Transcript History of aortic surgery

DESCENDING AND THORACO ABDOMINAL
AORTIC ANEURYSMS
KITTICHAI LUENGTAVIBOON M.D.
17TH SEPTEMBER 2011
HISTORY OF AORTIC SURGERY
1950 Dubost French surgeon 1914-1991 resected ascending aortic aneurysm with
end to end anastomosis.
1951 Dubost resected abdominal aortic aneurysm and replaced with homograft.
1956 Dacron and teflon were used as aortic substitute.
The start of golden age of aortic surgery, Houston became the Mecca of aortic
surgery.
1953 De Bakey used Dacron graft to treat descending thoracic aneurysm using
Clamp and Go technique.
1956 Houston group was the first to treat an aneurysm of the ascending aorta.
1962 De Bakey published the results of a first series of 52 cases of aneurysms of the
aortic arch.
1963 De Bakey classification of aortic dissection.
1970 Stanford classification.
PROTECTION OF VISCERA DURING DESCENDING AORTIC ANEURYSM REPAIR
1953 moderate hypothermia
Hardin body surface hypothermia
1957 Frank Gerbode – left heart bypass
1963 Vincent Gott – shunt (heparin treated polyvinyl)
1970 CM Dixon – Biomedicus pump
1973 E Stanley Crawford – sequential aortic clamping in a caudal direction,
1991 One year before his death, Crawford introduced a new classification of TAAA into
4 types.
1983 German surgeon- Hans George Borst proposed Elephant trunk technique.
1988 use of CSF drainage to prevent paraplegia
1992 Michael D. Dake (Stanford) used endograft to treat descending aneurysm.
2000 French surgeon – Edouard Kieffer proposed classification of descending
aneurysm.
CLASSIFICATION OF DESCENDING THORACIC AORTIC ANEURYSMS
Depend on extent of the aneurysm
type A from LSCA to T6
type B from T6 to celiac A
type C = A+B
Related to potential complications
type A – stroke, hoarseness of voice
type B – renal failure and paraplegia
type C = all
ETIOLOGY
Degenerative
Chronic aortic dissection
Inflammatory
infected aortitis
saccular form
occur in region near visceral branches
Takayasu’s disease
INDICATION FOR SURGICAL MANAGEMENT
Size
Growth rate
Symptoms
Etiology
dissection
infection
TECHNIQUE OF REPAIR
Endovascular
with hybrid
arch
coverage of celiac A
LSCA coverage
Open repair
OPEN REPAIR
Depend on type of DTA
Type A
if unable to clamp distal to LCCCA – DHCA
if clamp distal to LSCA is possible
clamp and go
distal adjunct
left atriofemoral bypass
femoro femoral bypass
Type B
clamp and go
with distal perfusion
left atriofemoral bypasss
femoro femoral bypass
Gott’s shunt
Type C
same as type A
151patients with DTA from 1989-2008
47% concurrent distal arch replacement
Femoro femoral bypass
Use thiopentone and methylprednisolone with
head ice packing
No cardioplegia, no monitoring of somato
sensory and motor evoked potential
Stop circulation after isoelectric EEG and
nasopharyngeal temperature < 22 degree
celcius
THORACO ABDOMINAL AORTIC ANEURYSM
Definition – dilatation of aorta to a diameter at least 50% greater than expected
normal diameter at diaphragmatic hiatus, with varying degrees of thoracic and
abdominal extension.
Crawford’s classification
risk stratification
surgical approach
select protective adjunct
standarized reporting of results
THORACO ABDOMINAL AORTIC ANEURYSM
ORGAN PROTECTION – COSELLI’S TECHNIQUE
strategy
Extent 1
Extent 2
Extent 3
Extent 4
Mild
routine
hypothermia
routine
routine
routine
Left heart
bypass
routine
routine
selective
rare
Selective
visceral
perfusion
selective
routine
selective
rare
Cold renal
perfusion
selective
routine
routine
routine
CSF
drainage
routine
routine
selective
rare
Intercostal
routine
artery
reattachmen
t
routine
seletive
rare
2,286 TAAA, HOUSTON GROUP
COSELLI 2007
extent
patients
30 day
death(%)
Paraplegia,p
aresis(%)
Renal
failure(%)
1
706
5.0
3.3
2.7
2
762
6.0
6.3
8.3
3
391
5.4
2.6
6.1
4
427
3.0
1.4
5.4
3 major vascular units in Europe
107 elective and urgent, high risk patients
All stents involved whole descending and abdominal aorta
Covered LSCA in 19, revascularization in 12
Distal landing zone 75% infrarenal aorta, 25% iliac artery
30 days mortality 14.95%
Spinal cord ischemia 12.1%, 8.4% complete and permanent
Long term dialysis 3.7%
Segmental bowel infarction 2.8%
89 one stage 19 two stage
50 years apart
ENDOVASCULAR TREATMENT FOR TAAA
FENESTRATED ENDOGRAFT
CONCLUSION
 A lot of CHANGES will be happening in the
management of THORACIC AORTIC DISEASES..
 More and more trends toward LESS invasive
treatment.
 Aortic arch is the next.
 Ascending aorta is the last frontier.