Transcript Thoracic aortic disease

Thoracic aortic disease
Kittichai Luengtaviboon
21 January 2011
Thoracic aortic disease is more common in the last
decade world wide.
Because
increasing life expectancy
better diagnostic tools – CTA, MRA
more public awareness
high incidence of systemic arterial
hypertension
most patients with hypertension are
untreated or inadequately treated.
 It usually results in deaths from rupture or dissection,
even the growth of aneurysm is slow initially in the
asymptomatic period. If the patient does not die
from other causes.

introduction
Natural history of thoracic aortic
aneurysms – one of progressive
expansion and weakening of the aortic
wall, leading to eventual rupture. With as
associated mortality of 94%.
 5 year survival rate of unoperated TAA
13%.
 Whereas 70-79% of those who undergo
elective surgical intervention are alive at 5
years.
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>60 m diameter or > 2x transverse
diameter of an adjacent normal aortic
segment
 Symptomatic regardless of size
 Growth rate of aneurysm > 3 mm/y
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Circulation 2005;112:1663-1675.
Indication for TAA repair
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1 aneurysm
2 dissection and acute aortic syndrome
3 nonspecific aortitis or Takayasu’s
disease
4 aortic trauma
5 aortic infection
Common thoracic aortic problems
in Thailand
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Classification – anatomical
ascending – root, tubular part
arch
descending type A,B and C
thoraco abdominal Crawford 1-4
Etiology
atherosclerotic
hereditary
chronic dissection
others – infection, trauma, inflammatory
Thoracic aortic aneurysm
There are three common types
acute aortic dissection
intramural hematoma
penetrating aortic ulcer
 Common etiologic factors
hypertension
older age
atherosclerosis
genetic disorder – Marfan, Ehler Danlos,
Turner, Loeys Dietz
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Acute aortic syndrome
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Aneurysm
common indication in all location
presence of symptoms
pain
compressive symptom
maximal diameter
non marfan
marfan and others
dissection or non dissection
rapid increase in maximal diameter
saccular aneurysm
Indication for surgery in thoracic
aortic disesease
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Acute aortic syndrome
require prompt diagnosis and treatment
life threatening
etiology
acute dissection
type
comorbid, patient’s condition
intramural hematoma
same as dissection
but no problems with malperfusion
PAU
treatment in all patients with symptoms
if no symptoms – controversial- size and depth
indication
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4 types, most common due to infected aortitis
Gold standard open resection with insitu graft
replacement
TEVAR still need more evidence BUT recurrent
infection is high. More appropriate if used as a
bridge. But may make open surgery more
difficult and very costly.
Comtemporary result of open repair is promising!
Recurrent infection after open repair is LOW. And
operative mortality is NOT HIGH.
In situ graft is safe even in some condition extra
anatomical bypass is feasible.
Thoracic aortic infection
Open repair
gold standard
for all segment (
descending aorta ?)
decreasing mortality,
morbidity in early post
operative period.
good long term
outcome
long lasting good
result
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TEVAR
evidence based
support its use in
descending aorta
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Option for treatment of thoracic
aortic diseases
Class 1
1 separate valve and ascending aortic
replacement in patients without root
dilatation if ascending aorta > 5 cm with
aortic valve disease ©
2 Marfan, Ehlers Danlos, Loeys-Dietz
with dilatation of aortic root -> David or
mod. Bentall’s operation (B)
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Recommendations for open surgery
for ascending aortic aneurysm
Class 2a
ascending aneurysm with proximal arch involvement
–partial arch with ascending aortic replacement using
right subclavian/axillary inflow and hypothermic
circulartory arrest is reasonable. (B)
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patients with low operative risk, with degenerative or
atherosclerotic aneurysm of arch, operative treatment
is reasonable for asymptomatic patients when diameter
> 5.5 cm.(B)
No recommedation about using Hybrid TEVAR in arch
aneurysm.
Recommendation for aortic arch
aneurysm
Class1
chronic dissection without significant
comorbid -> open repair if diameter >5.5
cm (B)
degenerative, traumatic aneurysm,
diameter > 5.5 cm -> TEVAR if feasible (B)
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Recommendation of treatment of
descending thoracic aortic
aneurysm
Society of Thoracic Surgeons Recommendations
for Thoracic Stent Graft Insertion (summary)
Entity/Subgroup
Classification
Level of Evidence
Asymptomatic
III
C
Symptomatic
IIa
C
Acute traumatic
I
B
IIa
C
I
A
IIb
C
Subacute dissection
IIb
B
Chronic dissection
IIb
B
>5.5 cm, comorbidity
IIa
B
>5.5 cm, no comorbidity
IIb
C
<5.5 cm
III
C
Reasonable open risk
III
A
Severe comorbidity
IIb
C
IIb
C
Penetrating ulcer/intramural hematoma
Chronic traumatic
Acute Type B dissection
Ischemia
No ischemia
Degenerative descending
Arch
Thoracoabdominal/Severe comorbidity
Note: Table 15 in full-text version of TAD Guidelines. Reprinted from Svensson et al. Expert
consensus document on the treatment of descending thoracic aortic disease using endovascular stent
grafts. Ann Thorac Surg. 2008;85:S1– 41.
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Joseph E. Bavaria et al
J Thorac Cardiovasc Surgery 2007;133:369-77.
The first completed multicenter trial directed at
gaining approval from the US Food and Drug
Administration .
From Sep 1999 and May 2001 140 patients with
descending thoracic aortic aneurysms enrolled at
17 sites and evaluated for Gore TAG thoracic
endograft
Compared to open surgical control cohort of 94
patients (enrolling historical and concurrent
subjects)
Endovascular stent grafting versus open
surgical repair of descending thoracic aortic
aneurysms in low risk patients: a multicenter
comparative trial
Perioperative mortality and morbidity
were significantly less with TEVAR
 Overall stroke rate was similar
 Reintervention rate and continued
presence of complications, such as
endoleaks, is higher in the endograft
group.
 No survival advantage associated with
either strategy after 2 years of follow up.
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conclusion
Ascending aorta
involve root – modified Bentall or David
not involve root – replace aorta above
sinotubular junction
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Techniques in open repair of
thoraic aortic aneurysms
If with ascending, but no descending –
median sternotomy
canulate left femoral or left common
carotid artery
canulate RA for venous return
use cardioplegia
use DHCA alone or with ACP
hemiarch technique preserving
greater curve of arch
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Aortic arch
Incision – median sternotomy
Cannulation
arterial – ascending aorta, right
subclavian, left common carotid, femroal
A
venous – right atrium
 Technique of arch replacement
island – arch first
individual arch branch
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Total arch replacement
Incision – clamshell
 Canulation
ascending aorta, femoral artery
venous right atrium
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Ascending, arch and descending
aortic aneurysms
Incision left posterolateral thoracotomy
 Use DHCA
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Descending aorta type A or C
Incision – left posterolateral thoracotomy
 Technique
clamp and go
femoral vein- descending aorta partial
CPB
shunt
left atrio femoral bypass with
centrifugal pump
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Descending aorta type B