Aortic dissection following endovascular aneurysm repair (EVAR) may be iatrogenic or a de-novo event. This study aims to systematically review all cases of dissection following EVAR to identify complications specific to each scenario and develop a management algorithm depending on the clinical presentation.
Methods
A comprehensive literature search of MEDLINE, Embase, and CENTRAL databases was performed for all studies relating to dissection following EVAR or fenestrated/branched EVAR (F/BrEVAR). Data collected included timing (differentiating iatrogenic and de-novo events), entry tear location, endograft involved, complications, management, and subsequent outcomes. Due to limited data availability, descriptive data was collected and outcomes compared depending on dissection type and timing. Risk of bias was assessed using a standardised tool for case reports.
Results
46 patients in 37 studies were included. Complications included endograft compression (52.2%), endoleak (15.2%), and rupture (13.0%). Compression was less likely in endografts with proximal fixation (41.9%), compared to those without (69.2%). Type A dissection after EVAR required cardiac surgery with a high mortality (20.0%). In Type B dissection, 2 cases were diagnosed intra-operatively during F/BrEVAR, 1 died. 8 were diagnosed <4 weeks post-operatively, all managed medically with no complications or mortality. 31 were diagnosed >4 weeks, with mortality of 25.8% and high rates of endograft compression (58.1%), endoleak (16.1%), and rupture (19.4%).
Conclusion
Aortic dissection following EVAR may cause endograft compression, endoleak, or rupture, with significant mortality. Complications are more frequent following Type A dissection and late Type B dissection. Early Type B dissection may be amenable to medical management.
GarlandSKFalsterMOBeilesCB, et al.Long-term outcomes following elective repair of intact abdominal aortic aneurysms: a comparison between open surgical and endovascular repair using linked administrative and clinical registry data. Ann Surg. 2023;277(4):e955-e962. doi:10.1097/sla.0000000000005259
2.
SirignanoPPrantedaCCapocciaLMennaDMansourWSpezialeF. Retrograde type B aortic dissection as a complication of standard endovascular aortic repair. Ann Vasc Surg. 2015;29(1):127.e5-127.e9. doi:10.1016/j.avsg.2014.08.011
3.
ShintaniTAtsutaKSaitoT. Successful hybrid treatment of stent-graft migration caused by type B aortic dissection after endovascular aortic aneurysm repair: a case report. Ann Vasc Dis. 2017;10(3):270-273. doi:10.3400/avd.cr.17-00044
4.
PulliRFargionAPratesiGDorigoWAngilettaDPratesiC. Aortic type B dissection with acute expansion of iliac artery aneurysm in previous endovascular repair with iliac branched graft. J Vasc Surg. 2011;54(6):1788-1791. doi:10.1016/j.jvs.2011.06.029
IyerVRigbyMVrabecGS. Type B aortic dissection after endovascular abdominal aortic aneurysm repair causing endograft collapse and severe malperfusion. J Vasc Surg. 2009;50(2):413-416. doi:10.1016/j.jvs.2009.03.060
7.
AkbulutMAkAOzturkerKSismanogluMTuncerA. Treatment of retrograde type B aortic dissection after endovascular repair of abdominal aortic aneurysm. Ann Vasc Surg. 2019;56:354.e1-354.e4. doi:10.1016/j.avsg.2018.08.107
8.
JayakumarLLombardiJVCaputoFJ. Type B dissection resulting in acute limb ischemia in a patient with a history of EVAR. Vasc Endovascular Surg. 2017;51(2):98-102. doi:10.1177/1538574417689983
9.
HughesGC. Stent graft induced new entry tear (SINE): intentional and NOT. J Thorac Cardiovasc Surg. 2019;157(1):101-106.e3. doi:10.1016/j.jtcvs.2018.10.060
10.
KhanbhaiMGhoshJAshleighRBaguneidM. Type B aortic dissection after standard endovascular repair of abdominal aortic aneurysm. BMJ Case Rep. 2013;2013:bcr2012007209. doi:10.1136/bcr-2012-007209
11.
PsacharopuloDFerreroEViazzoAFerriMRipepiMNessiF. Abdominal aortic endograft collapse due to false lumen radial force of an acute type B aortic dissection. Ann Vasc Surg. 2014;28(8):1931.e9-1931.e12. doi:10.1016/j.avsg.2014.06.067
12.
VainasTTielliuIFJde VriesBMWvan der LaanMZeebregtsCJvan den DungenJJAM. Acute type B dissection complicated by infrarenal aortic stent-graft collapse with spontaneous re-expansion. J Endovasc Ther. 2014;21(2):353-355.
13.
DanielGBen AhmedSWareinEGallonARossetE. Type B aortic dissection with abdominal aortic aneurysm rupture 1 year after endovascular repair of abdominal aortic aneurysm. Ann Vasc Surg. 2016;33:229.e7-229.e10. doi:10.1016/j.avsg.2015.11.022
14.
GotoYHosobaSOgawaSKinoshitaY. Collapsed stent graft and severe malperfusion 2 years after endovascular aortic repair. Eur J Cardio Thorac Surg. 2017;52(3):599-600. doi:10.1093/ejcts/ezx195
15.
KimH-EJooH-C. Acute type A aortic dissection causing collapse of previous stent graft. Ann Thorac Surg. 2018;105(5):e221-e223. doi:10.1016/j.athoracsur.2017.11.049
16.
OkumuraSFukumotoAMaedaK. Squashed abdominal aortic stent graft by Stanford type B acute aortic dissection. Ann Thorac Surg. 2013;96(3):1092. doi:10.1016/j.athoracsur.2013.01.037
17.
PageMJMoherDBossuytPM, et al.PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. doi:10.1136/bmj.n160
18.
MuradMHSultanSHaffarSBazerbachiF. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med. 2018;23(2):60-63. doi:10.1136/bmjebm-2017-110853
19.
EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005;365(9478):2179-2186. doi:10.1016/s0140-6736(05)66627-5
20.
EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. Lancet. 2005;365(9478):2187-2192. doi:10.1016/S0140-6736(05)66628-7
21.
LederleFFreischlagJKyriakidesT, et al.Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;367(21):1988-1997. doi:10.1056/NEJMoa1207481
22.
BulderRMABastiaannetEHammingJFLindemanJHN. Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm. Br J Surg. 2019;106(5):523-533. doi:10.1002/bjs.11123
23.
ChenJFTanKTLindsayTF. Retrograde type B aortic dissection after fenestrated endovascular aortic aneurysm repair. J Vasc Surg. 2023;77(4 Supplement):57S-58S. doi:10.1016/j.jvs.2023.01.155
24.
KoudounasGGiannopoulosSVolteasPKarkosCVirvilisDTassiopoulosAK. De novo acute type B aortic dissection in two patients with previous infrarenal endovascular aortic aneurysm repair with EndoAnchors. J Vasc Surg Cases Innov Tech. 2023;9(2):101120. doi:10.1016/j.jvscit.2023.101120
25.
TolenaarJLvan KeulenJWVonkenE-Jvan HerwaardenJAMollFLde BorstGJ. Fenestration of an iatrogenic aortic dissection after endovascular aneurysm repair. J Endovasc Ther. 2011;18(2):256-260. doi:10.1583/10-3330.1
26.
GirardiLNBushHL. Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm. J Vasc Surg. 1999;29(5):936-938. doi:10.1016/S0741-5214(99)70222-3
27.
HaulonSGreenbergRKKhwajaJ, et al.Aortic dissection in the setting of an infrarenal endoprosthesis: a fatal combination. J Vasc Surg. 2003;38(5):1121-1124. doi:10.1016/s0741-5214(03)00931-5
28.
van KeulenJWTooropRJde BorstGJ, et al.Abdominal stent-graft collapse due to progression of a Stanford type B dissection. J Endovasc Ther. 2009;16(6):752-754.
29.
MamopoulosATNowakTLutherB. Retrograde ascending Stanford B aortic dissection complicating a routine infrarenal endovascular aortic reconstruction. J Vasc Surg. 2013;58(1):208-211. doi:10.1016/j.jvs.2012.10.111
30.
YamamotoSHoshinaKTakazawaY, et al.Aortic dissection occurring 18 months after successful endovascular repair in an anatomically difficult case of abdominal aortic aneurysm. Case Rep Vasc Med. 2013;2013(101585357):412708. doi:10.1155/2013/412708
31.
YoshigaRMorisakiKMatsubaraY, et al.Emergency thoracic aortic stent grafting for acute complicated type B aortic dissection after a previous abdominal endovascular aneurysm repair. Surg Case Rep. 2015;1(1):99. doi:10.1186/s40792-015-0096-3
32.
ParkSHRhaS-W. Acute type B aortic dissection in a patient with previous endovascular abdominal aortic aneurysm repair. Vasc Specialist Int. 2017;33(1):43-46. doi:10.5758/vsi.2017.33.1.43
33.
ItogaNKWuTDakeMDDalmanRLLeeJT. Acute type B dissection causing collapse of EVAR endograft and iliac limb occlusion. Ann Vasc Surg. 2018;46:206.e1-206.e4. doi:10.1016/j.avsg.2017.07.024
34.
NomuraYNagaoKHasegawaS, et al.Fatal complications of new-onset complicated type B aortic dissection after endovascular abdominal aortic aneurysm repair: report of 2 cases and literature review. Vasc Endovasc Surg. 2019;53(3):255-258. doi:10.1177/1538574418819540
OstapenkoARichardMNDietzekAM. Rare case of acute type B dissection causing complete collapse of EVAR stent. Vasc Endovasc Surg. 2019;53(5):420-423. doi:10.1177/1538574419840873
37.
Rodriguez CzaplickiEJMartinez MiraCAnaya SifuentesDMAisa AldamaJ. Acute type B aortic dissection one month after fenestrated EVAR procedure. EJVES Short Rep. 2019;44(101695075):38-43. doi:10.1016/j.ejvssr.2019.07.004
38.
NagatomiSYamamotoHToyokawaK, et al.Stent-graft re-expansion following axillo-bifemoral bypass: a case of stent graft collapse due to acute type B aortic dissection. Nihon Shinzo Kekkan Geka Gakkai zasshi. 2019;48:206-209.
39.
FooJSJTangTDamodharanKChokeTE. Type B aortic dissection after nellix endovascular aneurysm sealing. Ann Vasc Surg. 2019;58:378.e5-378.e9. doi:10.1016/j.avsg.2018.11.014
40.
KawaguchiYKitamuraHSakakuraTTamakiM. Stent graft collapse caused by acute aortic dissection after endovascular repair for thoracoabdominal aortic aneurysm repair. J Vasc Surg Cases Innov Tech. 2020;6(4):509-510. doi:10.1016/j.jvscit.2020.08.012
41.
MotojiYKatoTSekiJTsumuraKTomitaSOkawaY. A case of collapsed stent graft, severe lower limb ischemia, and ruptured abdominal aortic aneurysm due to type B acute aortic dissection 3 years after endovascular aneurysm repair. Ann Vasc Dis. 2020;13(3):308-311. doi:10.3400/avd.cr.19-00142
42.
OgawaYWatkinsACLeeA, et al.Acute type A dissection causing impending rupture of abdominal aortic aneurysm previously treated with EVAR. Ann Vasc Surg. 2020;65:289.e7-289.e11. doi:10.1016/j.avsg.2019.11.047
43.
WolfersMPYuQMontorfanoLBordesSJKingT. Type A thoracic aortic dissection following endovascular repair of a common iliac artery aneurysm. Cureus. 2021;13(3):e13971. doi:10.7759/cureus.13971
44.
NatsumeKShintaniTHayahiMOhkuraKHasegawaYAriyaT. Type B acute aortic dissection as a perioperative complication after an endovascular abdominal aortic repair. Ann Vasc Dis. 2021;14(1):83-87. doi:10.3400/avd.cr.20-00107
45.
TakagiSGotoYYanagisawaJNakasuA. Stent graft in abdominal aortic aneurysm collapsed suddenly after thoracic endovascular aortic repair. BMJ Case Rep. 2021;14(12):e246798. doi:10.1136/bcr-2021-246798
46.
StreckESouriYHyhlik-DürrA. A rare case of an acute type B aortic dissection contained infrarenal rupture of the false lumen after prior endovascular abdominal aneurysm repair. J Vasc Surg Cases Innov Tech. 2024;10(1):101366. doi:10.1016/j.jvscit.2023.101366
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
