TEVAR of descending aortic aneurysm is a widely accepted procedure, mostly in emergencies, as followed by us . After endovascular repair the possibility of aortic pathology progression and/or procedure related complications should always be kept in mind.
Retrograde type A aortic dissection has been deemed a rare complication after endovascular stent graft placement for descending thoracic aortic diseases. The incidence is low (1.33 %) with an high mortality rate (42%) . When the ascending aorta is involved open surgery for ascending aorta replacement was necessary. Conversely, if the dissection involved only the aortic arch, an endovascular treatment with transfemoral uncovered bare stent implantation is possible .
Although aneurismal growth may follow an indolent course, published reports (1-2) note that in older populations the descending and thoracoabdominal aorta grows at a rate of about 0.19 cm per year.
To avoid measurement error, we compared identical segments of the aorta in sequential studies measuring the aortic axis at the origin of the visceral vessels.
In this patient we observed, at the superior mesenteric artery level, a rapid and pathological overall growth of 1.53 cm (1.02 cm /year), requiring prompt treatment.
Despite the improvement of surgical and anaesthesiological techniques, open repair of a thoracoabdominal aneurysm still entails consistent risk of mortality and morbidity , mostly in older patients. As an alternative, a combined endovascular repair and retrograde visceral vessel revascularization has been considered .
To minimize the risk of paraplegia, the non-aneurysmatic aortic critical segment between T8 and T10 and the internal iliac arteries have been spared by endovascular and surgical approach, respectively. Furthermore, the reported technique of sequential visceral vessel revascularization reduces significantly life-threatening celiac and mesenteric vessel ischemia and acute renal failure. Finally, this hybrid approach, avoiding a wide thoracophrenolaparotomy, could decrease the incidence of pulmonary complications, the most common morbidity after open surgery, observed in more than 30% of patients even in excellent health [2, 6–9]. Compared to conventional surgery, this technique, in older patients, offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications and could result on shorter length of hospital stay. Thus, this hybrid approach, despite requiring several prosthetic devices, could be a promising cost-effectiveness strategy.