• Maximilian Luehr, Christian D Etz, Lukas Lehmkuhl, Andrej Schmidt, Martin Misfeld, Michael A Borger, and Friedrich-Wilhelm Mohr.
• Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany.
• Eur J Cardiothorac Surg. 2013 Nov 1;44(5):958-63.

ObjectivesHybrid endovascular procedures are rapidly evolving and have recently been adopted for high-risk patients deemed unsuitable for conventional aortic arch surgery. We describe here our initial experience with this technique, including the management of 2 patients who developed a retrograde type A aortic dissection post-de-branching.MethodsBetween May 2010 and October 2012, 109 patients underwent conventional aortic arch repair at our institution. A further 9 high-risk patients with complex aortic arch pathology (median logistic EuroSCORE: 26, range: 11-41) were deemed unsuitable for conventional total aortic arch replacement and therefore underwent hybrid aortic arch repair. Complete supra-aortic de-branching, followed by endovascular stent-grafting (TEVAR) of the transverse arch and descending aorta, was performed in these high-risk patients.ResultsIn-hospital mortality was zero and no patient developed paraplegia/paraparesis due to spinal cord ischaemia. However, 2 patients (22%) developed retrograde type A aortic dissection on Days 10 and 12 post-TEVAR. Both patients had a dilated ascending aorta and received a stent graft containing bare metal springs at the proximal end. Emergency ascending aortic replacement was performed during moderate-to-mild hypothermia (28-34°C) and bilateral antegrade cerebral perfusion via cannulation of the de-branching prosthesis. A Hemashield prosthetic graft was anastomosed to the proximal stent graft in an elephant trunk technique. Both patients suffered from minor non-debilitating stroke, with 1 being discharged home and 1 transferred to a neurological rehabilitation centre 2 and 3 weeks after reoperation, respectively.ConclusionsRetrograde type A aortic dissection after hybrid endovascular treatment of the aortic arch represents a new-most likely under-reported-pathology that may be successfully treated with open surgical repair. The use of stent grafts with protruding proximal bare springs and the implementation of oversizing and post-deployment ballooning should be avoided in patients undergoing hybrid arch procedures, particularly if the ascending aorta is dilated.

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