arch final harkit2015 __

Hybrid Procedures forAortic Arch Involvement

Harapan Kita Experience2013-2014

Dicky Aligheri, MD FIHA FICACardiac & Vascular Surgeon

National Cardiac & Vascular Centre Harapan KitaJakarta 2015

Disclosures : none

Mr HR, 65yoChest & Back Pain 4d before

admissionsUncontroled hipertension,

DMHistory (+) 6 month

Mr ES, 55yoChest & Back Pain 24h before admissionsHeavy smokers, uncontroled hipertension

EXTENSIVE ARCH REPAIR FOR TYPE A DISSECTIONS ??

In the case of distal extension to the aortic arch, an limited but open distal anastomosis with the aortic arch or a hemiarch replacement should be performed

Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M. Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre

experience with 548 patients. Eur J Cardiothorac Surg 2013;44:337-345.

2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

Interact Cardiovasc Thorac Surg. 2015 Jan;20(1):120-6. doi: 10.1093/icvts/ivu323. Epub 2014 Oct 3.Is extended arch replacement justified for acute type A aortic dissection?

In [patients undergoing surgery, for acute type A aortic dissection] does [aggressive initial treatment with total arch repair] result in [reduced mortality and improved closure of the distal false lumen]?

Medline 1950 to December 2013

We conclude that a more extensive surgical strategy can be justified when it is based on circumstances, on the individual patient's clinical condition, and on the anatomical and pathological features of the dissection

↵ Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405-9.

↵ Ohtsubo S, Itoh T, Takarabe K, Rikitake K, Furukawa K, Suda H, et al. Surgical results of hemiarch replacement for acute type A dissection. Ann Thorac Surg 2002;74:S1853-6. discussion S1857–3. Tan ME, Dossche KM, Morshuis WJ, Kelder ↵JC, Waanders FG, Schepens MA. Is extended arch replacement for acute type A aortic dissection an additional risk factor for mortality? Ann Thorac Surg 2003;76:1209-14.

↵ Shiono M, Hata M, Sezai A, Niino T, Yagi S, Negishi N. Validity of a limited ascending and hemiarch replacement for acute type A aortic dissection. Ann Thorac Surg 2006;82:1665-9

↵ Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented elephant trunk implantation: a new ‘standard’ therapy for type a dissection involving repair of the aortic arch? Circulation 2011;123:971-8.

↵ Easo J, Weigang E, Holzl PP, Horst M, Hoffmann I, Blettner M, et al. Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection: analysis of the German Registry for Acute Aortic Dissection type A. J Thorac Cardiovasc Surg 2012;144:617-23.

↵ Zhang H, Lang X, Lu F, Song Z, Wang J, Han L, et al. Acute type A dissection without intimal tear in arch: proximal or extensive repair? J Thorac Cardiovasc Surg 2014;147:1251-5.

ACS Vol 2, No 2 (March 2013)

• Pre-existing arch aneurysm• Primary intimal tear identified on pre-operative CT in

the distal arch or descending thoracic aorta• Secondary intimal tear in the arch measuring >10 mm• Clinical signs of visceral or peripheral extremity

malperfusion• Radiologic signs of potential visceral, renal and

peripheral compromise such as a severely effaced true lumen in descending thoracic aorta

• False lumen diameter > than 22 mm (20)• Descending thoracic aorta diameter >35 mm

Mostly dissection Total arch replacement

Hemi arch replacement

Mostly aneurysm

Pathologic exclusion

L-Sc & ARM involvement

59Yo male, Chest pain, smokingHHD,ASHD, CHF IV, CKD III

74 yo FemaleChronic Cought, HHD, ASHD Heavy breath during last 3 moFamily history (+)

Total debranching

ECR 2014 / C-0818

Areas of Controversy: Covering the Left Subclavian Artery

Indications for Left C-S Bypass or Transposition

• Always• Patent IMA or anticipated• Left vertebral critical to posterior circulation

• Previous AAA repair• Internal iliac status

No Consensus

**

It is still debatable whether a hybrid technique is comparable to total open repair, as the former strategy is reserved for high-risk patients who are unable to withstand an open repair. According to the available literature and taking into account the less invasive nature of hybrid repair, it could be speculated that short-term mortality and morbidity should appear to be reduced in hybrid repair patients. A recent meta-analysis attempted to elucidate this issue (53). However, it was based on four non-randomized observational studies, which makes the analysis prone to selection and patient profile biases. Surprisingly, this study showed that a hybrid repair did not significantly improve operative mortality, whereas it was associated with a slight but non-significant increase in permanent neurologic deficits. A non-significant trend towards increased late mortality was observed in the hybrid group.

A systematic review and meta-analysis of hybrid aortic arch replacementACS May 2013AuthorsKonstantinos G. Moulakakis1,2, Spyridon N. Mylonas3, Fotis Markatis1, Thomas Kotsis3, John Kakisis1, Christos D. Liapis1

The chimney-graft technique for preserving supra-aortic branches: a reviewACS May 2013Konstantinos G. Moulakakis1,2, Spyridon N. Mylonas1,2,3, Ilias Dalainas1, George S. Sfyroeras1, Fotis Markatis1, Thomas Kotsis3, John Kakisis1, Christos D. Liapis1

The “chimney” technique is a method that requires advanced endovascular skills. Endovascular aortic arch repair with chimney grafts is associated with a lower mortality rate compared to totally open and hybrid reconstruction. However, the stroke rate remains noteworthy. The technique has acceptable short term results. As there are no available longterm data, it should be approached with a skeptical view and a reasonable hesitation for a wide embracement of the method. Compared to fenestrated it has the advantage of avoiding the delay in device manufacturing and the high cost. Long-term data and larger series are needed to determine the safety and efficacy of this technique.

FROZEN ELEPHANT TRUNK SURGERY

ACS Vol 2, No 5 (September 2013)

FROZEN ELEPHANT TRUNK SURGERY

Frozen elephant trunk surgery in type B aortic dissectionACS Submitted Mar 18, 2014.

A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgeryACS Vol 2, No 5 (September 2013)

Aortic arch replacement with frozen elephant trunk—when not to use itAuthorsAxel HaverichAuthorsDepartment of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, GermanyCorresponding to: Axel Haverich, MD. Klinik für Herz-, Thorax-, Transplantations-und Gefäßchirurgie, OE6210, Medizinische Hochschule Hannover, Carl-Neuberg-Straβe 1, 30625 Hannover, Germany. Email: [email protected]

Vol 2, No 5 (September 2013)

Hypothesis-driven surgical research in aortic surgery. Following the initial disrupted innovation with the introduction of the elephant trunk technique, two incremental steps of innovation were driven by subsequently developed hypotheses

Aortic arch replacement with frozen elephant trunk—when not to use itACS Submitted Mar 18, 2014.

Conclusions

• Aortic arch is the most challenging part.• Aortic arch should be considered in

proximal/distal aortic procedures• Some advancement with few drawback

Thank you

arch final harkit2015 __

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