AORTIC SURGERYfocus on Aortic Dissection & Aneurysm

Dicky A.Wartono ,MDNational Cardiovascular Centre Harapan Kita Jakarta

2014

Disclosure : none

Principle of Surgery

• Preventing the risk of dissection or rupture by restoring the normal dimension of the aorta

• Entry tear Exclusion & False lumen thrombosis• Pathology based level of surgery /

replacement

Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre

experience with 548 patients. Eur J Cardiothorac Surg 2013;44:337-345

Achneck HE, Rizzo JA, Tranquilli M, Elefteriades JA. Safety of thoracic aortic surgery in the present era. Ann Thorac Surg 2007;84:1180-1185

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM

Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic

Disease

March 2010

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM

Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic

Disease

March 2010

In the case of a normal tricuspid valve, without aortic regurgitation or central regurgitation due to annular dilation, an aortic valve-preserving technique should be performed

Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre experience with 548 patients. Eur J Cardiothorac Surg 2013;44:337-345.

2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM

Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic

Disease

March 2010

• mid & long term result of “valve sparring”– Severity (>mild)– Connective Tissue Diseases– Cuspid repair / pathology– Bicuspid– Type A Dissection

David T, Feindel C (1992). "An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.". J Thorac Cardiovasc Surg 103 (4): 617–21; discussion 622

"The Modified David's Reimplantation Procedure". clevelandclinic.org. Retrieved 15 July 2014David valve-sparing aortic root replacement: Equivalent mid-term outcome for different valve types

with or without connective tissue disorder John-Peder Escobar Kvitting, Fabian A. Kari, Michael P. Fischbein, David H. Liang, Anne-Sophie Beraud, Elizabeth H. Stephens, R. Scott Mitchell and D. Craig

Miller J Thorac Cardiovasc Surg 2013;145:117-1275

2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM

Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

March 2010

Fischbein, David H. Liang, Anne-Sophie Beraud, Elizabeth H. Stephens, R. Scott Mitchell and D. Craig Miller J Thorac Cardiovasc Surg 2013;145:117-1275

In the case of distal extension to the aortic arch, an limited but open distal anastomosis with the aortic arch or a hemiarch replacement should be performed

Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre

experience with 548 patients. Eur J Cardiothorac Surg 2013;44:337-345.

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM

Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic

Disease

March 2010

In the case of distal dissection extension to the aortic arch, an limited but open distal anastomosis with the aortic arch or a hemiarch replacement should be performed

Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre

experience with 548 patients. Eur J Cardiothorac Surg 2013;44:337-345.

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

Shrestha M, Martens A, Kruger H, Maeding I, Ius F, Fleissner F, Haverich A. Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results. Eur J

Cardiothorac Surg 2014;45:289-296

Extensive repair including graft replacement of the ascending aorta and aortic arch and integrated stent grafting of the descending aorta (‘frozen

elephant trunk') was introduced as a single-stage procedure

Cochennec F, Tresson P, Cross J, Desgranges P, Allaire E, Becquemin JP. Hybrid repair of aortic arch dissections. J Vasc Surg 2013;57:1560-1567

Arch vessel transposition (debranching) and TEVAR might be considered, especially when there is reluctance to expose patients to hypothermic circulatory arrest;Patients with the underlying diagnosis of acute Type B AD, the risk of retrograde Type A AD as a direct consequence of the procedure is elevated

Marana MAI, Alonso VG, Revuelta NC, et al.: Combined treatment, endovascular and surgical treatment of posttraumatic pseudoaneurysm in the aortic arch. EJVES Extra 2006, 12(9):25-29. Choi BK, Lee HC, Lee HW, et al.: Successful treatment of a ruptured aortic arch aneurysm using a hybrid procedure. Korean Circ J 2011, 41:469-473. PubMed Abstract | Publisher Full Text | PubMed Central Full Text Sanchez MJ, Ananian CL, Berkmen T: Embolization of an aortic arch pseudoaneurysm with coils and N-Butyl-Cyanoacrylate. J Vasc Interv Radiol 2006, 17:1677-1679. PubMed Abstract | Publisher Full Text Westaby S, Katsumata T, Vaccari G: Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg 1999, 15:180-185. PubMed Abstract | Publisher Full Text Baguley CJ, Sibal AK, Alison PM: Repair of injuries to the thoracic aorta and great vessels. ANZ J Surg 2005, 75(6):383-387. PubMed Abstract | Publisher Full Text Bouchart F, Bessou JP, Tabley A, et al.: Acute traumatic rupture of the thoracic aorta and its branches. Results of surgical management. Ann Chir 2001, 126(3):201-211. PubMed Abstract | Publisher Full Text

Marana MAI, Alonso VG, Revuelta NC, et al.: Combined treatment, endovascular and surgical treatment of posttraumatic pseudoaneurysm in the aortic arch. EJVES Extra 2006, 12(9):25-29. Choi BK, Lee HC, Lee HW, et al.: Successful treatment of a ruptured aortic arch aneurysm using a hybrid procedure. Korean Circ J 2011, 41:469-473. PubMed Abstract | Publisher Full Text | PubMed Central Full Text Sanchez MJ, Ananian CL, Berkmen T: Embolization of an aortic arch pseudoaneurysm with coils and N-Butyl-Cyanoacrylate. J Vasc Interv Radiol 2006, 17:1677-1679. PubMed Abstract | Publisher Full Text Westaby S, Katsumata T, Vaccari G: Arch and descending aortic aneurysms: influence of perfusion technique on neurological outcome. Eur J Cardiothorac Surg 1999, 15:180-185. PubMed Abstract | Publisher Full Text Baguley CJ, Sibal AK, Alison PM: Repair of injuries to the thoracic aorta and great vessels. ANZ J Surg 2005, 75(6):383-387. PubMed Abstract | Publisher Full Text Bouchart F, Bessou JP, Tabley A, et al.: Acute traumatic rupture of the thoracic aorta and its branches. Results of surgical management. Ann Chir 2001, 126(3):201-211. PubMed Abstract | Publisher Full Text

We feel that hybrid procedure may be a valuable therapeutic alternative when treating this type of lesion. However, long-term clinical efficacy and safety have yet to be confirmed.

The simple ‘clamp and sew’ technique may not be advisable because the risk of post-operative neurological deficit, mesenteric and renal ischaemia is significant when the aortic cross-clamp procedure exceeds 30 minutes

Johansson G, Markstrom U, Swedenborg J. Ruptured thoracic aortic aneurysms: a study of incidence and mortality rates. J Vasc Surg

2013;21:985-988

Acher CW, Wynn MM, Hoch JR, Popic P, Archibald J, Turnipseed WD. Combined use of cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in

thoracoabdominal aneurysm repair. J Vasc Surg 1994;19:236-246

Kulik A, Castner CF, Kouchoukos NT. Outcomes after thoracoabdominal aortic aneurysm repair with hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2011

Future

• Single Stage Hybrid Surgery • Endovascular Complication Surgery• Aortic Re-operation

THANK YOU