Accepted Manuscript Mechanism and management of retrograde type A aortic dissection complicating TEVAR for type B aortic dissection Guoquan Wang, Shuiting Zhai, Tianxiao Li, Shuaitao Shi, Zhidong Zhang, Kai Liang, Xiaoyang Fu, Kewei Zhang, Kun Li, Weixiao Li, Bo Wang, Dongbin Zhang, Danghui Lu PII:
S0890-5096(16)30010-3
DOI:
10.1016/j.avsg.2015.09.028
Reference:
AVSG 2669
To appear in:
Annals of Vascular Surgery
Received Date: 7 May 2015 Revised Date:
24 September 2015
Accepted Date: 30 September 2015
Please cite this article as: Wang G, Zhai S, Li T, Shi S, Zhang Z, Liang K, Fu X, Zhang K, Li K, Li W, Wang B, Zhang D, Lu D, Mechanism and management of retrograde type A aortic dissection complicating TEVAR for type B aortic dissection, Annals of Vascular Surgery (2016), doi: 10.1016/ j.avsg.2015.09.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Mechanism and management of retrograde type A aortic dissection complicating
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TEVAR for type B aortic dissection
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Guoquan Wang, Shuiting Zhai*, Tianxiao Li, Shuaitao Shi, Zhidong Zhang, Kai
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Liang, Xiaoyang Fu, Kewei Zhang, Kun Li, Weixiao Li, Bo Wang, Dongbin Zhang,
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Danghui Lu
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Department of Vascular and Endovascular Surgery, Henan Provincial Peoples’
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Hospital, Zhengzhou University, Zhengzhou 450003, P. R. China
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*
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Department of Vascular and Endovascular Surgery, Henan Provincial Peoples’
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Hospital, Zhengzhou University,
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No 7, Weiwu Road, Zhengzhou 450003, P. R. China
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Tel: +86-13838166610
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E-mail: [email protected]
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Running title: Stanford type A and B aortic dissections
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Keywords: Stanford type B aortic dissection; Stanford type A aortic dissection;
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TEVAR; complication
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Corresponding author: Shuiting Zhai,
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ACCEPTED MANUSCRIPT Abstract
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Objective: This study is to investigate the causes, treatment methods and preventive
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measures of retrograde type A aortic dissection (RAAD) complicating thoracic
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endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).
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Methods: From January 2005 to December 2013, 360 TBAD patients receiving
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TEVAR were enrolled in this study. Among them, 304 cases were male and 56 cases
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were female. They were from 19 to 85 years old, with a mean age of 52 ± 12.8 years
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old. The average follow-up time was 32 ± 11.3 months (3-63 months), the follow-up
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rate was 69.1% (249 cases) and the lost rate was 30.9% (111 cases). The reasons and
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the treatment methods of RAAD complicating TEVAR for TBAD were analyzed.
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Results: There were 5 cases of RAAD complicating TEVAR in TBAD (1.4%)
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patients, among them, 4 cases were male and 1 case was female. TEVAR operation
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failed in 1 case due to RAAD occurrence during TEVAR. This case was treated with
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open operation. In the other 4 cases, TEVAR operation was successfully carried out.
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During follow up, RAAD was found in 3 cases within 1 month after TEVAR and in 1
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case at 1 year after TEVAR. Conservative treatment was applied to 2 cases whereas
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surgical operation treatment was performed in the other 3 cases. One case of
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conservative treatment patient was dead and the other 4 cases are still alive.
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Conclusions: Incomplete design of stent graft system, rough handling and presence of
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vascular wall lesions are the main reasons of RAAD complicating TEVAR for TBAD.
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Surgical operation is the most effective treatment measure for RAAD complicating
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TEVAR for TBAD.
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ACCEPTED MANUSCRIPT Introduction
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Acute aortic dissection (AAD), a potentially catastrophic event, is characterized by an intimal dissection of the aortic wall. In AAD, the blood flows into the medial
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layer. Dissection can extend to both the proximal and distal of the dissection and this
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may involve arteries branching from the aorta, resulting in coronary, cerebral, spinal,
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and visceral ischemia, or culminate in aortic rupture (1, 2). AADs are classified into
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Stanford type A dissection (TAAD) (those involve the ascending aorta) and Stanford
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type B dissection (TBAD) (those not involve the ascending aorta). TAAD can result
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in coronary ischemia, cardiac, acute aortic regurgitation and stroke but without
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surgical intervention. This kind of dissections has high mortality rates: 20% by 24 h
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and 40% by day in the general population (3). In contrast, TBAD have a 30 day
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mortality rate of 10% and are effectively managed without tissue ischemia or risk of
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aortic rupture (4).
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Thoracic endovascular aortic repair (TEVAR) for the treatment of thoracic aortic diseases such as TBAD, aneurysm of thoracic aorta, and penetrating aortic ulcer
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has become mature (5). According to previous reports, although the long-term
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efficacy of TEVAR operation is not very clear, intermediate-term follow-up results
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show that compared with traditional open surgery, the mortality rate and paraplegia
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rate of TEVAR are significantly reduced (6-8). Retrograde type A aortic dissection
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(RAAD) is a very rare but deadly serious complication occurs after TEVAR (9-11).
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This study is focused on RAAD complicating TEVAR for TBAD and aims to analyze
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the causes, treatment methods and preventive measures.
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ACCEPTED MANUSCRIPT Materials and methods
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Patients’ data A total of 360 patients with TBAD receiving TEVAR treatment in our center
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from January 2005 to December 2013 were enrolled in this study. Among them, 304
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cases were male and 56 cases were female. They were from 19 to 85 years old, with a
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mean age of 52 ± 12.8 years old. The average follow-up time was 32 ± 11.3 months
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(3-63 months), the follow-up rate was 69.1% (249 cases) and the lost rate was 30.9%
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(111 cases). They were with different clinical presentations such as severe chest and
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back pain, refractory hypertension, visceral artery or extremity arterial ischemia,
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hoarseness, threatened rupture etc. Prior written and informed consent were obtained
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from every patient and the study was approved by the ethics review board of
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Zhengzhou University.
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Preoperative preparation
All patients underwent 16 row or 64 row CTA total aortic axial scanning and
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3D reconstruction, including arch vascular branches especially bilateral vertebral
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artery (CTA for short). The location of the proximal and distal dissection was
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evaluated. The diameters of ascending aorta, aortic arch and descending aorta were
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accurately measured so as to understand the blood supply of important organs and
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bilateral femoral artery conditions. A variety of different brands of aortic stents
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including Talent (Medtronic inc, Minneapolis, Minnesota ,US), Captivia (Medtronic
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inc, Minneapolis, Minnesota , US), Zenith TX2 (Cook inc, Indiana, Bloomington,
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US ), TAG (Gore inc, Newark, Delaware, US ) and Shanghai minimally invasive
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(Microport inc, Shanghai, China) were selected.
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TEVAR surgery
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After general anesthesia and left radial artery or brachial artery puncture,
placement of 5F radial artery sheath was carried out and gold labeled pigtail catheter
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was sent to the ascending aorta, connecting with a high pressure syringe and ventilator.
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Angiography was carried 2 times to show blood supply of important organs of aortic
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arch and abdominal aorta respectively. Separation of the right or left femoral artery
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(sometimes femoral artery was too fine, then the incision was extended upward and
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the external iliac artery was isolated) was followed by placement of 6F femoral artery
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sheath tube, then a 5F head hunter catheter was inserted by a guide wire (pigtail
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catheter was chosen in some cases where only true lumen developer existed).
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Retrograde urography was performed for aortic true lumen until the catheter was sent
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to the ascending aorta and a COOK Lunderquist (Cook inc, Indiana, Bloomington, US)
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wire was substituted. Then a bracket was guided by the wire to the aortic arch and
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was released after accurate positioned. Once the bracket was completely released, the
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conveying system was carefully recycled into the sheath and retreated to the bracket.
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Then a high pressure syringe was connected and thoracic aorta and abdominal
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aortography was carried out to compare the conditions with those of before stent
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implantation. The conditions of the first rupture and false lumen confinement, bracket
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morphology, brachiocephalic vessels developing, reverse developing of existence of
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ACCEPTED MANUSCRIPT other breach or false lumen, existence of type I endoleak and blood supply
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improvement of important abdominal organs were focused. The delivery sheath was
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pulled out and the wound was sewed up if the first rupture and false lumen closed
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well and the abdominal important organs blood supply was improved. After the
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surgery, the vital signs like blood pressure, heart rate, heart rhythm, oxygen saturation,
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respiratory care were monitored and water, electrolyte balance, nutrition support,
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antibiotic, gastric mucosal protective drugs were applied.
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Postoperative follow-up
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All patients had taken 16 or 64 rows whole aorta CTA review at 1 week, 3 month, 6 month and 1 year after discharge. Then a routine CTA review was carried
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out each year and at any time if the patients were with special symptoms. The purpose
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of follow-up was mainly to understand blood pressure control and whether the
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patients had clinical symptoms etc. If the patient had clinical symptoms such as chest
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pain, they should be hospitalized for further observation. Compared with former CTA
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results, if there were new changes like false lumen, DSA was needed so as to
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determine whether re-intervention was required.
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Statistical analysis
All the statistical analyses were performed using SPSS version 13.0 (SPSS Inc, -
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Chicago, IL, USA) for Windows and the data were expressed as x ± s. Independent
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samples t test was used between the two groups and P value less than 0.05 was 6
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considered as statistically significant.
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ACCEPTED MANUSCRIPT Results
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Among the 360 TBAD patients, 210 cases were with complicated TBAD and 150 cases were with uncomplicated TBAD. The average time from presentation to
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TEVAR was 4 days. And, 33 cases out of 360 cases received hybrid operation. Among
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these 33 cases, 14 cases received debranching procedures. There were 5 cases of
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RAAD complicating TEVAR for TBAD in total (1.4%). For these 5 cases, TEVAR
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was performed at the acute phase of dissection. TEVAR was failed in 1 case due to
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RAAD occurrence during TEVAR and thus open operation was performed in this case.
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Successful TEVAR operation was carried out in the other 4 cases. Among these 4
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cases, 3 cases had RAAD within 1 month after TEVAR and 1 case had RAAD at 1
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year after TEVAR. The detailed basic information of the 5 patients was listed in Table
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1 and Table 2.
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Case 1 of the five patients was a 55 year old male and preoperative CTA (Fig.1 A and B) confirmed that he was with typical TBAD. On the 13th day after the TEVAR,
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disturbance of consciousness and blood pressure decrease suddenly appeared. The
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general condition was gradually stabilized by active rescue and immediate emergency
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CTA (Fig. 1E and F) examination was performed. Compared with 10 day CTA review
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(Fig. 1C and D), it was found that ascending aortic wall thickening was obvious with
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intramural hematoma, indicating the occurrence of RAAD. This patient refused to
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take open surgical operation and was followed up continuously for 58 months. CTA
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review scanning (Fig. 2) showed progresses in ascending aortic dissection and this
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patient eventually died of heart failure.
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ACCEPTED MANUSCRIPT In case 2, 1 month after TEVAR, severe chest and back pain and other
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symptoms accompanied by a sharp increase in blood pressure appeared. Emergency
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CTA confirmed that RAAD occurred and emergency "ascending aorta + aortic arch
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replacement" was carried the day he was hospitalized. Intraoperative findings showed
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that the dissection located near the first section of bare stent, retrogradely tearing the
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ascending aorta. The coronary artery and aortic valve were not affected, indicating
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that the new dissection might be vascular wall damage caused by the bare stent. CTA
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review was taken 2 weeks after the second operation and the result showed that the
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ascending aortic false lumen completely disappeared, the true lumen was intact and
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the surgical repair result was satisfactory. This case is now still in follow-up. Because of insufficient anchoring zone, case 3 received the surgery of
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"ascending aorta - left innominate artery / common carotid artery + TEVAR ". Chest
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discomfort occurred 10 days after surgery and CTA scan confirmed that RAAD
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occurred. The dissection was near the ascending aorta artificial vascular anastomosis
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and it might be new dissection caused by hemostat on the basis of weak vessel wall.
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This patient was followed up for more than 1 year and no new symptoms occurred.
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In case 4, symptoms similar to the symptoms of the initial onset occurred at 1
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year after discharge and CTA review confirmed that RAAD occurred. This patient
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took "ascending aorta + aortic arch + distal hard trunk operation", with good
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postoperative recovery. Now, he has been followed up for almost 1 year.
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RAAD of case 5 occurred in the operation process of TEVAR. Because of insufficient anchoring zone, the predetermined operation scheme for this patient was 9
ACCEPTED MANUSCRIPT "ascending aorta - innominate artery / left common carotid artery + TEVAR". After
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the side wall of the ascending aorta was clamped, sudden thickening of ascending
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aorta appeared. High-speed blood flow entering the aortic wall was observed. It was
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visible that the ascending aorta dissection was located in the side wall forceps.
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Meanwhile, this patient had two leaf type aortic valve malformation. Thus, the
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operation mode was changed into open operation (Ascending aorta replacement +
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total arch replacement + distal hard trunk stenting) and emergency extracorporeal
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circulation was established. The postoperative recovery of this patient was good, and
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he ultimately survived.
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ACCEPTED MANUSCRIPT Discussion
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RAAD is a serious complication associated with TEVAR. Previous studies show that the incidences are 14.3%, 2.4%, 2.3% and 1.9%, respectively (1-4). In this
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study, the morbidity was 1.4%, which, was consistent with other reports except that
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by Beate Neuhauser et al. (6). The rate of RAAD complicating TEVAR for TBAD is
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relatively uncommon, however, it has risks which can not be ignored. Due to the
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relatively high mortality, attention should be paid to this situation as far as possible.
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As shown in Table 3, we consider that there are three reasons for the
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occurrence of this complication. Firstly, vascular disease is one of the most important
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causes of this complication. Judson B. Williams et al. (9) found that Marfan syndrome
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and aortic diameter more than 40 mm were two main reasons for the occurrence of
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RAAD complicating TEVAR for TBAD. Comparative analysis found that, patients
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with dissection are prone to this complication than patients with aneurysm. At the
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same time, the position of the support anchor may also be related with this
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complication. They argue that this complication is more prone to occur when the
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supports are anchored in the 0 - 2 area. In this study, 4 cases (80%) of patients were
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with ascending aortic diameter more than 40 mm, which were much higher than the
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patients without complications. At the same time, stents were anchored in the 0 - 2
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area in 4 cases who were with successful TEVAR operation. These results suggest that
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broadening of ascending aorta makes the aortic wall weak and the stent anchored near
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or in the ascending aorta increases the risk for this complication.
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Secondly, stent graft might be another important cause of this complication. 11
ACCEPTED MANUSCRIPT Dong et al. (8) considered that the elastic back stress after passive bending could
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damage the vascular wall and that the head and tail bracket bonding site was easy to
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induce new break, thus leading to the complication. Beate Neuhauser and Judson B.
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Williams et al. (6, 9) pointed out that bare frame design of the first section and head
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barbed design of the support were related to the complication. However, Jacques
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Kpodonu et al. (7) considered that full covered support without barb could induce the
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same complication. In this study, in the 4 cases of patients with successful TEVAR,
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head bare frame design of stents was used. Whether stent graft plays a role in the
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occurrence of this kind of complication is still unknown, pending further study.
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Finally, operation induced vessel wall injury is also an important reason for this complication (5). In the delivery process of guide wire, catheter and stent, the
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vascular wall may be damaged and RAAD may appear in the high speed flow impact.
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Balloon dilation after stent implantation is another iatrogenic risk factor. According to
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Jacques Kpodonu et al. (7), among the 7 cases of RAAD complicating TEVAR for
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TBAD, 5 cases underwent balloon dilation. According to our experience, balloon
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dilation is not routinely performed after TEVAR. When the stents are bended or have
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serious "fish mouth" phenomenon, balloon dilation is performed. When performing
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balloon dilation, the balloon should be expanded as soon as possible. Once the
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balloon is expanded, the balloon should be released as soon as possible. And, the
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balloon should be expanded inside the stent and can not exceed the stent. Moreover,
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under the action of the forceps, the vessel wall is easily to be damaged, thus inducing
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RAAD. In this study, in case 5, when the vascular side wall was clamped, ascending
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aorta thickening suddenly appeared and the blood flow was in a vortex state in the
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adventitia. The aortic wall was more than 40 mm, further indicating that weakness of
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aortic wall is one of the reasons that cause the complication. In this study, there were 210 patients with complicated TBAD, accounting for
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58.3% of all patients. The average time from presentation to TEVAR was 4 days.
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Totally, 5 patients (1.4%) had TEVAR complicating RAAD. Currently, whether the
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timing of TEVAR is related with the occurrence of RAAD is still unclear. And, the
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timing of TEVAR for TBAD is still controversial. It is generally considered that, for
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complicated TBAD, TEVAR should be performed as early as possible. However, for
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uncomplicated TBAD, different centers hold different views (12). According to our
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experiences, the condition of dissection is always changing. Uncomplicated TBAD
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may at some point convert into complicated TBAD. The key problem is that we do
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not know the exact time of the transition. Therefore, we consider that aortic dissection
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can never be taken lightly and TEVAR should be prepared as soon as possible.
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In addition, in order to reduce the occurrence of RAAD complicating TEVAR
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for TBAD, we believe that the following points must be given special attention. First,
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TEVAR operation indication should be taken strictly. To the patients with Marfan
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syndrome, it is better to choose surgical operation and it is particularly important to
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select suitable support in view of different lesions. At the same time, excessive
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oversize of stent graft should be avoided so as to reduce the radial force of the stent to
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the vascular wall. Second, the standardized operation is rather important. Gentle and
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careful operation is necessary so as to minimize repeated stimulation and damage
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ACCEPTED MANUSCRIPT caused by catheter and guide wire to vascular wall. Meanwhile, reduce or avoid
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unnecessary balloon dilation could also reduce the incidence of complication. Third,
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postoperative blood pressure management and life support are equally important.
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Active control of blood pressure and stool softening can also play a certain role
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(13-16).
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TEVAR operation patients should be followed up in case of the occurrence of RAAD. Beate Neuhauser et al. reported that 4 cases of RAAD during the follow-up
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were found. They all had taken surgical operation treatment and 3 people survived.
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Judson B. Williams et al. had found 6 cases with RAAD in their study. Five cases
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underwent emergency operation and achieved good effectiveness. However, the other
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case took conservative treatment and eventually died. In our study, 1 case had RAAD
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during TEVAR, 3 cases had RAAD within 1 month after TEVAR and 1 case had
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RAAD at 1 year after TEVAR. Thus, continuous follow up is necessary. For treatment,
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3 cases underwent surgical operation and 2 cases took conservative treatment. Finally,
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1 case of conservative treatment patient died and the other 4 cases are followed up.
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Therefore, surgical operation is almost the only effective treatment method for RAAD
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and the short and long-term efficacy of conservative treatment is poor (6-8).
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In conclusion, RAAD complicating TEVAR for TBAD is a rare but fatal
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complication. The causes include vascular disease, stent graft and surgical operation.
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Among them, the stent graft forces on the vessel wall and the vessel wall injury
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caused by operation should be noted. Appropriate support for different patients
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together with standardized operation may effectively reduce the complication 14
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incidence.
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ACCEPTED MANUSCRIPT Acknowledgement
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None.
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Disclosures
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All authors declare no financial competing interests.
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All authors declare no non-financial competing interests.
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ACCEPTED MANUSCRIPT References
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ACCEPTED MANUSCRIPT Table 1. General clinical data of 5 patients.
Age CAD CVD Diabetes (type Ⅰ andⅡ) Hypertension Hypercholesterolemia Renal failure Current smoking COPD
Case 1 55 yes no no yes yes no yes no
Case 2 35 no no no yes yes no yes no
Case 3 72 yes yes type yes yes no yes yes
Case 4 53 no no no yes no no no no
Case 5 44 no no no yes no no yes no
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Note: CAD, coronary artery disease; CVD, cerebrovascular disease; COPD, chronic
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obstructive pulmonary disease.
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ACCEPTED MANUSCRIPT Table 2. General condition of the five cases of retrograde type A aortic dissection. RAAD occurring time
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M ale M ale M ale Fe ma le M ale
2 3 4
5 2
Anchor position
Bracket type
13 day
Ascending aorta diameter (mm) 43
Z1
30 day
36
Z2
10 day
41
Z0
1 year
43
Intraopera tive
45
Treatment method
Follow-up (month)
Result
Medtronic Conservat ive Medtronic Operation
58
Died
30
Alive
15
Alive
Z1
Medtronic Conservat ive Medtronic Operation
24
Alive
-
-
8
Alive
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Operation
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Table 3. Reasons of RAAD complicating TEVAR for TBAD. Stent graft (device-related)
Bare frame design of the first section and head barbed design of the support Excessive oversize, resulting in too large radial force Elastic back stress after passive bending can damage the vascular wall and the head and tail bracket bonding site Marfan syndrome Ascending aortic diameter greater than 40 mm Landing zone locates in 0-2 region AD is prone to occur than AAA Guide wire, catheter, delivery sheath and stent graft Balloon dilatation Side wall clamp function
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Note: RAAD, retrograde type A aortic dissection. TBAD, type B aortic dissection. AD,
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Aortic Dissection; AAA: Abdominal aortic aneurysm.
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ACCEPTED MANUSCRIPT Figure legends
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Fig. 1 Representative images of Case 1. (A) and (B) Existence of TBAD shown by
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TEVAR preoperative 64 rows CTA. Preoperative reconstruction of three-dimensional
4
showed the first rupture located in the arch and descending aorta and was about 2 cm
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from the left subclavian artery opening (A). Axial image showed the rupture diameter
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was about 1.5 cm, the ascending aorta and arch were intact (arrow) and thoracic aorta
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and abdominal aortic were both affected (B). (C) and (D) Review the 64 rows CTA 10
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day after TEVAR showed that the first rupture of aortic dissection closed completely.
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Proximal end of the false lumen thrombus existed (C), the true lumen was in good
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shape and no internal leakage formation existed and the ascending aorta was normal
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(arrow) (D). (E) and (F) Review the 64 rows CTA 13 day after TEVAR. Sagittal plane
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(E) and horizontal plane (F) showed ascending aorta and arch vascular wall
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thickening (arrow) with the formation of RAAD.
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Fig. 2 Representative images of Case 1. (A) and (B) Review the 64 rows CTA 36
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month after TEVAR showed process of RAAD compared with former review.
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Preoperative reconstruction of three-dimension (A) and horizontal plane (B) showed
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that the ascending aorta was with multiple lacerations (arrow) and true and false
18
lumen were displayed clearly. (C) and (D) Review the 64 rows CTA 46 month after
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TEVAR showed process of RAAD compared with former review. Preoperative
20
reconstruction of three-dimension (C) and horizontal plane (D) showed that the
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ascending aorta was with multiple lacerations (arrow) and true and false lumen were
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displayed clearly. (E) and (F) Review the 64 rows CTA 64 month after TEVAR
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showed process of RAAD compared with former review. Preoperative reconstruction
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of three-dimension (E) and horizontal plane (F) showed that the ascending aorta was
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with multiple lacerations (arrow) and true and false lumen were displayed clearly.
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S0890-5096(16)30010-3
DOI:
10.1016/j.avsg.2015.09.028
Reference:
AVSG 2669
To appear in:
Annals of Vascular Surgery
Received Date: 7 May 2015 Revised Date:
24 September 2015
Accepted Date: 30 September 2015
Please cite this article as: Wang G, Zhai S, Li T, Shi S, Zhang Z, Liang K, Fu X, Zhang K, Li K, Li W, Wang B, Zhang D, Lu D, Mechanism and management of retrograde type A aortic dissection complicating TEVAR for type B aortic dissection, Annals of Vascular Surgery (2016), doi: 10.1016/ j.avsg.2015.09.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Mechanism and management of retrograde type A aortic dissection complicating
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TEVAR for type B aortic dissection
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Guoquan Wang, Shuiting Zhai*, Tianxiao Li, Shuaitao Shi, Zhidong Zhang, Kai
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Liang, Xiaoyang Fu, Kewei Zhang, Kun Li, Weixiao Li, Bo Wang, Dongbin Zhang,
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Danghui Lu
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Department of Vascular and Endovascular Surgery, Henan Provincial Peoples’
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Hospital, Zhengzhou University, Zhengzhou 450003, P. R. China
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*
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Department of Vascular and Endovascular Surgery, Henan Provincial Peoples’
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Hospital, Zhengzhou University,
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No 7, Weiwu Road, Zhengzhou 450003, P. R. China
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Tel: +86-13838166610
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E-mail: [email protected]
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Running title: Stanford type A and B aortic dissections
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Keywords: Stanford type B aortic dissection; Stanford type A aortic dissection;
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TEVAR; complication
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Corresponding author: Shuiting Zhai,
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ACCEPTED MANUSCRIPT Abstract
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Objective: This study is to investigate the causes, treatment methods and preventive
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measures of retrograde type A aortic dissection (RAAD) complicating thoracic
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endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).
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Methods: From January 2005 to December 2013, 360 TBAD patients receiving
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TEVAR were enrolled in this study. Among them, 304 cases were male and 56 cases
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were female. They were from 19 to 85 years old, with a mean age of 52 ± 12.8 years
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old. The average follow-up time was 32 ± 11.3 months (3-63 months), the follow-up
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rate was 69.1% (249 cases) and the lost rate was 30.9% (111 cases). The reasons and
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the treatment methods of RAAD complicating TEVAR for TBAD were analyzed.
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Results: There were 5 cases of RAAD complicating TEVAR in TBAD (1.4%)
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patients, among them, 4 cases were male and 1 case was female. TEVAR operation
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failed in 1 case due to RAAD occurrence during TEVAR. This case was treated with
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open operation. In the other 4 cases, TEVAR operation was successfully carried out.
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During follow up, RAAD was found in 3 cases within 1 month after TEVAR and in 1
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case at 1 year after TEVAR. Conservative treatment was applied to 2 cases whereas
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surgical operation treatment was performed in the other 3 cases. One case of
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conservative treatment patient was dead and the other 4 cases are still alive.
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Conclusions: Incomplete design of stent graft system, rough handling and presence of
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vascular wall lesions are the main reasons of RAAD complicating TEVAR for TBAD.
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Surgical operation is the most effective treatment measure for RAAD complicating
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TEVAR for TBAD.
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ACCEPTED MANUSCRIPT Introduction
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Acute aortic dissection (AAD), a potentially catastrophic event, is characterized by an intimal dissection of the aortic wall. In AAD, the blood flows into the medial
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layer. Dissection can extend to both the proximal and distal of the dissection and this
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may involve arteries branching from the aorta, resulting in coronary, cerebral, spinal,
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and visceral ischemia, or culminate in aortic rupture (1, 2). AADs are classified into
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Stanford type A dissection (TAAD) (those involve the ascending aorta) and Stanford
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type B dissection (TBAD) (those not involve the ascending aorta). TAAD can result
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in coronary ischemia, cardiac, acute aortic regurgitation and stroke but without
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surgical intervention. This kind of dissections has high mortality rates: 20% by 24 h
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and 40% by day in the general population (3). In contrast, TBAD have a 30 day
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mortality rate of 10% and are effectively managed without tissue ischemia or risk of
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aortic rupture (4).
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Thoracic endovascular aortic repair (TEVAR) for the treatment of thoracic aortic diseases such as TBAD, aneurysm of thoracic aorta, and penetrating aortic ulcer
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has become mature (5). According to previous reports, although the long-term
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efficacy of TEVAR operation is not very clear, intermediate-term follow-up results
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show that compared with traditional open surgery, the mortality rate and paraplegia
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rate of TEVAR are significantly reduced (6-8). Retrograde type A aortic dissection
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(RAAD) is a very rare but deadly serious complication occurs after TEVAR (9-11).
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This study is focused on RAAD complicating TEVAR for TBAD and aims to analyze
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the causes, treatment methods and preventive measures.
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ACCEPTED MANUSCRIPT Materials and methods
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Patients’ data A total of 360 patients with TBAD receiving TEVAR treatment in our center
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from January 2005 to December 2013 were enrolled in this study. Among them, 304
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cases were male and 56 cases were female. They were from 19 to 85 years old, with a
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mean age of 52 ± 12.8 years old. The average follow-up time was 32 ± 11.3 months
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(3-63 months), the follow-up rate was 69.1% (249 cases) and the lost rate was 30.9%
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(111 cases). They were with different clinical presentations such as severe chest and
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back pain, refractory hypertension, visceral artery or extremity arterial ischemia,
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hoarseness, threatened rupture etc. Prior written and informed consent were obtained
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from every patient and the study was approved by the ethics review board of
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Zhengzhou University.
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Preoperative preparation
All patients underwent 16 row or 64 row CTA total aortic axial scanning and
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3D reconstruction, including arch vascular branches especially bilateral vertebral
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artery (CTA for short). The location of the proximal and distal dissection was
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evaluated. The diameters of ascending aorta, aortic arch and descending aorta were
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accurately measured so as to understand the blood supply of important organs and
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bilateral femoral artery conditions. A variety of different brands of aortic stents
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including Talent (Medtronic inc, Minneapolis, Minnesota ,US), Captivia (Medtronic
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inc, Minneapolis, Minnesota , US), Zenith TX2 (Cook inc, Indiana, Bloomington,
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US ), TAG (Gore inc, Newark, Delaware, US ) and Shanghai minimally invasive
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(Microport inc, Shanghai, China) were selected.
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TEVAR surgery
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After general anesthesia and left radial artery or brachial artery puncture,
placement of 5F radial artery sheath was carried out and gold labeled pigtail catheter
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was sent to the ascending aorta, connecting with a high pressure syringe and ventilator.
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Angiography was carried 2 times to show blood supply of important organs of aortic
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arch and abdominal aorta respectively. Separation of the right or left femoral artery
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(sometimes femoral artery was too fine, then the incision was extended upward and
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the external iliac artery was isolated) was followed by placement of 6F femoral artery
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sheath tube, then a 5F head hunter catheter was inserted by a guide wire (pigtail
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catheter was chosen in some cases where only true lumen developer existed).
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Retrograde urography was performed for aortic true lumen until the catheter was sent
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to the ascending aorta and a COOK Lunderquist (Cook inc, Indiana, Bloomington, US)
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wire was substituted. Then a bracket was guided by the wire to the aortic arch and
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was released after accurate positioned. Once the bracket was completely released, the
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conveying system was carefully recycled into the sheath and retreated to the bracket.
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Then a high pressure syringe was connected and thoracic aorta and abdominal
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aortography was carried out to compare the conditions with those of before stent
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implantation. The conditions of the first rupture and false lumen confinement, bracket
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morphology, brachiocephalic vessels developing, reverse developing of existence of
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improvement of important abdominal organs were focused. The delivery sheath was
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pulled out and the wound was sewed up if the first rupture and false lumen closed
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well and the abdominal important organs blood supply was improved. After the
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surgery, the vital signs like blood pressure, heart rate, heart rhythm, oxygen saturation,
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respiratory care were monitored and water, electrolyte balance, nutrition support,
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antibiotic, gastric mucosal protective drugs were applied.
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Postoperative follow-up
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All patients had taken 16 or 64 rows whole aorta CTA review at 1 week, 3 month, 6 month and 1 year after discharge. Then a routine CTA review was carried
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out each year and at any time if the patients were with special symptoms. The purpose
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of follow-up was mainly to understand blood pressure control and whether the
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patients had clinical symptoms etc. If the patient had clinical symptoms such as chest
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pain, they should be hospitalized for further observation. Compared with former CTA
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results, if there were new changes like false lumen, DSA was needed so as to
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determine whether re-intervention was required.
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Statistical analysis
All the statistical analyses were performed using SPSS version 13.0 (SPSS Inc, -
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Chicago, IL, USA) for Windows and the data were expressed as x ± s. Independent
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samples t test was used between the two groups and P value less than 0.05 was 6
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considered as statistically significant.
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Among the 360 TBAD patients, 210 cases were with complicated TBAD and 150 cases were with uncomplicated TBAD. The average time from presentation to
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TEVAR was 4 days. And, 33 cases out of 360 cases received hybrid operation. Among
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these 33 cases, 14 cases received debranching procedures. There were 5 cases of
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RAAD complicating TEVAR for TBAD in total (1.4%). For these 5 cases, TEVAR
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was performed at the acute phase of dissection. TEVAR was failed in 1 case due to
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RAAD occurrence during TEVAR and thus open operation was performed in this case.
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Successful TEVAR operation was carried out in the other 4 cases. Among these 4
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cases, 3 cases had RAAD within 1 month after TEVAR and 1 case had RAAD at 1
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year after TEVAR. The detailed basic information of the 5 patients was listed in Table
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1 and Table 2.
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Case 1 of the five patients was a 55 year old male and preoperative CTA (Fig.1 A and B) confirmed that he was with typical TBAD. On the 13th day after the TEVAR,
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disturbance of consciousness and blood pressure decrease suddenly appeared. The
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general condition was gradually stabilized by active rescue and immediate emergency
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CTA (Fig. 1E and F) examination was performed. Compared with 10 day CTA review
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(Fig. 1C and D), it was found that ascending aortic wall thickening was obvious with
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intramural hematoma, indicating the occurrence of RAAD. This patient refused to
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take open surgical operation and was followed up continuously for 58 months. CTA
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review scanning (Fig. 2) showed progresses in ascending aortic dissection and this
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patient eventually died of heart failure.
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ACCEPTED MANUSCRIPT In case 2, 1 month after TEVAR, severe chest and back pain and other
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symptoms accompanied by a sharp increase in blood pressure appeared. Emergency
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CTA confirmed that RAAD occurred and emergency "ascending aorta + aortic arch
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replacement" was carried the day he was hospitalized. Intraoperative findings showed
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that the dissection located near the first section of bare stent, retrogradely tearing the
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ascending aorta. The coronary artery and aortic valve were not affected, indicating
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that the new dissection might be vascular wall damage caused by the bare stent. CTA
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review was taken 2 weeks after the second operation and the result showed that the
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ascending aortic false lumen completely disappeared, the true lumen was intact and
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the surgical repair result was satisfactory. This case is now still in follow-up. Because of insufficient anchoring zone, case 3 received the surgery of
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"ascending aorta - left innominate artery / common carotid artery + TEVAR ". Chest
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discomfort occurred 10 days after surgery and CTA scan confirmed that RAAD
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occurred. The dissection was near the ascending aorta artificial vascular anastomosis
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and it might be new dissection caused by hemostat on the basis of weak vessel wall.
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This patient was followed up for more than 1 year and no new symptoms occurred.
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In case 4, symptoms similar to the symptoms of the initial onset occurred at 1
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year after discharge and CTA review confirmed that RAAD occurred. This patient
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took "ascending aorta + aortic arch + distal hard trunk operation", with good
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postoperative recovery. Now, he has been followed up for almost 1 year.
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RAAD of case 5 occurred in the operation process of TEVAR. Because of insufficient anchoring zone, the predetermined operation scheme for this patient was 9
ACCEPTED MANUSCRIPT "ascending aorta - innominate artery / left common carotid artery + TEVAR". After
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the side wall of the ascending aorta was clamped, sudden thickening of ascending
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aorta appeared. High-speed blood flow entering the aortic wall was observed. It was
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visible that the ascending aorta dissection was located in the side wall forceps.
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Meanwhile, this patient had two leaf type aortic valve malformation. Thus, the
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operation mode was changed into open operation (Ascending aorta replacement +
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total arch replacement + distal hard trunk stenting) and emergency extracorporeal
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circulation was established. The postoperative recovery of this patient was good, and
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he ultimately survived.
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ACCEPTED MANUSCRIPT Discussion
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RAAD is a serious complication associated with TEVAR. Previous studies show that the incidences are 14.3%, 2.4%, 2.3% and 1.9%, respectively (1-4). In this
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study, the morbidity was 1.4%, which, was consistent with other reports except that
5
by Beate Neuhauser et al. (6). The rate of RAAD complicating TEVAR for TBAD is
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relatively uncommon, however, it has risks which can not be ignored. Due to the
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relatively high mortality, attention should be paid to this situation as far as possible.
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As shown in Table 3, we consider that there are three reasons for the
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occurrence of this complication. Firstly, vascular disease is one of the most important
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causes of this complication. Judson B. Williams et al. (9) found that Marfan syndrome
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and aortic diameter more than 40 mm were two main reasons for the occurrence of
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RAAD complicating TEVAR for TBAD. Comparative analysis found that, patients
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with dissection are prone to this complication than patients with aneurysm. At the
14
same time, the position of the support anchor may also be related with this
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complication. They argue that this complication is more prone to occur when the
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supports are anchored in the 0 - 2 area. In this study, 4 cases (80%) of patients were
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with ascending aortic diameter more than 40 mm, which were much higher than the
18
patients without complications. At the same time, stents were anchored in the 0 - 2
19
area in 4 cases who were with successful TEVAR operation. These results suggest that
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broadening of ascending aorta makes the aortic wall weak and the stent anchored near
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or in the ascending aorta increases the risk for this complication.
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Secondly, stent graft might be another important cause of this complication. 11
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damage the vascular wall and that the head and tail bracket bonding site was easy to
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induce new break, thus leading to the complication. Beate Neuhauser and Judson B.
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Williams et al. (6, 9) pointed out that bare frame design of the first section and head
5
barbed design of the support were related to the complication. However, Jacques
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Kpodonu et al. (7) considered that full covered support without barb could induce the
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same complication. In this study, in the 4 cases of patients with successful TEVAR,
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head bare frame design of stents was used. Whether stent graft plays a role in the
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occurrence of this kind of complication is still unknown, pending further study.
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Finally, operation induced vessel wall injury is also an important reason for this complication (5). In the delivery process of guide wire, catheter and stent, the
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vascular wall may be damaged and RAAD may appear in the high speed flow impact.
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Balloon dilation after stent implantation is another iatrogenic risk factor. According to
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Jacques Kpodonu et al. (7), among the 7 cases of RAAD complicating TEVAR for
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TBAD, 5 cases underwent balloon dilation. According to our experience, balloon
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dilation is not routinely performed after TEVAR. When the stents are bended or have
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serious "fish mouth" phenomenon, balloon dilation is performed. When performing
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balloon dilation, the balloon should be expanded as soon as possible. Once the
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balloon is expanded, the balloon should be released as soon as possible. And, the
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balloon should be expanded inside the stent and can not exceed the stent. Moreover,
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under the action of the forceps, the vessel wall is easily to be damaged, thus inducing
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RAAD. In this study, in case 5, when the vascular side wall was clamped, ascending
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aorta thickening suddenly appeared and the blood flow was in a vortex state in the
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adventitia. The aortic wall was more than 40 mm, further indicating that weakness of
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aortic wall is one of the reasons that cause the complication. In this study, there were 210 patients with complicated TBAD, accounting for
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58.3% of all patients. The average time from presentation to TEVAR was 4 days.
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Totally, 5 patients (1.4%) had TEVAR complicating RAAD. Currently, whether the
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timing of TEVAR is related with the occurrence of RAAD is still unclear. And, the
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timing of TEVAR for TBAD is still controversial. It is generally considered that, for
9
complicated TBAD, TEVAR should be performed as early as possible. However, for
10
uncomplicated TBAD, different centers hold different views (12). According to our
11
experiences, the condition of dissection is always changing. Uncomplicated TBAD
12
may at some point convert into complicated TBAD. The key problem is that we do
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not know the exact time of the transition. Therefore, we consider that aortic dissection
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can never be taken lightly and TEVAR should be prepared as soon as possible.
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In addition, in order to reduce the occurrence of RAAD complicating TEVAR
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for TBAD, we believe that the following points must be given special attention. First,
17
TEVAR operation indication should be taken strictly. To the patients with Marfan
18
syndrome, it is better to choose surgical operation and it is particularly important to
19
select suitable support in view of different lesions. At the same time, excessive
20
oversize of stent graft should be avoided so as to reduce the radial force of the stent to
21
the vascular wall. Second, the standardized operation is rather important. Gentle and
22
careful operation is necessary so as to minimize repeated stimulation and damage
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ACCEPTED MANUSCRIPT caused by catheter and guide wire to vascular wall. Meanwhile, reduce or avoid
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unnecessary balloon dilation could also reduce the incidence of complication. Third,
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postoperative blood pressure management and life support are equally important.
4
Active control of blood pressure and stool softening can also play a certain role
5
(13-16).
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TEVAR operation patients should be followed up in case of the occurrence of RAAD. Beate Neuhauser et al. reported that 4 cases of RAAD during the follow-up
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were found. They all had taken surgical operation treatment and 3 people survived.
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Judson B. Williams et al. had found 6 cases with RAAD in their study. Five cases
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underwent emergency operation and achieved good effectiveness. However, the other
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case took conservative treatment and eventually died. In our study, 1 case had RAAD
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during TEVAR, 3 cases had RAAD within 1 month after TEVAR and 1 case had
13
RAAD at 1 year after TEVAR. Thus, continuous follow up is necessary. For treatment,
14
3 cases underwent surgical operation and 2 cases took conservative treatment. Finally,
15
1 case of conservative treatment patient died and the other 4 cases are followed up.
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Therefore, surgical operation is almost the only effective treatment method for RAAD
17
and the short and long-term efficacy of conservative treatment is poor (6-8).
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In conclusion, RAAD complicating TEVAR for TBAD is a rare but fatal
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complication. The causes include vascular disease, stent graft and surgical operation.
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Among them, the stent graft forces on the vessel wall and the vessel wall injury
21
caused by operation should be noted. Appropriate support for different patients
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together with standardized operation may effectively reduce the complication 14
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incidence.
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None.
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Disclosures
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All authors declare no financial competing interests.
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All authors declare no non-financial competing interests.
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Applications and Directions of Thoracic Endovascular Aortic Repair (TEVAR).
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Canadian Journal of Cardiology 2014; 30:52-63.
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13. Kim U, Hong SJ, Kim J, et al. Intermediate to long-term outcomes of
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endoluminal stent-graft repair in patients with chronic type B aortic dissection.
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Journal of endovascular therapy : an official journal of the International Society of
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Endovascular Specialists 2009;16:42-7.
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14. Czerny M, Roedler S, Fakhimi S, et al. Midterm results of thoracic endovascular
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aortic repair in patients with aneurysms involving the descending aorta originating
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from chronic type B dissections. The Annals of thoracic surgery 2010;90:90-4.
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15. Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of
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strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic
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Dissection (INSTEAD) trial. Circulation 2009;120:2519-28.
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16. Trimarchi S, Nienaber CA, Rampoldi V, et al. Role and results of surgery in acute
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type B aortic dissection: insights from the International Registry of Acute Aortic
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Dissection (IRAD). Circulation 2006;114:I357-64.
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ACCEPTED MANUSCRIPT Table 1. General clinical data of 5 patients.
Age CAD CVD Diabetes (type Ⅰ andⅡ) Hypertension Hypercholesterolemia Renal failure Current smoking COPD
Case 1 55 yes no no yes yes no yes no
Case 2 35 no no no yes yes no yes no
Case 3 72 yes yes type yes yes no yes yes
Case 4 53 no no no yes no no no no
Case 5 44 no no no yes no no yes no
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Note: CAD, coronary artery disease; CVD, cerebrovascular disease; COPD, chronic
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obstructive pulmonary disease.
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ACCEPTED MANUSCRIPT Table 2. General condition of the five cases of retrograde type A aortic dissection. RAAD occurring time
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M ale M ale M ale Fe ma le M ale
2 3 4
5 2
Anchor position
Bracket type
13 day
Ascending aorta diameter (mm) 43
Z1
30 day
36
Z2
10 day
41
Z0
1 year
43
Intraopera tive
45
Treatment method
Follow-up (month)
Result
Medtronic Conservat ive Medtronic Operation
58
Died
30
Alive
15
Alive
Z1
Medtronic Conservat ive Medtronic Operation
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Alive
-
-
8
Alive
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Note: RAAD, retrograde type A aortic dissection.
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Table 3. Reasons of RAAD complicating TEVAR for TBAD. Stent graft (device-related)
Bare frame design of the first section and head barbed design of the support Excessive oversize, resulting in too large radial force Elastic back stress after passive bending can damage the vascular wall and the head and tail bracket bonding site Marfan syndrome Ascending aortic diameter greater than 40 mm Landing zone locates in 0-2 region AD is prone to occur than AAA Guide wire, catheter, delivery sheath and stent graft Balloon dilatation Side wall clamp function
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Note: RAAD, retrograde type A aortic dissection. TBAD, type B aortic dissection. AD,
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Aortic Dissection; AAA: Abdominal aortic aneurysm.
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ACCEPTED MANUSCRIPT Figure legends
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Fig. 1 Representative images of Case 1. (A) and (B) Existence of TBAD shown by
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TEVAR preoperative 64 rows CTA. Preoperative reconstruction of three-dimensional
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showed the first rupture located in the arch and descending aorta and was about 2 cm
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from the left subclavian artery opening (A). Axial image showed the rupture diameter
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was about 1.5 cm, the ascending aorta and arch were intact (arrow) and thoracic aorta
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and abdominal aortic were both affected (B). (C) and (D) Review the 64 rows CTA 10
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day after TEVAR showed that the first rupture of aortic dissection closed completely.
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Proximal end of the false lumen thrombus existed (C), the true lumen was in good
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shape and no internal leakage formation existed and the ascending aorta was normal
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(arrow) (D). (E) and (F) Review the 64 rows CTA 13 day after TEVAR. Sagittal plane
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(E) and horizontal plane (F) showed ascending aorta and arch vascular wall
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thickening (arrow) with the formation of RAAD.
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Fig. 2 Representative images of Case 1. (A) and (B) Review the 64 rows CTA 36
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month after TEVAR showed process of RAAD compared with former review.
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Preoperative reconstruction of three-dimension (A) and horizontal plane (B) showed
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that the ascending aorta was with multiple lacerations (arrow) and true and false
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lumen were displayed clearly. (C) and (D) Review the 64 rows CTA 46 month after
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TEVAR showed process of RAAD compared with former review. Preoperative
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reconstruction of three-dimension (C) and horizontal plane (D) showed that the
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ascending aorta was with multiple lacerations (arrow) and true and false lumen were
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displayed clearly. (E) and (F) Review the 64 rows CTA 64 month after TEVAR
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showed process of RAAD compared with former review. Preoperative reconstruction
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of three-dimension (E) and horizontal plane (F) showed that the ascending aorta was
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with multiple lacerations (arrow) and true and false lumen were displayed clearly.
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