Ascending Thoracic Aorta: Postsurgical CT Evaluation

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Ascending Thoracic Aorta: Postsurgical CT Evaluation Santiago Martinez Jimenez, MD GOALS Ascending Thoracic Aorta: Postsurgical CT Evaluation Santiago Martínez MD smartinez-jimenez@saint-lukes.org Saint Luke s Hospital of Kansas City, KCMO Recognize several common surgical techniques and indications Identify normal imaging aspects of the postsurgical aorta Highlight frequent complications in the postsurgical setting WHEN TO TREAT? Ascending aorta > 5-6 cm Descending aorta > 6-7 cm OVERVIEW How to choose? -Long and short-term outcome Marfan or familial > 4.5 cm Bicuspid valve > 4.5 cm Growth > 0.5 cm/year All symptomatic aneurysm -Preserve valve - surgical time ischemia - DHCA -Annuloaortic ectasia -Percentage of aneurysmal arch Coady MA et al. J Thorac and Cardiovasc Surg 1997; 113: 476-491 Svensson LG, et al.ann Thorac Surg 2008; 85: S1-S41 SURGICAL TECHNIQUES OPEN REPAIR 1. SUPRACORONARY GRAFT +/-VALVE WHEAT,AA GRAFT Interposition - excision native aorta SURGICAL TREATMENT OPEN REPAIR CLOSE REPAIR 2. COMPOSITE ARTIFICIAL GRAFT COMPOSITE BIOLOGIC GRAFT ARCH REPAIR TEVAR BENTALL, CABROL ROSS, HOMOGRAFT GORE TAG ZENITH TX2 Inclusion - wrapping native aorta Inclusion - morbidity and mortality -Technically easier TALENT -Potential space - thrombus, flow or both 556

INTERPOSITION - INCLUSION COMPONENTS Graft - hyperdense (wo contrast) Modified from Cardiovascular and Vascular Disease of the Aorta. Ed. LG Svensson, Crawford ES. WB Saunders. 1997 COMPONENTS Graft - hyperdense (wo contrast) Graft margin - attenuation felts caliber SUPRACORONARY GRAFT Ascending aortic aneurysm with aortic degenerative valve without dilatation of the sinotubular junction or sinuses of Valsalva Atherosclerotic origin SUPRACORONARY GRAFT 1. Ascending aortic graft 2. Preservation of native coronary ostia 3. Valve replacement - Wheat Procedure SUPRACORONARY GRAFT Late development of aneurysmal and dissection of the native aortic root More common in annuloaortic ectasia (Marfan s), collagen disease or aortitis in which a composite method is preferred 557

COMPOSITE - BENTALL Dilatation (or dissection) of the sinotubular junction or sinuses of Valsalva With aortic degenerative valve COMPOSITE - BENTALL 558 COMPOSITE - BENTALL 1. Ascending aortic + aortic valve composite graft Classic Bentall - pseudoaneurysm coronary anastomosis 2. Anastomosis coronary arteries 3. Classic Bentall Modified Bentall - the button technique decreases incidence of pseudoaneurysm at the anastomotic site 4. Modified Bentall (Also button Bentall) Pseudoaneurysm aortic proximal or distal anastomosis

COMPOSITE - CABROL When button techniques are not feasible Aortic dissection, annuloaortic ectasia, atherosclerotic aneurysm, poststenotic dilatation COMPOSITE - CABROL 1. Ascending aortic + aortic valve composite graft 2. Second graft interposed between the coronary arteries and anastomized side-toside to the composite graft COMPOSITE - CABROL High mortality first 30 days (4-20%) in patients with aortic dissection Long term complications (uncommon) - coronary insufficiency from kinking of graft limbs or intimal hyperplasia, acute thrombosis of one limb of the coronary graft, detachment of the prosthetic valve, endocarditis 559

COMPOSITE - ROSS Aortic valve pathology in young patients Advantages over prosthetic valves: favorable hemodynamics, low risk of endocarditis, low thrombogenicity, no anticoagulant therapy, growth potential in children COMPOSITE - ROSS 1. Replacement of the abnormal aortic valve 2. Replacement of aortic valve with patient s own pulmonary valve 3. Pulmonary valve replace with cadaveric pulmonary valve COMPOSITE - ROSS Low mortality (2.5%) Aneurysmal dilatation aortic root Extensive thoracic aortic aneurysm involving the arch and descending aorta Aortic dissection, annuloaortic ectasia, atherosclerotic aneurysm, poststenotic dilatation 560

First stage - mortality (~10%), aortic rupture, stroke (5.3%), neurological deficits, vocal cord paralysis, bleeding Interval - mortality (~8%) - rupture untreated segment Second stage - mortality (~7%), paraplegia Mortality wo second stage ~30% GOALS Recognize several common surgical techniques and indications Identify normal imaging aspects of the postsurgical aorta Highlight frequent complications in the postsurgical setting THANKS 561

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