VESS02 - TEVAR with Dissection Stent for Malperfusion in Acute Type A Aortic Dissection: A Bridge to Open Repair

Objectives: Acute Type A aortic dissection (TAAD) complicated by malperfusion syndrome is associated with significant morbidity and mortality. Traditional emergent open surgical repair poses significant risks for this patient population. However, treatment algorithms for the endovascular role in revascularization remain fluid and subject to ongoing debate. At our institution, thoracic endovascular aortic repair (TEVAR) using the Zenith Dissection Endovascular Stent has been employed as a less invasive strategy to stabilize patients and resolve malperfusion before definitive open intervention. This study summarizes our institutional experience and outcomes with this approach.

Methods: From October 2021 to July 2024, we treated 9 cases of TAAD with malperfusion with TEVAR before open repair. Outcomes from TEVAR were analyzed.

Results: Patients commonly presented with chest pain (75%) and right leg pain (62.5%) with elevated serum lactate and white blood cell count. Acute kidney injury (AKI) was diagnosed in 3 patients (33.3%) (Table I). No patients presented with aortic rupture. The majority of entry tears were proximal to the innominate artery (88.9%), with 44.4% extending to the abdominal aorta and 55.6% to the iliofemoral arteries (Table II).

Five patients received two dissection stents and one stent graft, one patient received one dissection stent and one stent graft, and three patients received one dissection stent. Adjunctive visceral artery stenting was performed in four cases. There were no intraoperative complications. Technical success resolving malperfusion with an endovascular approach was 100%. No patients required open surgical repair for revascularization.

Two patients (22.2%) died within 30 days before they advanced to the second stage of repair, from sepsis and withdrawal of care, respectively. Seven patients (77.8%) advanced to open repair. Renal insufficiency developed in five patients, with four requiring hemodialysis (HD); HD was transient in two, while two others died while on dialysis (Table III). The length of hospital stay was 20.1 ± 12.9 days. One patient developed an endoleak, and there has been no late mortality, stroke, new dissection, or device migration.

Conclusions: TEVAR for TAAD with malperfusion is a viable temporizing measure that can stabilize patients for potential central repair or obviate the need for further intervention. Endovascular repair before open intervention can be performed with success. Further work is required to determine differences in endovascular treatment algorithm outcomes in TAAD with malperfusion.