; 17: 116-120Crossref Scopus (9) Google Scholar, 18Eggebrecht H. Thompson M. Rousseau H. Czerny M. Lonn L. Mehta R.H. et al.Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.Circulation. 2009 Sep 15; 120: S276-S281Crossref PubMed Scopus (315) Google Scholar, 19Parsa C.J. Williams J.B. Bhattacharya S.D. Wolfe W.G. Daneshmand M.A. McCann R.L. et al.Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm.J Thorac Cardiovasc Surg. 2011; 141: 322-327Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 20Dong Z. Fu W. Wang Y. Wang C. Yan Z. Guo D. et al.Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection.J Vasc Surg. 2010; 52: 1450-1457Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 21Dun Y. Shi Y. Guo H. Liu Y. Zhang B. Sun X. Qian X. Yu C. The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.Interact Cardiovasc Thorac Surg. 2020 May 1; 30: 732-738Crossref Scopus (9) Google Scholar], and sometimes higher, surpassing those of spontaneously occurring acute type A aortic dissection. Subgroup analyses indicate that patients experiencing RTAD during TEVAR—particularly those with a proximal stent graft-induced new entry (SINE)—exhibit poorer outcomes compared to those with RTAD detected during follow up.[10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar,15Charlton-Ouw K.M. Sandhu H.K. Leake S.S. Miller CC 3rd Afifi R.O. Azizzadeh A. et al.New type A dissection after acute type B aortic dissection.J Vasc Surg. 2018 Jan; 67: 85-92Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,18Eggebrecht H. Thompson M. Rousseau H. Czerny M. Lonn L. Mehta R.H. et al.Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.Circulation. 2009 Sep 15; 120: S276-S281Crossref PubMed Scopus (315) Google Scholar]. Consequently, opting for subsequent open conversion is deemed the preferred treatment to mitigate these life-threatening complications. A Duke group report revealed that 66% of RTADs occurred intraoperatively, with 75% initially identified through transesophageal ECHO or IVUS, underscoring the critical importance of swift diagnosis and the potential role of intraoperative diagnostic tools in early RTAD detection.[4Williams J.B. Andersen N.D. Bhattacharya S.D. Scheer E. Piccini J.P. McCann R.L. Hughes G.C. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair.J Vasc Surg. 2012 May; 55: 1255-1262Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar,19Parsa C.J. Williams J.B. Bhattacharya S.D. Wolfe W.G. Daneshmand M.A. McCann R.L. et al.Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm.J Thorac Cardiovasc Surg. 2011; 141: 322-327Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar]. RTADs associated with wire/sheath manipulation typically manifest in the distal ascending aortic arch or proximal aortic arch in approximately half of patients. Moreover, proximal SINE, occurring more frequently along the greater curve, encompasses the entire ascending aorta in the majority (83%) of cases.[18Eggebrecht H. Thompson M. Rousseau H. Czerny M. Lonn L. Mehta R.H. et al.Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.Circulation. 2009 Sep 15; 120: S276-S281Crossref PubMed Scopus (315) Google Scholar, 19Parsa C.J. Williams J.B. Bhattacharya S.D. Wolfe W.G. Daneshmand M.A. McCann R.L. et al.Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm.J Thorac Cardiovasc Surg. 2011; 141: 322-327Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 20Dong Z. Fu W. Wang Y. Wang C. Yan Z. Guo D. et al.Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection.J Vasc Surg. 2010; 52: 1450-1457Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar] Consequently, the presumed cause and location of RTAD may significantly impact the chosen treatment strategy. The preferred surgical repair involves substituting the entire aortic arch with direct vascular graft suturing to the endograft.[4Williams J.B. Andersen N.D. Bhattacharya S.D. Scheer E. Piccini J.P. McCann R.L. Hughes G.C. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair.J Vasc Surg. 2012 May; 55: 1255-1262Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar,10Zhang S. Chen Y. Lu Q. Retrograde type A aortic dissection complicating endovascular therapy of type B aortic dissection and descending thoracic aneurysm disease.Curr Opin Cardiol. 2018 Nov; 33: 581-586Crossref Scopus (4) Google Scholar,13Lopez-Marco A. Adams B. Oo A.Y. Retrograde type A aortic dissection: a different evil.Interact Cardiovasc Thorac Surg. 2022 Nov 8; 35ivac264Crossref Scopus (2) Google Scholar,15Charlton-Ouw K.M. Sandhu H.K. Leake S.S. Miller CC 3rd Afifi R.O. Azizzadeh A. et al.New type A dissection after acute type B aortic dissection.J Vasc Surg. 2018 Jan; 67: 85-92Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,16Khoynezhad A. White R.A. Pathogenesis and management of retrograde type A aortic dissection after thoracic endovascular aortic repair.Ann Vasc Surg. 2013 Nov; 27: 1201-1206Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,18Eggebrecht H. Thompson M. Rousseau H. Czerny M. Lonn L. Mehta R.H. et al.Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.Circulation. 2009 Sep 15; 120: S276-S281Crossref PubMed Scopus (315) Google Scholar,19Parsa C.J. Williams J.B. Bhattacharya S.D. Wolfe W.G. Daneshmand M.A. McCann R.L. et al.Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm.J Thorac Cardiovasc Surg. 2011; 141: 322-327Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar] Rarely employed, an alternative strategy involves complete removal of the endograft and Dacron graft replacement utilizing the modified "elephant trunk" technique.[17Estrera A.L. Shah P. Lee T.Y. Irani A.D. Safi H.J. Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique.Vascular. 2009 Mar-Apr; 17: 116-120Crossref Scopus (9) Google Scholar] Conservative treatment finds application in selected cases, particularly for those with wire-induced wall injury or the presence of focal, asymptomatic lesions.[17Estrera A.L. Shah P. Lee T.Y. Irani A.D. Safi H.J. Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique.Vascular. 2009 Mar-Apr; 17: 116-120Crossref Scopus (9) Google Scholar, 18Eggebrecht H. Thompson M. Rousseau H. Czerny M. Lonn L. Mehta R.H. et al.Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.Circulation. 2009 Sep 15; 120: S276-S281Crossref PubMed Scopus (315) Google Scholar, 19Parsa C.J. Williams J.B. Bhattacharya S.D. Wolfe W.G. Daneshmand M.A. McCann R.L. et al.Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm.J Thorac Cardiovasc Surg. 2011; 141: 322-327Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 20Dong Z. Fu W. Wang Y. Wang C. Yan Z. Guo D. et al.Stent graft-induced new entry after endovascular repair for Stanford type B aortic dissection.J Vasc Surg. 2010; 52: 1450-1457Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 21Dun Y. Shi Y. Guo H. Liu Y. Zhang B. Sun X. Qian X. Yu C. The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.Interact Cardiovasc Thorac Surg. 2020 May 1; 30: 732-738Crossref Scopus (9) Google Scholar] The late outcome of survivors after an operation for RTAD was optimal.[21Dun Y. Shi Y. Guo H. Liu Y. Zhang B. Sun X. Qian X. Yu C. The surgical management of retrograde type A aortic dissection after thoracic endovascular aortic repair.Interact Cardiovasc Thorac Surg. 2020 May 1; 30: 732-738Crossref Scopus (9) Google Scholar] Idrees and colleagues reported 16.7% (4/24) aortic reoperations at a median follow-up period of 26 months,[22Idrees J. Arafat A. Johnston D.R. Svensson L.G. Roselli E.E. Repair of retrograde ascending dissection after descending stent grafting.J Thorac Cardiovasc Surg. 2014 Jan; 147: 151-154Abstract Full Text Full Text PDF PubMed Google Scholar] whereas Li and colleagues reported no deaths and only one reoperation for replacement of the thoracoabdominal aorta at a mean follow-up of 32.2 months.[23Li B. Pan X.D. Ma W.G. Zheng J. Liu Y.L. Zhu J.M. et al.Stented elephant trunk technique for retrograde type A aortic dissection after endovascular stent graft repair.Ann Thorac Surg. 2014 Feb; 97: 596-602Abstract Full Text Full Text PDF PubMed Google Scholar] The overall prognosis of this group was also very good, with no late deaths and only one aortic reoperation during the follow-up period.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) In summary, a multidisciplinary collaboration among vascular surgeons and other specialists, such as cardiac surgeons, cardiologists, and anesthesiologists, is vital. This collaborative approach facilitates a comprehensive evaluation of patients, enabling discussions on the best strategies for prevention and management, based on individual patient characteristics. Preventing and treating RTAD after TEVAR involves meticulous patient selection, optimal procedural techniques, vigilant postoperative care, and a multidisciplinary approach, with a continuous refinement of practices based on evolving research findings for enhanced safety and improved outcomes in TEVAR.