surgical treatment for aortic arch aneurysms

Lenox Hill Heart and VascularInstitute of New York

Surgical Treatment for AorticArch Aneurysms

Konstadinos A Plestis, MD

Associate Professor

Director of Aortic Surgery

Department of Thoracic and Cardiovascular Surgery

Lenox Hill Hospital, NY


Hemiarch


Total Arch


Types of Cerebral Injuryduring Arch Surgery

Focal embolic

Diffuse ischemic


METHODS OF CEREBRAL PROTECTION

Deep hypothermic circulatory arrest HCA

Griepp 1975

Retrograde cerebral perfusion RCP

Ueda 1990, Takamoto 1992, Safi 1993

Antegrade cerebral perfusion ACP

Debakey 1957, Frist 1986, Bachet 1991, Kazui 1992


Griepp, et. al. JTCVS, 1975

Deep Hypothermic Circulatory Arrest


Suppression of Metabolism with HCA

at Different Temperatures

Mezrow et al, JTCVS 1994

McCullough et. al. Ann Thorac Surg, 1999


0

20

40

60

80

100

120

37 30 25 20 15 10

0

5

10

15

20

25

30

35

40

45

% CMRO2

SAFE HCA

Duration of HCAMin

% C

MR

O2

Temperature °C

Actual Q10 directly calculated in 37 Adult patients during DHCA

What is the LIMIT of “SAFE” HCA?

McCullough et. al. Ann Thorac Surg, 1999


Temporary Dysfunction Duration

Grade 1 simple confusion short

Grade 2 confusion + lethargy short

Grade 3 confusion + agitation short

Grade 4 overt psychosis long

Grade 5 psychosis, parkinsonism long

Cognitive Function and Temporary Neurological Dysfunction


DHCA > 25 minutes

Advanced age

Neuropsychological impairment in fine motor and memory functions

Temporary Neurologic Dysfunction


Selective Antegrade Cerebral Perfusion


Neurological Outcome after Thoracic Aortic Surgery

Effect of Cerebral Protection Method on Stroke,

0

5

10

15

20

HCA HCA+ACP

Transient

Permanent

Stroke [%]

Transient

Permanent

Hagl et. al. JTCVS, 2001


Neurological Outcome after Thoracic Aortic Surgery

TND by Cerebral Protection Method

0

10

20

30

40

50

60

70

HCA HCA+ACP

TND [%]

*

* p = 0.05OR 0.33

Hagl et. Al. JTCVS, 2001


Srategies to Minimize Cerebral Injury in Arch Surgery

Minimize particulate embolization

Axillary cannulation

Avoid manipulation of diseased vessels

Trifurcation graft

Aspirate cerebral vessels prior to resuming cerebral perfusion


• 22F – 26F

• wire-reinforced

• right angled

• flexible cannula


Pre-operative Aneurysm


Srategies to Minimize Cerebral Injuryduring Aortic Arch Surgery

Optimize implementation of HCA

Trifurcation graft (arch first technique)

EEG, SSEP

INVUS

Head packed in ice

Antegrade selective cerebral perfusion


OPTIMAL PARAMETERS FOR SELECTIVE CEREBRAL PERFUSION

Temperature: 10º-15ºC

Pressure: 50-70 torr

pH management: alpha stat

Hematocrit: 30%


Re-Operative Complex

Aortic Arch Repair

Konstadinos A Plestis, MDDirector, Aortic Surgery

Lenox Hill Hospital



Case presentation 53 yr male

s/p AVR (bioprosthesis)- 2006

s/p Type A Aortic Dissection – 2007

Aortic Root Replacement

bioprosthetic composite valve graft

reimplantation of the right and left main coronary arteries (Cabrol)



BovineAortic Arch

L MainCabrol



True Lumen

False Lumen

Left Subclavian

RightCabrol Left Cabrol



True Lumen Thrombus



Celiacaxis

SMA

True lumen



• Right subclavian artery and right femoral vein cannulation

• Re-redo median sternotomy on bypass

• Deep Hypothermic Circulatory Arrest at 20° C



Surgical Strategy

• Trifurcation graft to innominate, left carotid and left subclavian arteries

• Antegrade selective cerebral perfusion

• Fenestration of the descending aorta

• Elephant trunk (Stage I)



• 66 yo Female

• S/P Right Nephrectomy

• Severe retrosternal chest pain


CT Angiogram:

Ascending: 8 cm Arch: 5.4 cm Descending: 8cm.

Abdominal: 11.7 cm.


Distal Arch


Ascending

Descending


Descending


Supraceliac Aorta


Abdominal Aorta


Ascending Aorta

Abdominal Aorta


Thoracoabdominal Aneurysm


• Aortic Valve Repair

• Replacement of Ascending/ Arch Aorta

•(Stage I – Elephant Trunk)

• Reimplantation of Brachiocephalic, left Carotid

and left Subclavian

•(Trifurcation graft)

•DHCA, ACP, SSEP, EEG


Elephant Trunk


Elephant Trunk Graft


•Replacement of type I TAAA (stage II ET)

•Reimplantation of Celiac, SMA, Left Renal Artery

(trifurcation graft)

•Perfusion of Celiac, SMA, and Left Renal with cold blood

•DAP, CSF drainage, SSEP, MEP


Trifurcation graft


Celiac

SMA

Left Renal


Left renal


Distal Anastomosis


• 70 yo Female

• S/P Type A - Aortic dissection repair (‘96)

• Severe retrosternal chest pain


CT Angiogram:

Ascending Aorta = 5.0 cm.

Aortic Arch = 6.0 cm.

Descending Aorta = 3.4 cm.


Brachiocephalic ArteryLeft Common Carotid Artery

Left Subclavian Artery


False Lumen of Dissection

Brachiocephalic Artery


Left Common Carotid Artery


False Lumen

Brachiocephalic Artery


Left Common Carotid Artery


False Lumen

True Lumen


False lumen

True Lumen


Ascending Aorta

False LumenTrue Lumen


False Lumen

True Lumen


True LumenFalse Lumen False Lumen


•Bilateral Anterior Thoracotomy

•Replacement of Ascending/ Arch/ Descending with a 22 mm Dacron graft.

•Reimplantation of Brachiochephalic, Left Carotid, Left Subclavian with a trifurcation graft.

•DHCA, ACP, EEG,SSEP


Trifurcation Graft


Descending Aortic Graft

Ascending Aortic Graft


Trifurcation


Trifurcation Graft Origin


Ascending Aortic Graft

Brachiocephalic branch of graft

Left Carotid


Aortic Graft Arch

Trifurcation Branches:• Brachiocephalic

• Left CCA

• Left Subclavian


False Lumen

Graft

Distal End of GraftGraft


Arch Replacement

9/05-9/11

N=157 Pts

Hemiarch 100

Total Arch 57


Etiology

Acute Dissection 17 17% 8 14%

Chronic Dissection 19 19% 18 32%

Medial degeneration 48 48% 24 42%

Atherosclerosis 6 6% 7 17%

Hemiarch Total Arch


Demographics

HTN 80 80% 47 82%

ASHD 1 9 19% 15 26%

COPD 24 24% 9 16%

Cerebrovascular 12 12% 10 18%

disease

Hemiarch Total Arch


Operative Variables

Root 57 57% 13 23%

Redo 33 33% 21 37%

Elective 60 60% 31 54%

Hemiarch Total Arch


Operative variables

Right Axillary 33 33% 50 88%

cannulation

RCP 44 44% 4 7%

ACP 15 15% 44 77%

Hemiarch Total Arch


Trifurcated Graft Arch Replacement

Mortality 8 8% 2 4%

Stroke 5 5% 2 4%

TIA 1 1% 2 4%

TND 4 4% 4 7%

Hemiarch Total Arch


Conclusions

Total Aortic Arch replacement with the trifurcation graft has led to simplification of the technical aspects of the operation

The technique is very versatile and can be used in all the anatomical circumstances

The mortality and neurologic morbidity of arch replacement have improved significantly with the aid of antegrade and retrograde cerebral perfusion techniques


Thank you

surgical treatment for aortic arch aneurysms

Presentations & Public Speaking

nylenox hill heart

storage of memory

memory board

hippocampus acts

mccullough et

constant flow of energy

different rates

neuropsychometric testing