Some alternative procedures for an aortic arch aneurysm. Yan G. Kolesnikov Resident surgeon, Moscow
Aortic arch…
And how about 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. S) Infection Dissection • Trauma - External (fall, motor-vehicle accident) - Internal (AS, BAV, Co. Ao)
Diagnostics: • • Symptoms! Physical exam Laboratory investigation Instrumental evaluation
MSCTAngiography What R U thinking of ?
How big & how long ?
Branching pattern ?
“Onlay” problems ? • Coronaries • Echo • +/- Daily ECG
“Sublay” problems ? • • • Aorta (aneurysm, thrombosis) Lungs (COPD, FT) Kidneys (RVH, EGFR) Bowel (3 VD) Legs (Leriche)
“Inlay” problems ? • Stenosis • Willis compensation
Anything else ?
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 Up 2 DAo - Entire arch - Elephant trunk • TAAo • •
Hemi-arch
Proximal arch
Entire arch • Distal – 1 st • Proximal – 1 st • Branches – 1 st - Continuous brain perfusion via RAx. A + TOS - Branched grafts - Moderate hypothermia
Distal arch
Elephant trunk • 2 -stage procedure
Is it so conventional
Why it is so ? • Mortality • Morbidity
- Time of operation Trauma & blood loss General anesthesia & ventilation Aortic cross-clamping CPB (cardioplegia, brain & low-body perfusion) Hypothermia Arrest
Hybrid
Goals • ↓ t (operation, anesthesia, ventilation, CPB, DHCA) • ↓ trauma (transfemoral puncture) • ↓ cross-clamping
Frozen elephant trunk (FET) • 1 stage procedure Thora. Flex “E-vita open +”
st Surgery – 1
Endovascular – st 1 Open distal anastomosis
Endovascular – st 1
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) BCA-to-BCA (RCCA/LCCA +/- LSc. A)
Debranching
“Hybrid”
Totally endovascular = investigational… yet
Totally endovascular
Perforation
Bifurcation
Clues
Great thanks 4 Your attention !
Sun’s modification of Borst