Aortic dissection surgery
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Aortic dissection Microchapters |
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Diagnosis |
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Treatment |
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Special Scenarios |
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Case Studies |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Aarti Narayan, M.B.B.S [3]; Hardik Patel, M.D.; Hibatullah Abdul Aleem, M.B.B.S[4]
Overview
The surgical and endovascular management of aortic dissection is determined by the type of dissection, the presence of complications, and patient-specific anatomy and risk. Acute type A aortic dissection is a surgical emergency; medical management alone carries a mortality of approximately 57% compared with 18% with surgical repair in contemporary registry data. Urgent surgical repair is recommended for all patients with suspected or confirmed acute type A dissection. Transfer to a high-volume aortic center is reasonable for stable patients. Type B aortic dissection is managed medically in the uncomplicated setting. Complicated type B dissection — defined by rupture, branch artery malperfusion, progressive aortic enlargement, intractable pain, or refractory hypertension — requires intervention, with endovascular stent grafting (TEVAR) preferred over open repair when anatomy is suitable. Preemptive TEVAR for uncomplicated type B dissection with high-risk anatomic features is supported by a Class IIb recommendation (2022 ACC/AHA) and upgraded to Class IIa in the subacute phase by the 2024 EACTS/STS Guidelines. Intramural hematoma (IMH) involving the ascending aorta is managed surgically; type B IMH is managed medically with selective endovascular repair for high-risk features or unfavorable anatomy.
Surgery
Acute Type A Aortic Dissection
Indications and Urgency
Acute type A aortic dissection is a surgical emergency.[1] IRAD data demonstrate surgical mortality declining from 25% to 18% over two decades, while in-hospital mortality with medical management alone remains approximately 57%.[2] Among patients with intended surgical treatment, 48-hour mortality approximates 0.09% per hour; among medically managed patients, the corresponding rate approximates 0.5% per hour, a difference that includes the approximately 1% who die before reaching the operating room in the surgical group.[3]
Nonhemorrhagic stroke complicating acute type A dissection is not a contraindication to surgery; surgical intervention is reasonable to reduce mortality and improve neurologic outcomes. Acute hemorrhagic stroke is a relative contraindication due to the necessity of intraoperative heparinization.
Risk factors associated with higher surgical mortality include tamponade, shock, neurologic or visceral malperfusion, and preoperative myocardial ischemia. Even elderly patients benefit from surgery over medical management; circulatory collapse is the primary predictor of long-term survival.
Aortic Root and Valve Management
- When the aortic root is partially dissected but aortic valve leaflets are structurally intact, aortic valve resuspension is recommended over valve replacement (Class I, LOE B-NR). Algorithmic use of resuspension as the preferred strategy yields operative mortality as low as 8.1%.
- When there is extensive root destruction, a root aneurysm, or a known genetic aortic disorder, aortic root replacement with a mechanical or biological valved conduit is recommended (Class I, LOE B-NR).
- Valve-sparing root repair (VSRR) may be reasonable in selected stable patients when performed by experienced surgeons in a Multidisciplinary Aortic Team (Class IIb, LOE C-LD).[1]
Distal Repair Strategy
- An open distal anastomosis (without aortic cross-clamping during circulatory arrest) is recommended to improve survival and increase false lumen thrombosis rates (Class I, LOE B-NR).[1]
- Hemiarch repair is recommended over more extensive arch replacement when no intimal tear in the arch and no significant arch aneurysm is present (Class I, LOE B-NR).
- Extended aortic repair with antegrade stenting of the proximal descending thoracic aorta (frozen elephant trunk, FET) may be considered when the dissection flap extends through the arch into the descending aorta, to treat malperfusion and reduce late distal aortic complications (Class IIb, LOE C-LD).[1]
Frozen Elephant Trunk
The 2024 EACTS/STS Guidelines recommend a tear-oriented approach with exclusion or resection of the primary entry tear (Class I, LOE B) and state that inspection and coverage of communications between lumina in the proximal descending aorta may be considered in specialized centers (Class IIb, LOE C).[4]
Per the 2022 ACC/AHA Guideline, the FET stent length should be less than 15 cm and coverage should not extend to T8, to avoid spinal cord ischaemia.[1] Delayed spinal cord ischaemia may occur up to 2 weeks after surgery, and delayed paraplegia accounts for nearly 60% of all spinal cord deficits encountered; early recognition and treatment with blood pressure augmentation and CSF drainage remain critical.[1]
Perfusion and Cannulation Strategies
- Axillary cannulation is reasonable over femoral cannulation to reduce the risk of stroke or retrograde malperfusion when feasible (Class IIa, LOE B-NR). The 2024 EACTS/STS Guidelines similarly recommend antegrade systemic perfusion via axillary or direct aortic cannulation (Class IIa, LOE B).[1][4]
- Selective antegrade cerebral perfusion during circulatory arrest is reasonable to improve neurologic outcomes (Class IIa, LOE B-NR).
- Direct aortic or innominate artery cannulation with imaging guidance is reasonable as an alternative to femoral or axillary cannulation (Class IIa, LOE B-NR).[1]
Malperfusion Syndromes
Imaging evidence of malperfusion is present in up to 25% of patients with acute type A dissection. Clinical malperfusion syndrome carries a mortality of 30.5% versus 6.2% without malperfusion, and mortality correlates with the number of malperfused organs.[1]
- For renal, mesenteric, or lower extremity malperfusion: immediate operative repair of the ascending aorta is recommended (Class I, LOE B-NR). Residual malperfusion should be assessed postoperatively with secondary endovascular or surgical interventions as needed.
- For clinically significant mesenteric (celiac, SMA) malperfusion: either immediate ascending aortic repair or immediate mesenteric revascularization (endovascular or open) before ascending aortic repair is reasonable (Class IIa, LOE C-LD).[1]
Mesenteric malperfusion carries mortality exceeding 63%; untreated, IRAD data show in-hospital mortality of 95%. A hybrid operating room with endovascular capability is ideal for centers managing this complication.
Acute Type B Aortic Dissection
Uncomplicated Type B Dissection
Medical therapy is recommended as the initial management strategy for all patients with uncomplicated acute type B dissection (Class I, LOE B-NR).
Complicated Type B Dissection
Intervention is recommended for complicated acute type B dissection (Class I, LOE C-LD). Complications include rupture, branch artery occlusion with malperfusion, extension of dissection, progressive aortic enlargement, intractable pain, and refractory hypertension.[1]
- The 2024 EACTS/STS Guidelines provide a Class I, LOE B recommendation: in any TEVAR involving zone 2, left subclavian artery revascularization is recommended to reduce the risk of neurologic complications including stroke and spinal cord ischaemia.[4] This applies regardless of whether the TEVAR is performed for dissection, aneurysm, or other indications, and should be planned prospectively when zone 2 coverage is anticipated.
- For other complications with suitable anatomy: endovascular approaches are reasonable over open repair (Class IIa, LOE C-LD).
- The 2024 EACTS/STS Guidelines similarly recommend TEVAR for complicated acute type B dissection with suitable anatomy (Class I, LOE B) and FET repair when TEVAR anatomy is unsuitable (Class IIa, LOE B).[4]
High-Risk Anatomic Features in Uncomplicated Type B Dissection
Endovascular management may be considered for uncomplicated acute type B dissection with high-risk anatomic features (2022 ACC/AHA: Class IIb, LOE B-R; 2024 EACTS/STS: Class IIa for the subacute phase).[1][4]
High-risk imaging features (2022 ACC/AHA Table 28) include:
- Maximal aortic diameter >40 mm
- False lumen diameter >20–22 mm
- Entry tear >10 mm
- Entry tear on the lesser curvature of the aortic arch
- Increase in total aortic diameter >5 mm between serial imaging studies
- Bloody pleural effusion
- Imaging-only evidence of malperfusion
High-risk clinical features include refractory hypertension despite three or more antihypertensive classes at maximal doses, refractory pain persisting beyond 12 hours, and readmission.[1]
Connective Tissue Disorders
The 2022 STS/AATS Guidelines recommend open surgical repair as more durable than TEVAR in patients with connective tissue disorders (such as Marfan syndrome or Loeys-Dietz syndrome) who have type B dissection with disease progression despite optimal medical therapy (OMT).[5] TEVAR may be considered in the emergency setting or as a bridge.
Chronic Type B Aortic Dissection
Indications for elective intervention include aneurysmal dilation (total diameter ≥55–60 mm), rate of diameter growth >10 mm/year, or symptoms. The 2022 ACC/AHA Guideline recommends elective thoracic aortic repair for chronic residual dissection with total aortic diameter ≥5.5 cm (Class I, LOE B-NR).[1]
- Open surgical repair should be considered for chronic type B dissection with indications for intervention unless comorbidities are prohibitive (STS/AATS Class I).[5]
- TEVAR is reasonable for chronic type B dissection with suitable anatomy in patients at high surgical risk due to comorbidities (STS/AATS Class IIa).[5]
Intramural Hematoma
- Complicated acute type A or type B IMH: urgent repair is recommended (Class I, LOE B-NR).
- Uncomplicated acute type A IMH: prompt open surgical repair is recommended (Class I, LOE B-NR).
- In selected patients with uncomplicated acute type A IMH at increased operative risk without high-risk imaging features, an expectant medical approach may be considered (Class IIb, LOE C-LD).
- Uncomplicated acute type B IMH: medical therapy as the initial management strategy is recommended (Class I, LOE B-NR).
- Type B IMH requiring repair in zones 2–5 with favorable anatomy: endovascular repair is reasonable (Class IIa, LOE C-LD).
- Uncomplicated type B IMH with high-risk imaging features: intervention may be reasonable (Class IIb, LOE C-LD).[1]
TEVAR Complications
| Complication | Key Details |
|---|---|
| Retrograde type A aortic dissection (RTAD) | Occurs in ~2.3% (95% CI: 1.9–2.8%); early RTAD is ~1.8 times more common than late. Mortality 42.2% (95% CI: 32.5–51.8%). Patients with acute type B dissection are at higher risk than those with chronic dissection.[6] |
| Spinal cord ischemia (SCI) | Occurs in up to 5.8% of TEVAR patients. Risk factors include stent graft coverage >200 mm, distal seal zone 5, left subclavian artery (LSA) coverage, prior abdominal aortic surgery, and emergency procedures. Distal seal zone 5 is strongly associated with SCI (OR 7.4; P=0.001).[7] The STS/AATS Guidelines recommend LSA revascularization when TEVAR coverage obstructs antegrade LSA flow.[5] |
| Stroke | Early rate ~1.5% in the GREAT registry; LSA coverage and aortic arch aneurysm are independent predictors.[8] |
| Retrograde VQI data | In the VQI TEVAR for Dissection Registry (n=588), RTAD occurred in 2.6% (1.8% acute, 3.6% chronic) with overall mortality of 33.3%.[9] |
| Stent-graft–induced new entry (SINE) tears | Reported complication of TEVAR; mechanism is mechanical disruption of the dissection membrane by stent graft ends. |
| Endoleak | Type I or III endoleaks may require reintervention. |
| Acute type B aortic dissection Confirmed on CTA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Complicated? Rupture, malperfusion, refractory pain/HTN, progression | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| YES — Complicated | NO — Uncomplicated | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Suitable anatomy for TEVAR? Adequate landing zone, access | Optimal medical therapy Class I, LOE B-NR — all patients Acute phase: SBP 100–120 mmHg HR <70–80 bpm; IV beta-blocker | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| TEVAR Class I, LOE C-EO (rupture) Class IIa, LOE C-LD (other complications) | Open surgical repair Unsuitable anatomy or connective tissue disorder | High-risk imaging features? Diam >40 mm; FL >22 mm; entry tear >10 mm; bloody effusion; imaging malperfusion | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| LSA revascularisation if zone 2 covered (EACTS/STS Class I, LOE B) | Consider preemptive TEVAR Class IIb acute phase Class IIa subacute phase | Continue OMT Serial CTA or MRI surveillance | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Lifelong surveillance CTA or MRI; chronic phase SBP <130 mmHg (acute phase: SBP 100–120 mmHg) Long-term beta-blocker based therapy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Late intervention if: Aneurysm ≥55 mm Growth >10 mm/yr or >5 mm in 6 months Symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Intraoperative Monitoring and Organ Protection
Brain protection is a key element of ascending and arch aortic repair. Deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and retrograde cerebral perfusion alone or in combination are reasonable to minimize brain injury; institutional experience guides technique selection. Perioperative brain hyperthermia should be avoided.[1]
Cerebrospinal fluid drainage is recommended for patients at high risk of spinal cord ischemic injury during open and endovascular thoracic aortic repair. Spinal cord perfusion pressure optimization with proximal aortic pressure maintenance and distal aortic perfusion is reasonable. Moderate systemic hypothermia is reasonable for open descending aortic repairs. Early detection and treatment of SCI with blood pressure augmentation and CSF drainage enables complete neurologic recovery in the majority of patients.[10]
Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta and in endovascular procedures for monitoring, procedural guidance, and endoleak detection.[1]
2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease[1]
Recommendations for Multidisciplinary Aortic Teams
| Class I |
| 1. For patients with acute aortic disease that requires urgent repair, a multidisciplinary team should determine the most suitable intervention. (Level of Evidence: C-EO) |
| Class IIa |
| 2. For patients who are asymptomatic with extensive aortic disease, or who may benefit from complex open and endovascular aortic repairs, or with multiple comorbidities for whom intervention is considered, referral to a high-volume center (performing at least 30–40 aortic procedures annually) with experienced surgeons in a Multidisciplinary Aortic Team is reasonable to optimize treatment outcomes. (Level of Evidence: C-LD) |
Recommendations for Initial Surgical Considerations in Acute Type A Aortic Dissection
| Class I |
| 1. In patients presenting with suspected or confirmed acute type A aortic dissection, emergency surgical consultation and evaluation and immediate surgical intervention is recommended because of the high risk of associated life-threatening complications. (Level of Evidence: B-NR) |
| Class IIa |
| 2. In patients presenting with acute type A aortic dissection, who are stable enough for transfer, transfer from a low- to a high-volume aortic center is reasonable to improve survival. (Level of Evidence: B-NR) 3. In patients presenting with nonhemorrhagic stroke complicating acute type A aortic dissection, surgical intervention is reasonable over medical therapy to reduce mortality and improve neurologic outcomes. (Level of Evidence: B-NR) |
Recommendations for Management of Malperfusion
| Class I |
| 1. In patients with acute type A aortic dissection presenting with renal, mesenteric, or lower extremity malperfusion, it is recommended to proceed to immediate operative repair of the ascending aorta. (Level of Evidence: B-NR) |
| Class IIa |
| 2. In patients with acute type A aortic dissection presenting with clinically significant mesenteric (celiac, SMA) malperfusion, either immediate operative repair of the ascending aorta or immediate mesenteric revascularization via endovascular or open surgical intervention before ascending aortic repair is reasonable. (Level of Evidence: C-LD) |
Recommendations for Surgical Repair Strategies in Acute Type A Aortic Dissection
Aortic Repair Strategies
| Class I |
| 1. In patients with acute type A aortic dissection and a partially dissected aortic root but no significant aortic valve leaflet pathology, aortic valve resuspension is recommended over valve replacement. (Level of Evidence: B-NR) 2. In patients with acute type A aortic dissection who have extensive destruction of the aortic root, a root aneurysm, or a known genetic aortic disorder, aortic root replacement is recommended with a mechanical or biological valved conduit. (Level of Evidence: B-NR) 3. In patients with acute type A aortic dissection undergoing aortic repair, an open distal anastomosis is recommended to improve survival and increase false-lumen thrombosis rates. (Level of Evidence: B-NR) 4. In patients with acute type A aortic dissection without an intimal tear in the arch or a significant arch aneurysm, hemiarch repair is recommended over more extensive arch replacement. (Level of Evidence: B-NR) |
| Class IIb |
| 5. In selected patients who are stable, valve-sparing root repair may be reasonable, when performed by experienced surgeons in a Multidisciplinary Aortic Team. (Level of Evidence: C-LD) 6. In patients with acute type A aortic dissection and a dissection flap extending through the arch into the descending thoracic aorta, an extended aortic repair with antegrade stenting of the proximal descending thoracic aorta may be considered to treat malperfusion and reduce late distal aortic complications. (Level of Evidence: C-LD) |
Perfusion and Cannulation Strategies
| Class IIa |
| 7. In patients with acute type A aortic dissection undergoing surgical repair, axillary cannulation, when feasible, is reasonable over femoral cannulation to reduce the risk of stroke or retrograde malperfusion. (Level of Evidence: B-NR) 8. In patients with acute type A aortic dissection undergoing surgical repair who require circulatory arrest, cerebral perfusion is reasonable to improve neurologic outcomes. (Level of Evidence: B-NR) 9. In patients with acute type A aortic dissection undergoing surgical repair, direct aortic or innominate artery cannulation with imaging guidance is reasonable as an alternative to femoral or axillary cannulation. (Level of Evidence: B-NR) |
Recommendations for Management of Acute Type B Aortic Dissection
| Class I |
| 1. In patients with uncomplicated acute type B aortic dissection, medical therapy as the initial management strategy is recommended. (Level of Evidence: B-NR) 2. In patients with acute type B aortic dissection and rupture or other complications, intervention is recommended. In patients with rupture, in the presence of suitable anatomy, endovascular stent grafting rather than open surgical repair is recommended. (Level of Evidence: C-EO) |
| Class IIa |
| 3. In patients with other complications, in the presence of suitable anatomy, the use of endovascular approaches rather than open surgical repair is reasonable. (Level of Evidence: C-LD) |
| Class IIb |
| 4. In patients with uncomplicated acute type B aortic dissection who have high-risk anatomic features, endovascular management may be considered. (Level of Evidence: B-R) |
Recommendations for Management of Intramural Hematoma
| Class I |
| 1. In patients with complicated acute type A or type B aortic intramural hematoma, urgent repair is recommended. (Level of Evidence: B-NR) 2. In patients with uncomplicated acute type A IMH, prompt open surgical repair is recommended. (Level of Evidence: B-NR) 3. In patients with uncomplicated acute type B IMH, medical therapy as the initial management strategy is recommended. (Level of Evidence: B-NR) |
| Class IIa |
| 4. In patients with type B IMH who require repair of the distal aortic arch or descending thoracic aorta (zones 2–5) and have favorable anatomy, endovascular repair is reasonable when performed by surgeons with endovascular expertise. (Level of Evidence: C-LD) 5. In patients with type B IMH who require repair of the distal aortic arch or descending thoracic aorta (zones 2–5) and have unfavorable anatomy for endovascular repair, open surgical repair is reasonable. (Level of Evidence: C-LD) |
| Class IIb |
| 6. In selected patients with uncomplicated acute type A IMH who are at increased operative risk and do not have high-risk imaging features, an initial expectant approach of medical management may be considered. (Level of Evidence: C-LD) 7. In patients with uncomplicated type B IMH and high-risk imaging features, intervention may be reasonable. (Level of Evidence: C-LD) |
Recommendation for Long-Term Management After Acute Aortic Dissection and IMH
| Class I |
| 1. In patients with a previous acute aortic dissection and IMH, whether initially treated medically or with intervention, who have chronic residual thoracic aortic dissection and an aneurysm with a total aortic diameter of ≥5.5 cm, elective thoracic aortic repair is recommended. (Level of Evidence: B-NR) |
Recommendations for Brain Protection During Ascending and Arch Surgery
| Class I |
| 1. A brain protection strategy to prevent stroke and preserve cognitive function should be a key element of the surgical, anesthetic, and perfusion techniques used to accomplish repairs of the ascending aorta and transverse aortic arch. (Level of Evidence: B) |
| Class IIa |
| 2. Deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and retrograde cerebral perfusion are techniques that alone or in combination are reasonable to minimize brain injury during surgical repairs of the ascending aorta and transverse aortic arch. Institutional experience is an important factor in selecting these techniques. (Level of Evidence: B) 3. Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta and in endovascular thoracic aortic procedures for monitoring, procedural guidance, and endoleak detection. (Level of Evidence: B) |
| Class III (Harm) |
| 4. Perioperative brain hyperthermia is not recommended in repairs of the ascending and transverse aortic arch as it is injurious to the brain. (Level of Evidence: B) |
Recommendations for Spinal Cord Protection
| Class I |
| 1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury. (Level of Evidence: A) (2022 ACC/AHA, Section 6.5.4.3)[1] |
| Class IIa |
| 2. Spinal cord perfusion pressure optimization using proximal aortic pressure maintenance and distal aortic perfusion is reasonable as an integral part of the surgical, anesthetic, and perfusion strategy in open and endovascular thoracic aortic repair. (Level of Evidence: B) 3. Moderate systemic hypothermia is reasonable for protection of the spinal cord during open repairs of the descending thoracic aorta. (Level of Evidence: B) |
Recommendations for Renal Protection
| Class I |
| 1. In patients undergoing open thoracoabdominal aortic aneurysm repair in which the renal arteries are exposed, cold blood or crystalloid renal perfusion is recommended for renal protection. (Level of Evidence: A) (2022 ACC/AHA Guideline, Section 6.5.4.4)[1] |
| Class III (Harm) |
| 2. Furosemide, mannitol, or dopamine should not be given solely for the purpose of renal protection in descending aortic repairs. (Level of Evidence: B) (2010 ACCF/AHA Guideline) |
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 Isselbacher EM, Preventza O, Hamilton Black J III; et al. (2022). "2022 ACC/AHA guideline for the diagnosis and management of aortic disease". J Am Coll Cardiol. 80 (24): e223–e393. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check
|pmid=value (help). - ↑ Pape LA, Awais M, Woznicki EM; et al. (2015). "Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection". J Am Coll Cardiol. 66 (4): 350–8. doi:10.1016/j.jacc.2015.05.029. PMID 26205591.
- ↑ Harris KM, Nienaber CA, Peterson MD; et al. (2022). "Early mortality in type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection". JAMA Cardiol. 7 (10): 1009–1015. doi:10.1001/jamacardio.2022.2718. PMID 36001309 Check
|pmid=value (help). - ↑ 4.0 4.1 4.2 4.3 4.4 Czerny M, Grabenwöger M, Berger T; et al. (2024). "EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ". Eur J Cardiothorac Surg. 65 (2): ezad426. doi:10.1093/ejcts/ezad426. PMID 38408364 Check
|pmid=value (help). - ↑ 5.0 5.1 5.2 5.3 MacGillivray TE, Gleason TG, Patel HJ; et al. (2022). "The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection". J Thorac Cardiovasc Surg. 163 (4): 1231–1249. doi:10.1016/j.jtcvs.2021.11.091. PMID 35090765 Check
|pmid=value (help). - ↑ Ali-Hasan-Al-Saegh S, Halloum N, Scali S; et al. (2023). "A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection". Medicine. 102 (15): e32944. doi:10.1097/MD.0000000000032944. PMID 37058052 Check
|pmid=value (help). - ↑ Potter HA, Ding L, Han SM; et al. (2024). "Spinal cord ischemia and reinterventions following thoracic endovascular repair for acute type B aortic dissections". J Vasc Surg. 80 (3): 656–664. doi:10.1016/j.jvs.2024.03.458. PMID 38723912 Check
|pmid=value (help). - ↑ Piazza M, Squizzato F, Milan L; et al. (2019). "Incidence and predictors of neurological complications following thoracic endovascular aneurysm repair in the global registry for endovascular aortic treatment". Eur J Vasc Endovasc Surg. 58 (4): 512–519. doi:10.1016/j.ejvs.2019.05.011. PMID 31239097.
- ↑ Beck AW, Wang G, Lombardi JV; et al. (2022). "Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection postapproval project". J Vasc Surg. 75 (5): 1539–1551. doi:10.1016/j.jvs.2021.11.075. PMID 35090993 Check
|pmid=value (help). - ↑ Ullery BW, Cheung AT, Fairman RM; et al. (2011). "Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair". J Vasc Surg. 54 (3): 677–84. doi:10.1016/j.jvs.2011.03.259. PMID 21571494.