ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC AORTIC ANEURYSMS

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1 ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC AORTIC ANEURYSMS Armando Mansilha MD, PhD, FEBVS Joel Sousa MD 16 th National Congress of the Italian Society of Vascular and Endovascular Surgery Bologna, 2017

2 Disclosure I have the following potential conflicts of interest to report: Receipt of grants/research support Receipt of honoraria and travel support Participation in a company sponsored speakers bureau Employment in industry Shareholder in a healthcare company Owner of a healthcare company X I do not have any potential conflict of interest

3 EPIDEMIOLOGY True incidence difficult to determine, as many go undiagnosed Incidence is reported as increasing, which may reflect advances in imaging techniques Estimated annual incidence in Olmstead County, Minnesota, was 10.4 per 100,000 person years

4 EPIDEMIOLOGY Several thoracic aortic segments involved 60% 10% 40% 10% Ascending Aorta TREATMENT OPTIONS? Aortic Arch Descending Aorta Thoracoabdominal Aorta

5 ASCENDING AORTIC ANEURYSM Supracoronary replacement of the AAo Wheat procedure Supracoronary replacement of the AAo and aortic valve David procedure Replacement of the AAo with direct reimplantation of the coronary arteries and reconstruction of the aortic valve, and sinutubular junction Bentall-DeBono procedure Replacement of the AAo and aortic valve with a valved conduit and direct reimplantation of the coronary arteries Cabrol procedure CARDIAC SURGERY Replacement of the AAo and the aortic valve with a valved conduit and reimplantation of the coronary arteries via an additional conduit

6 Supracoronary replacement of the AAo and aortic valve Replacement of the AAo with direct reimplantation of the coronary arteries and reconstruction of the aortic valve, and sinutubular junction

7 DESCENDING THORACIC ANEURYSM 1. TEVAR 2. OPEN SURGERY

8 1. TEVAR Endovascular thoracic repair reduces perioperative mortality and neurological morbidity in patients with descending thoracic aortic aneurysms 1 ST CHOICE VASCULAR SURGERY

9 2. OPEN REPAIR VASCULAR SURGERY + CARDIAC SURGERY

10 AORTIC ARCH Isolated arch aneurysms are a rare entity Aortic arch aneurysms are commonly associated with aneurysms of the adjacent ascending or descending aorta The criteria applied are those of ascending or descending aneurysms depending on whether the arch aneurysm is more closely related to the ascending or the descending aorta

11 ASCENDING AORTA AND ARCH INVOLVEMENT 1. ISLAND PATCH TECHNIQUE 2. Y-GRAFT TECHNIQUE CARDIAC SURGERY

12 ARCH AND DESCENDING THORACIC INVOLVEMENT Several treatment options available Open surgery Hybrid techniques (including debranching) Total endovascular interventions Indications are LESS CLEAR

13 Although, usually performed by CARDIAC SURGERY 1. Elephant trunk 2. Frozen elephant trunk

14 New endovascular techniques have allowed VASCULAR SURGEONS to treat this vascular territory 1. Hybrid techniques with SAT debranching 2. Total endovascular replacement with chimneys, branches and fenestrations

15 SO, WHAT TO DO? Both endo and open techniques have been develloped In patients without CONNECTIVE TISSUE DISORDERS, technique should be chosen accordingly to the patients physiological status as well as the center s experience In patients with CONNECTIVE TISSUE DISORDERS, OPEN interventions should be favoured over endo procedures Nonetheless,

16 PRE AND POST-OPERATIVE PLANNING AND SURVEILLANCE PROPER PRE-OPERATIVE ASSESSMENT of the aneurysm is essential, in order to plan either open or endovascular interventions In patients treated with aortic endografts, LIFELONG SURVEILLANCE is necessary to ensure proper placement of the graft

17 CONCLUSION Depending on the LOCATION of the thoracic aortic aneurysms, DIFFERENT INTERVENTIONS are available Patients with CONNECTIVE TISSUE DISORDERS should be offered OPEN SURGERY, whenever possible New ENDOVASCULAR interventions have allowed to push the bounderies of arch aneurysm treatment, although solid evidence is still LACKING Proper PRE-OPERATIVE PLANNING and STRICT FOLLOW-UP are essential, either in open or endo interventions Thoracic aortic aneurysms are COMPLEX PATHOLOGIES which may require a wide variety of interventions. Patients should be referred to centers where both VASCULAR and CARDIAC SURGEONS are available, as COOPERATION and JOINT PROCEDURES are often NECESSARY.

18 ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC AORTIC ANEURYSMS Armando Mansilha MD, PhD, FEBVS Joel Sousa MD 16 th National Congress of the Italian Society of Vascular and Endovascular Surgery Bologna, 2017