Retrograde type A aortic dissection following endovascular arch repair: what do clinicians need to be aware of?

INTRODUCTION: Retrograde Type A aortic dissection (RTAD) is a life-threatening complication following thoracic endovascular aortic repair (TEVAR) or hybrid arch repair. Expanding use of endovascular arch interventions has heightened the need to better understand its mechanisms, risk factors, prevention strategies, and diagnostic challenges. AREAS COVERED: This Special Report reviews current evidence regarding the mechanisms, risk factors, clinical presentation, and management of RTAD following TEVAR. A structured literature search was conducted using PubMed/MEDLINE, Embase, and Scopus to identify relevant studies published from database inception through February 2026. Device-related, procedural, anatomic, and hemodynamic contributors are discussed, with particular emphasis on optimal device sizing, deployment technique, and surveillance. Advanced imaging modalities, including dynamic computed tomography angiography and four-dimensional flow magnetic resonance imaging, are examined for their potential to identify hemodynamically significant flow disturbances and refine risk stratification beyond static morphologic assessment. EXPERT OPINION: RTAD remains uncommon but catastrophic. Greater emphasis on patient selection, procedural planning, graft design optimization, and early multimodality imaging may reduce incidence. Future progress will depend on standardized reporting, improved computational and imaging-based risk predictors, and next-generation aortic devices engineered specifically for the arch.