5.3 TEVAR with extrathoracic surgical transposition of the supra-aortic branches

A 2017 study by Rylski et al. reported surgical outcomes on 43 non-A non-B aortic dissection patients repaired using TEVAR with extrathoracic surgical transposition of the supra-aortic branches (Rylski et al. , 2017). In this study endovascular treatment involved TEVAR with or without carotid-subclavian bypass or transposition of both left carotid and left subclavian artery as well as isolated stenting of dissected visceral vessels (Rylski et al. , 2017). The authors classified Non-A non-B dissections as descending entry type with entry distal to the left subclavian artery and dissection extending into the aortic arch, and arch entry type with entry between the innominate and left subclavian arteries. These two groups were then compared in terms of presentation, treatment and outcomes with 21 patients forming this descending entry group and 22 the arch entry cohort (Rylski et al. , 2017). The cardiovascular risk profiles of these groups did not differ and the overwhelmingly majority of aortic segments were not dilated in patients from both groups. Across both groups the 30 day mortality rate was 9%, one patient suffered a stroke and two patients suffered a retrograde type A dissection (Rylski et al. , 2017). Aortic repair due to new organ malperfusion, rapid aortic growth or persisting pain was performed in 43% of descending entry patients and 36% arch entry patients with a 0% in hospital mortality.
An earlier study by Lu et al. retrospectively analysed 22 consecutive patients treated with extrathoracic surgical transposition of the supra aortic branches for Non-A non-B dissection (Lu et al. , 2011). Hybrid, scalloped or fenestrated endovascular stent grafts were selected based on dissection characteristics and median follow up time was 27.1 months with patients assessed with computed tomography angiography. Primary end points of the study included pathology, complications and survival rates (Lu et al. , 2011). The authors reported surgery was successful in all patients except one with an operative complication and they report a 30-day mortality rate of 9% (Lu et al. , 2011). Thrombosis had formed in the aortic false lumen of the graft exclusion segment in all patients however the maximum diameter of this segment was shown to be decreased in 18 patients and stable in two (Lu et al. , 2011). Patency was observed at both mid- and long-term follow-up and no proximal endoleak, graft displacement or deaths were reported in this period.