# Urgent and Emergent Endovascular Treatment of the Downstream Aorta Soon After Open Surgical Repair in Acute Type A Aortic Dissection: Analyzing Indications and Outcomes of an Institutional Case Series

## TL;DR

This study examines the outcomes of urgent or emergent endovascular treatment of the aorta soon after open surgery for aortic dissection, finding success in treating malperfusion but high mortality in rupture cases.

## Contribution

The paper provides novel clinical insights into the outcomes of urgent TEVAR following open surgical repair for acute type A aortic dissection.

## Key findings

- Technical success of TEVAR was 100% in treating true lumen collapse and malperfusion.
- Mortality was 66% in patients treated for descending thoracic aorta rupture due to hemorrhagic shock.
- No late aortic complications occurred in surviving patients during midterm follow-up.

## Abstract

Objectives: Thoracic endovascular aortic repair (TEVAR) is rarely indicated on an urgent or emergent basis soon after open surgical repair of type A aortic dissection (TAAD), and systematic data on clinical outcomes are therefore missing. In the present study, we analyze a contemporary case series regarding the outcome after urgent and emergent endovascular treatment of the downstream thoracic aorta, following open surgery for TAAD. Methods: The study was conducted as a retrospective observational analysis. From January 2024 until April 2025, seven patients (four male, aged 56.8 ± 5.6 years) were treated with TEVAR on an urgent or emergent basis within 48 h after open surgical repair of TAAD at our institution. In all seven patients, the initial dissection extended from the ascending to the abdominal aorta. All seven patients had previously received emergent open surgical repair by ascending aortic repair combined with hemiarch replacement (five patients) or total arch replacement, utilizing the frozen elephant trunk (FET) technique (two patients). Results: In four patients, the indication for urgent TEVAR was due to true lumen collapse (TLC) of the downstream aorta with resulting visceral or peripheral malperfusion symptoms. Three patients were treated on an emergent basis, due to rupture of the descending thoracic aorta with a resulting hemorrhage. Technical success of the TEVAR procedure was 100%. Thirty-day mortality was 0% in the TLC cases but 66% in the ruptured cases, where two of three patients died postoperatively due to the consequences of severe hemorrhagic shock. Within the surviving patients, no subsequent aortic events occurred during follow-up. Late mortality was 0%. The follow-up period was 15.7 ± 2.0 months. Conclusions: In our case series, mortality of urgent or emergent TEVAR soon after open surgical repair for TAAD is substantial, especially in patients that were treated due to acute rupture of the descending thoracic aorta and consecutive hemorrhagic shock. On the other hand, true lumen collapse with resulting malperfusion was successfully treated by instant TEVAR application in all patients without late aortic complications by the midterm follow-up.