Conservative Treatment of Retrograde Aortic Dissection After Endovascular or Hybrid Repair of Descending Aorta Pathologies.

Background: Retrograde type A dissection (RTAD) represents a rare but possible lethal complication of thoracic endovascular aortic repair. Intervention is often recommended, but conservative management has been advocated in selected cases.

Methods: We performed a systematic review of the literature through MedLine and Cochrane databases over the last 24 years to identify reported cases of RTAD managed conservatively. Primary endpoint was the overall and aortic-related mortality, the morbidity, and the need for intervention during follow-up. The underlining causes and indications for conservative management were also investigated. (Protocol on Prospero Centre for Reviews and Dissemination RD42024542966).

Results: A total of 2,305 papers were identified, and 10 articles were included (20 cases). The reasons for conservative treatment were age (n = 8.40%) and/or haemodynamic stability(n = 16,80%) and/or unfitness for surgery(n = 12,60%). The causes of RTAD were fragile aortic wall in acute type B aortic dissection (TBAD) (n = 10, 50%), Marfan syndrome (n = 2, 10%), use of stents with proximal barbs or bare springs (n = 5, 25%), diameter of the ascending aorta>40 mm (n = 2, 10%), and intraoperative type IA endoleak (n = 2, 10%). Three patients (15%) were lost to follow-up immediately after discharge; one (5%) died in hospital from aortic rupture. At a mean follow-up of 33.5 months (range 9-60), the overall survival was 88.2% (n = 15/17) and aortic-related mortality was 10% (n = 2/20). No complications or interventions during the follow-up period were reported.

Conclusions: The mortality rate following RTAD is high, and surgery allows improvement in survival. Conservative management might represent a viable option for selected patients. However, the current evidence is poor and needs to be validated by further and more robust data before such a strategy could be suggested more widely.