Inadvertent placement of thoracic stent-grafts in false lumen during aortic dissection surgery - unicentric analysis and systematic review.

Abstract

Background: The aim of this retrospective study and systematic review was to examine the causes, management strategies, and outcomes of thoracic endovascular aortic repair (TEVAR) stent graft misplacement in the false lumen (FL). Accordingly, we analyzed cases from our institution along with data from published articles.

Materials and methods: This single-center retrospective study analyzed six TEVAR stent graft misplacement cases among 1227 patients who had an aortic dissection and underwent TEVAR at our hospital (2011-2024). Furthermore, a systematic search of PubMed, Embase, Web of Science, and Cochrane CENTRAL and ClinicalTrials.gov for relevant studies was performed. Outcome data on symptoms, clinical outcomes, placement method, management strategies, treatment quality, potential causes of misplacement, and factors related to oversight were independently extracted by two reviewers in a standardized manner.

Results: A total of 35 cases from 23 studies, including 6 from our institution, were reviewed. TEVAR misplacement predominantly occurred in Type A dissections (62.9%) and in cases of anterogradely placed TEVAR stents (68.6%). Complications, mainly visceral malperfusion (48.6%), were reported in 77.1% of the cases. Intraoperative misplacement was more accurately detected by transesophageal echocardiogram (TEE) or intravascular ultrasound (IVUS) than by aortography alone (p < 0.001). Endovascular retrograde stent extension with or without septal fenestration was linked to improved survival (p = 0.018). Early symptom onset within 3 days and delayed treatment increased mortality (p = 0.029). Overall mortality was 28.6%, mainly due to multiorgan failure (80%).

Conclusion: Although rare, accidental TEVAR stent graft placement in the FL markedly increases mortality. Despite seemingly acceptable survival rates, challenges in diagnosis and the potential for publication bias may lead to misleading conclusions. Clinicians must immediately administer comprehensive aortography, TEE, IVUS, or intraoperative computed tomography when they suspect an instance of accidental placement to ensure timely intervention.