diseases of the aorta seoul national university hospital department of thoracic & cardiovascular...
TRANSCRIPT
![Page 1: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/1.jpg)
Diseases of the AortaDiseases of the Aorta
Seoul National University HospitalDepartment of Thoracic & Cardiovascular Surgery
![Page 2: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/2.jpg)
Anatomy of Aorta
Aortic root aortic valve, sinus of Valsalva, c
oronary artery Ascending aorta
aortic root ~ innominate artery Aortic arch
proximal, distal Descending thoracic aorta
distal to LSCA ~ 12th ICS Thoracoabdominal aorta
descending thoracic aorta & abdominal aorta
![Page 3: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/3.jpg)
Properties of Aorta & Major Conduit
1. Aorta
Compliant vessel (Windkessel function)
; transforms pulsatile hydraulic energy into a more ste
ady flow by elastic distension & contraction
2. Synthetic conduit
Noncompliant
; must result in alteration of arterial hemodynamics
& LV load (increased impedance & afterload)
![Page 4: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/4.jpg)
Diseases of Thoracic Aorta
Aortic aneurysm
Aortic dissection
Obstructive disease of branches
of the thoracic aorta
Traumatic aortic rupture
![Page 5: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/5.jpg)
Pathophysiology of Aortic AneurysmDefinition
localized or diffuse dilatation > 50% of normal diam. Most common aortic disease that require surgery
Etiology Atherosclerosis ( + underlying weakness) Chronic aortic dissection Annuloaortic ectasia (Marfan syndrome) Trauma Infection Associated with aortic valve disease
![Page 6: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/6.jpg)
Histopathology of Ascending Aortic Aneurysm
1. Cystic medial necrosis by pooling of mucoid material
2. Elastin fragmentation by disruption of elastin lamellae
3. Fibrosis as an increase in collagen at the expense of smooth muscle cells
4. Medionecrosis as areas with apparent loss of nuclei
![Page 7: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/7.jpg)
Pathophysiology of Ascending AA
Marfan syndrome Incidence
– 1 / 5,000 Annuloaortic ectasia is very common Associated defects
– Aortic regurgitation, mitral valve prolapse, dysrhythmia
– Tall stature, long limbs and digits, anterior chest deformity, joint laxity, vertebral column deformity
– High arched palate, lens disorder
![Page 8: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/8.jpg)
Marfan’s Syndrome
* Definition
1) A heritable disorder (AD) of connective tissue involving biochemic
al abnormality of extracellular matrix by a mutation in fibrillin gene on
chromosome 15 (Fibrillin-1, 350-KD glycoprotein : integral structural c
omponent of 10-nm noncollagenous microfibrils of extracellular matr
ix in most tissue)
2) The absence of structural integrity of skeletal, ocular, & cardiov
ascular system
3) Adult patients demonstrate abnormal elastic properties manifes
ted by decreased aortic distensibility & increased stiffness index
![Page 9: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/9.jpg)
Marfan’s Syndrome
Clinical manifestations Cardiovascular
Ocular
Skeletal abnormality
Cardiovascular manifestations Progress with time Mitral valve prolapse in 100% Aortic root dilatation in 80% Rarely atrial septal aneurysm
![Page 10: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/10.jpg)
Manifestations of Marfan’s Syndrome
1. Patterns of aortic dilatation 1) 80% of the patients shows aortic dilation
2) more commonly generalized form than localized form
3) more commonly aortic regurgitation in generalized form
2. Natural prognosis 1) Life expectancy is significantly reduced (40~50) as a
consequence of aortic dilatation & its complications
(aortic dissection, fatal rupture, AR, heart failure)
![Page 11: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/11.jpg)
Marfan’s Syndrome in Children
1. Diagnosis can be made at any age with marked variation
in clinical expression.
2. Patients without family history (in one third of patients
of all age) have more severe manifestation probably
due to sporadic mutation.
3. Surgery should be carried out even in asymptomatic
patients, once the diameter of the aortic root or
ascending aorta reaches 5 to 6cm as in adults.
4. Mitral valve prolapse is as common as aortic root
dilatation and progression can cause significant
morbidity & mortality.
![Page 12: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/12.jpg)
Patterns of Aortic Aneurysm
Locations of Aneurysm
Ascending aorta 45 %
Aortic arch 10 %
Descending thoracic aorta 35 %
Thoracoabdominal aorta 10 %
![Page 13: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/13.jpg)
Natural History of AA
Aortic aneurysm Incidence
– 5.9 new aneurysms / 100,000 person-years Life time probability of rupture : 75~80% 5-yr untreated survival rate : 10~20% Median time to rupture : 2~3 yrs
Size Risk of rupture within 1yr
< 5 cm 4 % 6 cm 43 % 8 cm 80 %
![Page 14: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/14.jpg)
Clinical Presentation of AA Symptoms & signs
Asymptomatic Compressive symptoms
– recurrent laryngeal n. or vagus n. : hoarseness– tracheobronchial tree : dyspnea– pulmonary a. : fistula, bleeding pulmonary HT & edema– esophagus : dysphagia– stomach : sensation of satiety wt. loss
Pain aneurysmal expansion
Intestinal angina, renovascular HT associated atherosclerotic obstructive disease (5% in TAAA)
Physical finding - usually unremarkable Wide pulse pressure, diastolic murmur AR
![Page 15: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/15.jpg)
Indications for Aortic Aneurysm
Aneurysm diameter 5cm Aneurysm with documented enlargementSymptomatic aneurysm
― chest pain or back pain indicating expansion
― significant aortic regurgitation
![Page 16: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/16.jpg)
Dissecting Aortic Aneurysm
Catastrophic event Intimal tear False channel
in the outer half of the media
highly susceptible to rupture
Acute dissection < 2 wks from Sx onset
Chronic dissection > 2 wks from Sx onset
![Page 17: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/17.jpg)
Pathophysiology of Aortic Dissection
Malperfusion Reentry
![Page 18: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/18.jpg)
Predisposing Factors of DA
Hypertension Cystic medial necrosis Marfan syndrome AAE(annuloaortic ectasia) Bicuspid aortic valve Coarctation Pregnancy Chest trauma
![Page 19: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/19.jpg)
Classification of Dissection
Standford Type A
Involvement of the a-Ao ( arch or d-Ao) regardless of site of primary intimal tear
Type BAll others without involvement of a-Ao
DeBakey I, II, IIIAccording to the location of intimal tear
![Page 20: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/20.jpg)
Classification of Aortic Dissection
A B
II I III
![Page 21: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/21.jpg)
Natural History of DA
Annual incidence 5~10 / million
Sex ratio M:F = 2:1 ~ 5:1
Acute dissection Median time to rupture : 3 days Mortality rate ; 50 % within 2 days
75 % within 2 wks
Chronic dissection Median time to rupture : 1~3 Yrs Follows patterns of non-dissecting aneurysm
![Page 22: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/22.jpg)
Clinical Presentation of DA
Acute dissection Excruciating pain
– abrupt onset– sudden rise to peak – Chest pain
2/3 of a-Ao dissection
– Back pain dissection distal to aortic arch
– Pain may migrate as the dissection moves distally.
Various extent of peripheral & central vessel occlusion– from progression of dissection through the false lumen
Failure of diagnosis : major problem
![Page 23: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/23.jpg)
Clinical Presentation of DA
Type A Type B Frequency
Pain anterior substernal posterior, midscapular, abdominal
Syncope +++ rareDyspnea + ―Blood pressure elevated 50%, low 20% elevated 80%Asymmetric pulses upper, lower extremity lower extremity 30-50%Diastolic murmur 50% 10%Pericardial effusion +++ rarePleural effusion ± +++Hemiparesis or plegia + ― 5-6%Paraparesis or plegia + + 2-6%Renal, intestinal infarction + + 3-5%Myocardial infarction + rare 10 %
![Page 24: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/24.jpg)
Principle of Treatment in DA
Type A acute aortic dissection Emergent operation
Type B acute aortic dissection Medical Tx and observation unless life threateni
ng Surgical indication
– Persistent pain– Aneurysmal dilatation ( 5cm)– End organ (kidney, bowel) or limb ischemia– Evidence of retrograde dissection to the a-Ao
![Page 25: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/25.jpg)
Medical Management of DA Initial management
Immediate ICU care
BP control & Monitoring
– Central line, arterial line, urine output
Imaging studies
– Daily Chest X-ray, weekly CT scan during hospitalization
Pharmacologic therapy Vasodilator : Sodium nitroprusside
β-blocker : Esmolol (β-1 selective & short acting)
![Page 26: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/26.jpg)
Diagnostic Studies for DA
CT & CT angiography Aneurysm size, location, extent, intimal tear site
Other pathologies in the chest & abdomen
Follow-up study : aneurysm growth
Limitation – unreliable detection of root enlargement
Contraindication – renal insufficiency, allergy to contrast agents
![Page 27: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/27.jpg)
MRI Noninvasive study Do not require contrast medium Better than CT at detecting aortic root dila
tation Disadvantages
cost required time (esp, in acute dissection)
Contraindication pacemaker, claustrophobia
Diagnostic Studies for DA
![Page 28: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/28.jpg)
Transesophageal Echocardiography (TEE) Accuracy in imaging intimal tear : 90%
Assessment of cardiac structure & function
Highly sensitive in aortic pathology diagnosis – aortic valve disease, aortic dilatation, dissection, thromb
i, atherosclerotic disease
Intraoperative monitoring– check cardiac function, aortic valve competency, atheroscl
erosis in the thoracic aorta Limitation
– requires a skilled cardiologist
Diagnostic Studies for DA
![Page 29: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/29.jpg)
Diagnostic Studies for DA Aortography
Geography of the aorta & condition of smaller vessels Previous gold standard in dissection
– double lumen, tear site, extent Indication
– renovascular HT, intermittent claudication, atherosclerotic occlusive abdominal aorta, symptoms of carotid artery occlusion
Disadvantages– invasive procedure using radiopaque dyes
Cardiac cath & coronary angiography Evaluation of the concomitant coronary artery disease
![Page 30: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/30.jpg)
Principles of Surgical Tx in Acute Dissection Resection of aortic segment containing intimal tear
Obliteration of false lumen in both end of remained aorta Graft replacement of resected aortic segment
Techniques Median sternotomy Femoral-femoral bypass Trendelenburg position Circulatory arrest with deep hypothermia Retrograde cerebral perfusion Reinforcement of the intima & adventitia together
(sandwich technique)
Surgery of Type A Dissection
![Page 31: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/31.jpg)
Operation of Type A Dissection
![Page 32: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/32.jpg)
Type A Dissection
![Page 33: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/33.jpg)
Techniques Similar to the techniques for aneurysm Rechanneling blood into the true lumen Ligation of all intercostal arteries in acute dissecti
on
Surgical indications Persistent pain Aneurysmal dilatation ( 5cm) End organ(kidney, bowel) or limb ischemia Evidence of retrograde dissection to the a-Ao
Surgery of Acute Type B Dissection
![Page 34: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/34.jpg)
Acute Type A Dissection Early mortality : 20~30 % Main cause of death underlying end-organ injury Major complications stroke (9%) Major risk factors for postop. stroke
– pump time, episode of severe hypotension
Acute Type B Dissection Early mortality : 25~50 % (cf. medical treatment : 7~32 %) Major complications : ischemic spinal cord injury
Surgical Results of DA
![Page 35: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/35.jpg)
Surgical Treatment of AA Aneurysm : Aortic Root, a-Ao, Aortic Arch
Historical evolution
1950s : Cardiopulmonary Bypass (Gibbon)
1955 : 1st successful a-Ao repair (Cooley & DeBakey)
1964 : 1st successful replacement of entire a-Ao (Wheat)
– CPB, coronary perfusion, myocardial cooling, cold cardiac arrest
1968 : Composite valve graft (Bentall & de Bono)
1975 : Replacement of entire aortic arch (Griepp)
– profound hypothermia & circulatory arrest
![Page 36: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/36.jpg)
Aortic Root, Ascending Aorta, Aortic Arch
Limitation of profound hypothermia< 30 min : safe duration > 45 min : increased incidence of stroke> 65 min : increased incidence of death
Calculated safe duration of hypothermic circulatory arrest Temperature Cerebral Metabolic Rate Safe Duration of HCA
(C) (% of baseline) (min)
37 100 5
30 56 ( 52 ~ 60 ) 9 ( 8 ~ 10 )
25 37 ( 33 ~ 42 ) 14 ( 12 ~ 15 )
20 24 ( 21 ~ 29 ) 21 ( 17 ~ 24 )
15 16 ( 13 ~ 20 ) 31 ( 25 ~ 38 )
10 11 ( 8 ~ 14 ) 45 ( 36 ~ 62 )
![Page 37: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/37.jpg)
Aortic Root, Ascending Aorta, Aortic Arch
Adjuncts for brain protection
Reintroduction of antegrade cere
bral perfusion (Frist, 1987)
Retrograde cerebral perfusion (U
eda, 1989)
![Page 38: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/38.jpg)
Aortic Root - Techniques
Median sternotomy Antegrade and/or retrograde cardioplegic perfusion Techniques for aortic root
– Wheat – Composite graft (esp, for Marfan)
Bentall Cabrol modified Cabrol button
– Homograft– Valve sparing procedure Choice of tube graft ; diameter of 10%
smaller than the length of the free
margin of the aortic leaflet
![Page 39: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/39.jpg)
Valve-sparing Operation
Resorting aortic root dimensions in an aortic valve-sparing operation when aortic annulus is normal and sinotubular junctio
n is enlarged
Resorting aortic root dimensions in an aortic valve-sparing operation when aortic annulus is normal and sinotubular junctio
n is enlarged
![Page 40: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/40.jpg)
Valve-sparing Operation
Resorting aortic root dimensions when aortic annulus & sinotubular junction are normal, as in aortic dissection
Resorting aortic root dimensions when aortic annulus & sinotubular junction are normal, as in aortic dissection
![Page 41: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/41.jpg)
Valve-sparing Operation
Resorting aortic root dimensions when aortic annulus and sinotubular junction are enla
rged, as in anuloaortic ectasia with Marfan syndrome
Resorting aortic root dimensions when aortic annulus and sinotubular junction are enla
rged, as in anuloaortic ectasia with Marfan syndrome
![Page 42: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/42.jpg)
Valve-sparing Operation
Reconstructing aortic root using a graft with the aortic valve placed within it
Reconstructing aortic root using a graft with the aortic valve placed within it
![Page 43: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/43.jpg)
Separate valve/graft replacement For older patients with mild to moderate sinus
dilatation
Aortic Root – Wheat Technique
![Page 44: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/44.jpg)
Bentall technique Coronary artery reattachment
side-to-side anastomosis Disadvantage
bleeding d/t anastomosis tension → pseudoaneurysm (7~25%)
Aortic Root – Composite Valve Graft
![Page 45: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/45.jpg)
Cabrol technique Coronary artery reattachment
– a small graft to the both coronary arteries
– side-to-side anastomosis of the small graft & composite graft
Advantage– ↓anastomosis tension
Disadvantage– kinking at the anastomosis sites
Aortic Root – Composite Valve Graft
![Page 46: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/46.jpg)
Modified Cabrol technique Coronary artery reattachment
– a small graft to the LCA– end-to-side anastomosis of the small gra
ft & composite graft– button attachment of the RCA
Advantage– ↓kinking
Aortic Root – Composite Valve Graft
![Page 47: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/47.jpg)
Button technique Coronary artery reattachment Carrel patch for both coronary a.
Direct anastomosis to the composite graft
Aortic Root – Composite valve graft
![Page 48: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/48.jpg)
Composite Valve Graft
A; aortic valve is excised
B; composite prosthetic valve conduit is
attached to annulus of aortic valve
A; aortic valve is excised
B; composite prosthetic valve conduit is
attached to annulus of aortic valve
![Page 49: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/49.jpg)
Results Early mortality : 2~15% Early complications : thromboembolism, bleeding Late complications : endocarditis, thromboembolism
pseudoaneurysmTechnique Major Complications 30-Day Survival (%) 5-Yr Survival (%)
Wheat Endocarditis (5%) 85 70
Bentall Thromboembolism (5~10%), endocarditis (5%)
85~90 70~85
Cabrol 90 75
Button Thromboembolism (2~10%), endocarditis (5%)
85~95 70~85
Surgery of Aortic Root
![Page 50: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/50.jpg)
Surgery of Aortic Root Results
![Page 51: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/51.jpg)
Closed technique Limited to a-Ao Aorta cross clamp
Ascending Aorta & Arch
Open techniqueArch involvementDeep hypothermia & circulatory arrest
–EEG monitoring–Retrograde cerebral perfusion
![Page 52: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/52.jpg)
Elephant Trunk Technique (by Borst, 1988) for extensive aortic aneurysm
(“mega-aorta”)
![Page 53: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/53.jpg)
Elephant Trunk Technique (Staged op.)
![Page 54: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/54.jpg)
Results
Major complications – stroke, encephalopathy
Major risk factors – circulatory arrest time, transverse arch involvement
Technique Major Complications 30-Day Survival (30%)
Normothermia Not reported 25
+ Antegrade cerebral perfusion Not reported 75
TCA with profound hypothermia Stroke (2~10%) 85~90
+ Antegrade cerebral perfusion Stroke (5~6%) 80~100
+ Retrograde cerebral perfusion Stroke (3%) 95
Surgery of Ascending Aorta & Arch
![Page 55: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/55.jpg)
Spinal protection Arterial radicularis magna (Adamkiewicz a.) Technique
– Shunt– Hypothermic circulatory arrest– Spinal cord cooling – Pharmacologic agent – Sequential aortic clamp– Distal aortic perfusion– CSF drainage– Intercostal artery reattachment (T9~12)
Descending Thoracic & Thoracoabdominal Aorta
![Page 56: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/56.jpg)
Indications – Poor surgical candidates for
thoracic aneurysm – Expected survival time < 5 yrs
Problem – Endoleaks (→ graft migration)– Exclusion of intercostal arteries– Lack of long-term data
Results– Early mortality : 9%– Complications
stroke (7%) paraplegia (3%) early endoleak (24%) reintervention (5%)
Endovascular Stent Graft
![Page 57: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/57.jpg)
Modified Crawford’s classification for TAAA
Thoracoabdominal Aorta
![Page 58: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/58.jpg)
–Technique Thoracoabdominal incision Descending thoracic aorta involvement
Distal aortic perfusionCSF drainageIntercostal artery reattachment
(T9~12) Celiac axis, SMA, IMA, renal arteries
Visceral perfusionCarrel patch or bypass graft
Thoracoabdominal Aorta
![Page 59: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/59.jpg)
Thoracoabdominal Aorta
![Page 60: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/60.jpg)
Descending Thoracic & Thoracoabdominal Aorta Results
Risk Factors for poor outcome– aneurysm extent (type II)– preop. renal dysfunction– aortic cross clamp time
Technique Major Complications 30-Day Survival 5-Yr Survival
Descendingthoracic
Neurologic deficit (2~15%),renal failure (14%)
50~80%
TAAA type I, II& IV
Neurologic deficit (0~15%),renal failure (5~25%)
90~95 % 60~75%
TAAA type II,no adjuncts
Neurologic deficit (30~40%),renal failure (17%)
78% 35%
TAAA type II,with adjuncts
Neurologic deficit (12%), renalfailure (7%)
90% 60~70%
![Page 61: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/61.jpg)
Abdominal Aortic Aneurysm
1. Type Fusiform : most
Sacciform
Dissecting : rare
False
2. Etiology Atherosclerosis : 90%
Traumatic
Syphilitic
Congenital
Infected
Pregnancy related
Anastomotic
![Page 62: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/62.jpg)
Pathophysiology of Abdominal Aorta
Nature of the aortic wall
1) Contain more elastin, deposition of
cholesterol and calcium
2) Stress factor and turbulent flow due to
origin of major branches
3) Stability of proximal abdominal aorta and
presence of large bifurcation
Hemodynamic factor
Physical factor
![Page 63: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/63.jpg)
Procedures for Abdominal AA
1 Heparin 1mg/kg IV
2 Mannitol 0.5g/kg in suprarenal clamp
3 Inferior mesenteric artery occlusion
4 Lumbar arteries oversewn
5 Proximal and distal anastomosis
6 Reimplantation of inferior mesenteric
artery
![Page 64: Diseases of the Aorta Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery](https://reader035.vdocuments.us/reader035/viewer/2022081420/56649dba5503460f94aaa9b2/html5/thumbnails/64.jpg)
Operative Complications
1 Division of parasympathetic and
sympathetic nerves crossing the
proximal common iliac arteries
2 Peripheral embolism
3 Paralytic ileus
4 Aortoenteric fistula