Скачать презентацию Some alternative procedures for an aortic arch aneurysm Скачать презентацию Some alternative procedures for an aortic arch aneurysm

Hybrid & EV aproaches to the arch.pptx

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Some alternative procedures for an aortic arch aneurysm. Yan G. Kolesnikov Resident surgeon, Moscow Some alternative procedures for an aortic arch aneurysm. Yan G. Kolesnikov Resident surgeon, Moscow

Aortic arch… Aortic arch…

And how about that? And how about that?

… or that … or that

… or that … or that

… or that … or that

… or that … or that

… or that … or that

… or that … or that

Causes: • Weakness of the wall: - Congenital (dysplasia, anomalies) Acquired (AH, smoking, Ath. Causes: • Weakness of the wall: - Congenital (dysplasia, anomalies) Acquired (AH, smoking, Ath. S) Infection Dissection • Trauma - External (fall, motor-vehicle accident) - Internal (AS, BAV, Co. Ao)

Diagnostics: • • Symptoms! Physical exam Laboratory investigation Instrumental evaluation Diagnostics: • • Symptoms! Physical exam Laboratory investigation Instrumental evaluation

MSCTAngiography What R U thinking of ? MSCTAngiography What R U thinking of ?

How big & how long ? How big & how long ?

Branching pattern ? Branching pattern ?

“Onlay” problems ? • Coronaries • Echo • +/- Daily ECG “Onlay” problems ? • Coronaries • Echo • +/- Daily ECG

“Sublay” problems ? • • • Aorta (aneurysm, thrombosis) Lungs (COPD, FT) Kidneys (RVH, “Sublay” problems ? • • • Aorta (aneurysm, thrombosis) Lungs (COPD, FT) Kidneys (RVH, EGFR) Bowel (3 VD) Legs (Leriche)

“Inlay” problems ? • Stenosis • Willis compensation “Inlay” problems ? • Stenosis • Willis compensation

Anything else ? Anything else ?

Proximal extension ? • Bentall-De. Bono • Valve sparing (Yacoub, David) • Supracoronary • Proximal extension ? • Bentall-De. Bono • Valve sparing (Yacoub, David) • Supracoronary • Up 2 BCT • Up 2 LCCA • Up 2 LSc. A • Reverse hemiarch

Distal extension ? Up 2 BCT (hemi-arch) Up 2 LCCA Up 2 LSc. A Distal extension ? Up 2 BCT (hemi-arch) Up 2 LCCA Up 2 LSc. A Up 2 DAo - Entire arch - Elephant trunk • TAAo • •

Hemi-arch Hemi-arch

Proximal arch Proximal arch

Entire arch • Distal – 1 st • Proximal – 1 st • Branches Entire arch • Distal – 1 st • Proximal – 1 st • Branches – 1 st - Continuous brain perfusion via RAx. A + TOS - Branched grafts - Moderate hypothermia

Distal arch Distal arch

Elephant trunk • 2 -stage procedure Elephant trunk • 2 -stage procedure

Is it so conventional Is it so conventional

Why it is so ? • Mortality • Morbidity Why it is so ? • Mortality • Morbidity

- Time of operation Trauma & blood loss General anesthesia & ventilation Aortic cross-clamping - Time of operation Trauma & blood loss General anesthesia & ventilation Aortic cross-clamping CPB (cardioplegia, brain & low-body perfusion) Hypothermia Arrest

Hybrid Hybrid

Goals • ↓ t (operation, anesthesia, ventilation, CPB, DHCA) • ↓ trauma (transfemoral puncture) Goals • ↓ t (operation, anesthesia, ventilation, CPB, DHCA) • ↓ trauma (transfemoral puncture) • ↓ cross-clamping

Frozen elephant trunk (FET) • 1 stage procedure Thora. Flex “E-vita open +” Frozen elephant trunk (FET) • 1 stage procedure Thora. Flex “E-vita open +”

st Surgery – 1 st Surgery – 1

Endovascular – st 1 Open distal anastomosis Endovascular – st 1 Open distal anastomosis

Endovascular – st 1 Endovascular – st 1

Endovascular Ishimaru sealing zones concept Pressure lowering Rapid pacing Drugs (nitro-/adenosine) Endovascular Ishimaru sealing zones concept Pressure lowering Rapid pacing Drugs (nitro-/adenosine)

Debranching Extraanatomic bypasses: Ascending-to- BCA (BCT / RSc. A/ RCCA/ LCCA +/- LSc. A) Debranching Extraanatomic bypasses: Ascending-to- BCA (BCT / RSc. A/ RCCA/ LCCA +/- LSc. A) BCA-to-BCA (RCCA/LCCA +/- LSc. A)

Debranching Debranching

“Hybrid” “Hybrid”

Totally endovascular = investigational… yet Totally endovascular = investigational… yet

Totally endovascular Totally endovascular

Perforation Perforation

Bifurcation Bifurcation

Clues Clues

Great thanks 4 Your attention ! Great thanks 4 Your attention !

Sun’s modification of Borst Sun’s modification of Borst