Management of Acute Aortic Syndromes. M. Grabenwoger, MD Dept. of Cardiovascular Surgery Hospital Hietzing, Vienna, Austria
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1 Management of Acute Aortic Syndromes M. Grabenwoger, MD Dept. of Cardiovascular Surgery Hospital Hietzing, Vienna, Austria
2 I have nothing to disclose.
3 Acute Aortic Syndromes Acute Aortic Dissection Type A Acute Aortic Dissection Type B Penetrating Atherosclerotic Ulcer (PAU) Intramural Hematoma (IMH) Traumatic Dissection
4 Treatment Strategies Conventional Surgery Endovascular Treatment Hybrid Approach combination of conventional surgical and endovascular techniques in a one or two stage procedure
5 Classification Type DeBakey I DeBakey II DeBakey III Stanford Type A Stanford Type B Percentage 60 % 10-15% 25-30%
6 Dissection Type A
7 Aortendissektion
8 Result of Limited Resection Satisfied with primary entry resection?
9 CT scans after successful surgery
10 Do we have a problem with the downstream aorta? R. Fattori et al. : Evolution of Aortic Dissection after Surgical Repair; Am J Cardiol Barron DJ et al.: Twenty year follow-up of acute type A dissection: the incidence and extend of distal aortic disease using MRI. J Card Surg %-77% patent false lumen Park KJ et al.: Midterm change of descending aortic false lumen 27%-30% re-interventions related to downstream aorta 5 to 10 after repair of acute type I dissection; Ann Thorac Surg 2009 years after successful operation Results Patent are false conform lumen:! significant increase in aortic diameter Thrombosed false lumen: shrinkage of the aorta Most common cause for late death: related to distal aortic disease
11 Hybrid Technique Combination of conventional aortic arch surgery with open antegrade endovascular stent grafting of the descending aorta: Treatment of the ascending, arch and descending aorta in a one stage procedure Frozen Elephant Trunk Technique
12 Frozen Elephant Trunk E-vita R open stent graft; JOTEC R (Germany)
13 Operative Technique Insertion of the FET in the proximal descending aorta in the period of circulatory arrest under moderate hypothermia (25 0 to 28 0 C) and bilateral antegrade cerebral perfusion After stent deployment the Dacron prosthesis is pulled out of the stent gaft and sutured to the proximal descending aorta Conventional replacement of the ascending aorta and the aortic arch
14 FET Peninsula Style
15 Rationale of Hybrid Procedure To extend the efficacy of the operation without increasing the risk (extend of the incision) Expansion of true lumen Closure of possible re-entries To promote thrombosis of the false lumen To facilitate consecutive surgical and endovascular procedures of the descending aorta Goal: Decreased re-intervention rate and survival in the long-term run
16 Antegrade Stent Grafting Landmark for stent graft placement: offspring of left subclavian artery
17 Stent Graft Fixation 1 cm of Dacron prosthesis is pulled out of the stent and sutured to the aorta distal to the left subclavian artery
18 CT-scans after Combined Procedure Closure of the false lumen at the height of the stent graft
19 CT-scan False lumen remains patent distal to the end of the stent grafts
20 Literature
21 Treatment of Ascending, Arch and Descending Aorta Consecutive endovascular stent grafting
22 Treatment of the thoracoabdominal aorta Consecutive open surgery
23 Acute Type B Dissection J Am Coll Card 2008; IRAD-registry 571 pat. acute type B dissection 390 pat. medical treatment (Mort.:8,7%) 66 pat. Endovascular (Mort.:10,6%) 59 pat. open surgery (Mort.:33,9%) Tevar seems to offer better outcome in terms of mortality and associated complications than open surgical repair
24 Definition of Complicated Type B signs of contained or free rupture signs of malperfusion (visceral, leg) recurrent or persistent pain rapid expanding false lumen Aortic diameter > 55mm Additional Criteria for complicated Location of entry site? Retrograde component? Diameter of false lumen? Diameter ascending aorta?
25 Survival in type B stratified by false lumen status Event-free survival curves for patients with small and large initial false lumen diameters at the upper descending thoracic aorta. Song JM, et al. JACC 2007; 50:
26 patent false-lumen maximum aortic diameter > 40 mm significantly higher event rates than other patients.
27 Treatment of Choice: TEVAR Rationale: Closure of primary entry tear Re-direct blood flow into the true lumen Decompression and expansion of true lumen Improved distal perfusion Coverage of perforations Remodeling of the aorta
28 Indication: contained rupture, malperfusion, rapid increase in aortic diameter, refractory pain 3 pat. consecutive surgical treatment: retrograde type A, acute stent dislocation, late aneurysm formation 10 patients; mortality (2/10) 20%
29 28 pat. with acute symptomatic type B dissection Secondary intervention 5/28 pat. Conversion to open (retro type A): 4 pat (14%) Procedure related mortality following secondary intervention 20% (1/5) TEVAR is an alternative to surgical repair,however, not without significant morbidity and mortality
30 Retrograde Type A
31 Antegrade Approach with FET-Technique for Type B Acute type B with retrograde component (hematoma, dissection) Diameter of ascending aorta > 4cm Acute angled aortic arch, hostile anatomy No distal access available Advantage of FET as compared to conventional surgery Treatment of arch and descending aorta possible Operation via median sternotomy in moderate hypothermia instead of lateral thoracotomy in deep hypothermia
32 Angioscopy and Biopsy of Descending Aorta
33 Penetrating Atherosclerotic Ulcer
34 Contained Rupture (post stenting)
35 Angioscopy PAU
36 IMH
37 Traumatic Aneurysm (Angio)
38 Arch Treatment without CPB Distal arch re-routing or total arch re-routing procedures enable endovascular treatment of the aortic arch without CPB Indication: Patients, who are judged not suitable for CPB and circulatory arrest
39 Distal Arch Rerouting Indications: pathologies (chronic aneurysms, type B dissections, penetrating ulcers) of the distal arch and descending aorta Double transposition of the subclavian artery to the left common carotid artery and of the left common carotid artery to the innominate artery
40 Result-distal arch rerouting
41 Total Arch Rerouting Indication: pathologies of the arch and descending aorta Reversed bifurcated prosthesis from the ascending aorta to the innominate artery and left common carotid artery.
42 Intraoperative view
43 Total Arch Stenting
44 Conclusions Hybrid approaches in aortic arch surgery are valid options in the armamentarium of cardiac sugeons Beneficial for different indications (Type A, B, PAU, IMH) Antegrade stent grafting (FET) improves long-term results after type A dissection FET: Excellent technique for pathologies of the distal arch and proximal descensing aorta Aortic arch rerouting techniques enable aortic arch treatment without the use of CPB and HCA Treatment of high risk patients feasible
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