Surgical Management of Aortic Arch Pathology

Dicky Aligheri, MDCardiac & Vascular Surgeon

National Cardiac & Vascular Centre Harapan KitaJakarta 2014

Mr ES, 55yoChest & Back Pain 24h before admissionsHeavy smokers, uncontroled hipertension

Mr HR, 65yoChest & Back Pain 4d before

admissionsUncontroled hipertension,

DMHistory (+) 6 month

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

Interact Cardiovasc Thorac Surg. 2015 Jan;20(1):120-6. doi: 10.1093/icvts/ivu323. Epub 2014 Oct 3.Is extended arch replacement justified for acute type A aortic dissection?

In [patients undergoing surgery, for acute type A aortic dissection] does [aggressive initial treatment with total arch repair] result in [reduced mortality and improved closure of the distal false lumen]?

Medline 1950 to December 2013

We conclude that a more extensive surgical strategy can be justified when it is based on circumstances, on the individual patient's clinical condition, and on the anatomical and pathological features of the dissection

↵ Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405-9.

↵ Ohtsubo S, Itoh T, Takarabe K, Rikitake K, Furukawa K, Suda H, et al. Surgical results of hemiarch replacement for acute type A dissection. Ann Thorac Surg 2002;74:S1853-6. discussion S1857–3. Tan ME, Dossche KM, Morshuis WJ, ↵Kelder JC, Waanders FG, Schepens MA. Is extended arch replacement for acute type A aortic dissection an additional risk factor for mortality? Ann Thorac Surg 2003;76:1209-14.

↵ Shiono M, Hata M, Sezai A, Niino T, Yagi S, Negishi N. Validity of a limited ascending and hemiarch replacement for acute type A aortic dissection. Ann Thorac Surg 2006;82:1665-9

↵ Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunk implantation: a new ‘standard’ therapy for type a dissection involving repair of the aortic arch? Circulation 2011;123:971-8.

↵ Easo J, Weigang E, Holzl PP, Horst M, Hoffmann I, Blettner M, et al. Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection: analysis of the German Registry for Acute Aortic Dissection type A. J Thorac Cardiovasc Surg 2012;144:617-23.

↵ Zhang H, Lang X, Lu F, Song Z, Wang J, Han L, et al. Acute type A dissection without intimal tear in arch: proximal or extensive repair? J Thorac Cardiovasc Surg 2014;147:1251-5.

• “Tapper” like diameter

• 30 – 40 deg backward angulation

• Surround structures ,eg nerve

• “Tapper” like diameter

• 30 – 40 deg backward angulation

• Surround structures ,eg nerve

Mostly dissection Total arch replacement

Hemi arch replacement

Mostly aneurysm

Pathologic exclusion

L-Sc & ARM involvement

Mostly dissection Total arch replacement

Hemi arch replacement

Mostly aneurysm

Pathologic exclusion

L-Sc & ARM involvement

Schafer, PWHardin, CA. The use of temporary polyethylene shunts to permit occlusion, resection and frozen homologous graft replacement of

vital vessel segments. Surgery. 1952;31:186

Cooley, DAMahaffey, DEDeBakey, ME. Total excision of the aortic arch for aneurysm. Surg Gynecol Obstet. 1955;101:667.

DeBakey, MECrawford, ESCooley, DAMorris, GC. Successful resection of a fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet. 1957;105:657.

Creech, ODeBakey, MEMahaffey, DE. Total resection of the aortic arch. Surgery. 1956;40:817

• Griepp and colleagues' introduction of hypothermic circulatory arrest (HCA) was a major advance that greatly enhanced the safety of arch-replacement procedures

• he use of cerebral perfusion was reconsidered by Frist and colleagues

ConventionalAortic arch Surgery

Aortic arch Surgery

• Techniques– Conventional– Hybrid

• Issues– Cerebral Protection– Hypothermic arrest– Intra operative monitoring– Elephant trunk & secondary procedures

hYPOTHERMIC cIRCULATORY aRREST

Antegrade selective cerebral perfusion

Antegrade selective cerebral perfusion

Antegrade selective cerebral perfusion

• prolonged safe time of cerebral protection• moderate hypothermia and reduced CPB time• improved cerebral cooling and maintenance of

hypothermia• independent control of cerebral and systemic circulations

• technically more complicated• additional equipment required

Retrograde Cerebral Perfusion

• maintenance of cerebral hypothermia• washout of embolic air or debris• cerebral perfusion and metabolic support.

• Competent cerebral valve n dominant azygos circulation

Retrograde Cerebral Perfusion

* Our Routine• Median sternotomy• Cannulation sites :

– Axillary / Femoral Artery– Right atrial / SVC & IVC

• Myocardial Protection :– Antegrade CPG (Osteal)– Retrograde CPG– Surface cooling– LV venting

• Organ / Brain Protection :– DHCA– ASCP / RSCP– External cooling

Conclusions

• Aortic arch surgery is the most challenging part.

• Aortic arch should be considered in proximal/distal aortic procedures

• Some advancement with few drawback

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