Incidence and Outcomes of Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection: A Systematic Review and Meta-analysis

Abstract

Objectives:

The objective of this systematic review was to provide evidence-based data regarding the incidence and outcome of retrograde type A dissection (RTAD) in patients treated with thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD).

Methods:

A systematic literature review was conducted through November 2025 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Primary outcomes included the overall incidence of retrograde dissection, as well as incidence stratified by to the phase (acute, subacute, and chronic) of TBAD at the time of TEVAR and by the proximal sealing zone of endograft. Secondary outcomes were 30-day and late mortality after open or conservative management of RTAD.

Results:

From 538 identified records, 22 studies met inclusion criteria, comprising 5088 patients (71% male) with a median follow-up of 28 months (range, 12–70 months). The pooled 30-day and late incidence of RTAD was 1.8% (95% confidence interval [CI], 1.2–2.7; I²=58%) and 2.2% (95% CI 1.6–3.0; I²=44%), respectively. The incidence of RTAD was highest after TEVAR performed for acute TBAD at 3.2% (95% CI 2.3–4.3), compared with 1.6% (95% CI 0.9–3.1) for subacute and 2.0% (95% CI 1.2–3.4) for chronic TBAD. Pooled 30-day mortality after open surgical repair was 43.7% (95% CI 27.6–61.2; I²=0%) and increased to 51.5% (95% CI 37.5–65.3; I²=10%) during late follow-up. Retrograde type A dissection occurred more frequently in complicated cases (2.6%; 95% CI 1.6–4.1) than in uncomplicated cases (1.5%; 95% CI 0.5–4.4). The highest RTAD incidence was observed with proximal sealing zone 1 (15.4%; 95% CI 8.2–27.2), compared with zone 2 (6.9%; 95% CI 4.8–9.9).

Conclusions:

Retrograde type A dissection remains a rare but highly lethal complication following TEVAR for TBAD. Immediate or delayed open surgical repair carries substantial mortality. Primarily uncomplicated clinical presentation, delayed TEVAR, and more distal sealing zones bear lower risk for RTAD.

Clinical Impact

Retrograde type A aortic dissection (RTAD) is a rare but catastrophic complication following thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Previous research has highlighted this risk emphasizing the lethal potential of RTAD suggesting etiological factors such as procedural manipulation and stent deployment techniques while demonstrated that RTAD after TEVAR for acute type B dissection may be successfully managed with staged hybrid surgical techniques and underscoring its clinical severity. Despite these important contributions, the literature remains fragmented with varying incidence estimates and outcomes. The aggregated evidence confirms that although uncommon, RTAD carries a high mortality risk and necessitates meticulous procedural planning, vigilant post-TEVAR surveillance, and well-defined management strategies. These findings help inform practice guidelines, risk stratification, and future device innovations to minimize this devastating complication.