Terms and techniques in Thoracic Aortic Surgery

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Terms and techniques in Thoracic Aortic Surgery

• Mike Poullis

• Assumptions
• Know aortic anatomy
• Read AHA guidelines

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Overview

• Terms
• Definitions
• Classification
• Indications for surgery / Intervention
• Techniques
• Root
• Ascending
• Arch
• Descending
• Stenting and extra anatomical bypass
• Perfusion
• Spinal cord protection
• Chronic Dissection

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Definitions

• Aneurysm
• Acute Aortic dissection
• Chronic aortic dissection
• Dissection in an aortic aneurysm
• Dissection causing an aortic aneurysm

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Definition of aneurysm

• Abnormal dilation of blood vessel
• Vessel
• Extent
• Type
• Fusiform
• Saccular
• Dissecting (Aorta)
• Aetiology

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Dissecting aortic aneuysm

• Dissection in an aortic aneurysm
• Aortic dissection that has subsequently become
  aneurysmal

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Classification of Dissections DeBakey
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Classification of Dissections Stanford / Daily
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Classification of Thoracoabdominal aneurysms
1Crawford
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Indications for surgery / Intervention

• Root 4.5-5.5 cm
• Ascending 5 cm
• Arch 7 cm
• Descending 6 cm
• Size
• Patient size
• Rate of enlargement
• Marfans
• What to do and when

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Techniques Root

• Bental
• Modified Bentall
• Cabrol
• David 1
• David 2 / Yacoub
• Wheat procedure
• Mechanical valved conduit
• Tissue valved conduit DIY
• Stentless root
• Full root
• Inclusion root
• Subcoronary implantation
• Homograft
• Autograft / Ross Procedure
• Reresuspension

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Bental
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Cabrol
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Cabrol
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David 1 David 2
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aka David II
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Wheat procedure
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Mechanical Valved conduit
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Stentless Valve
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Full root Root inclusion
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Subcoronary Modified sub coronary
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Autograft / Ross Procedure
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Reresuspension
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Techniques Ascending

• Aortoplasty
• Wrap
• Interposition graft

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Aortoplasty
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Aortoplasty
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Aortoplasty
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Wrap
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Techniques Arch

• Interposition graft
• Side branches
• Perfusion side arm
• Phlange
• Elephant trunk 1st stage
• Stenting and extra anatomical bypass

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Phlanged Graft
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Typical Candidate for Elephant Trunk
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Elephant trunk 1st stage
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Techniques Descending

• Descending do heart first
• Elephant trunk 2nd stage
• Reverse elephant trunk
• Intercostal patch
• Coarctation
• Left subclavian flap
• End to end
• Extended resection
• Patch /- shelf resection
• Interposition graft
• Traumatic aortic rupture
• Coselli

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Elephant Trunk 2nd Stage
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Intercostal patch
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Resection with end-to-end anastomosis2.
Patch-graft aortoplasty
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3. Subclavian flap aortoplasty4. Extended
resection end-to-end anastomosis
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5. Direct aortoplasty by transverse suture
repair6. Resection end-to-end conduit
interposition
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Patch /- shelf resection
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Coselli
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Techniques Other

• Stenting
• Stenting and extra anatomical bypass

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Stenting
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Stenting and extra anatomical bypass
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How Many Patients have a Suitable Anatomy for a
Stent Graft?
Patients examined for thoracic aortic disease
1997-2002 243 Stent graft 71 patients (29
) Surgery 164 patients (68) Medical
treatment 8 patients (3.2)
Stent
Stent
Surgery
Surgery
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Techniques - Perfusion

• Retrograde cerebral perfusion
• ? In dissections
• ? Best for flushing out air/debris
• Anterograde cerebral Perfusion
• ? Way forward in aneurysm work involving arch
• pH stat verses alpha stat
• Murkin paper
• False lumen perfusion
• CPB set up circuits
• Shunts
• ALLWAYS VENT HEART VIA RSPV WHEN FULL CPB
• RETROGRADE CARDIOPLEGIA VERY VALUABLE IN ROOT
  SURGERY

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False lumen perfusion
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CPB set up circuits

• Blood to pump
• RA
• LA
• PA
• Blood from pump
• Ascending aorta
• Arch
• Selective anterograde cerebral
• Retrograde cerebral
• Descending aorta
• Femoral
• Combinations off

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Left heart vs Fem-Fem Bypass
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Shunts Ascending aorta to aorta / femoral
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Techniques Spinal cord protection

• Pharmacological
• Na
• Ca 2
• NMDA antagonists MK801
• Hypothermia
• Systemic or local
• CSF drainage
• BP management
• Distal Perfusion
• Shunts
• Intercostal reimplantation

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CSF drainage

• Early paraplegia
• Late paraplegia

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Traditional Concept of Spinal Cord Blood Supply
T5-T8 15
The main Radiculomedullary artery (Adamkiewicz)
enters the vertebral canal
L1-L3 10
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Selective bypass to intercostal artery
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CSF Drainage
3 DAYS POSTOP.
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Techniques Chronic dissection

• Proximal fenestration
• Distal fenestration
• Surgical or Catheter based
• Beware malperfusion, if in doubt stay anterograde

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Surgical fenestration
Catheterfenestration
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Distal fenestration