Download - AORTIC ARCH SURGERY
![Page 1: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/1.jpg)
Surgical Management of Aortic Arch Pathology
Dicky Aligheri, MDCardiac & Vascular Surgeon
National Cardiac & Vascular Centre Harapan KitaJakarta 2014
![Page 2: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/2.jpg)
Mr ES, 55yoChest & Back Pain 24h before admissionsHeavy smokers, uncontroled hipertension
![Page 3: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/3.jpg)
![Page 4: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/4.jpg)
Mr HR, 65yoChest & Back Pain 4d before
admissionsUncontroled hipertension,
DMHistory (+) 6 month
![Page 5: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/5.jpg)
![Page 6: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/6.jpg)
![Page 7: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/7.jpg)
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
![Page 8: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/8.jpg)
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
![Page 9: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/9.jpg)
↵ 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.
![Page 10: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/10.jpg)
• “Tapper” like diameter
• 30 – 40 deg backward angulation
• Surround structures ,eg nerve
![Page 11: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/11.jpg)
• “Tapper” like diameter
• 30 – 40 deg backward angulation
• Surround structures ,eg nerve
![Page 12: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/12.jpg)
![Page 13: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/13.jpg)
![Page 14: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/14.jpg)
Mostly dissection Total arch replacement
Hemi arch replacement
Mostly aneurysm
Pathologic exclusion
L-Sc & ARM involvement
![Page 15: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/15.jpg)
Mostly dissection Total arch replacement
Hemi arch replacement
Mostly aneurysm
Pathologic exclusion
L-Sc & ARM involvement
![Page 16: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/16.jpg)
Schafer, PWHardin, CA. The use of temporary polyethylene shunts to permit occlusion, resection and frozen homologous graft replacement of
vital vessel segments. Surgery. 1952;31:186
![Page 17: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/17.jpg)
Cooley, DAMahaffey, DEDeBakey, ME. Total excision of the aortic arch for aneurysm. Surg Gynecol Obstet. 1955;101:667.
DeBakey, MECrawford, ESCooley, DAMorris, GC. Successful resection of a fusiform aneurysm of aortic arch with replacement by homograft. Surg Gynecol Obstet. 1957;105:657.
Creech, ODeBakey, MEMahaffey, DE. Total resection of the aortic arch. Surgery. 1956;40:817
![Page 18: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/18.jpg)
• Griepp and colleagues' introduction of hypothermic circulatory arrest (HCA) was a major advance that greatly enhanced the safety of arch-replacement procedures
• he use of cerebral perfusion was reconsidered by Frist and colleagues
![Page 19: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/19.jpg)
![Page 20: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/20.jpg)
ConventionalAortic arch Surgery
![Page 21: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/21.jpg)
![Page 22: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/22.jpg)
![Page 23: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/23.jpg)
Aortic arch Surgery
• Techniques– Conventional– Hybrid
• Issues– Cerebral Protection– Hypothermic arrest– Intra operative monitoring– Elephant trunk & secondary procedures
![Page 24: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/24.jpg)
hYPOTHERMIC cIRCULATORY aRREST
![Page 25: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/25.jpg)
Antegrade selective cerebral perfusion
![Page 26: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/26.jpg)
Antegrade selective cerebral perfusion
![Page 27: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/27.jpg)
Antegrade selective cerebral perfusion
• prolonged safe time of cerebral protection• moderate hypothermia and reduced CPB time• improved cerebral cooling and maintenance of
hypothermia• independent control of cerebral and systemic circulations
• technically more complicated• additional equipment required
![Page 28: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/28.jpg)
Retrograde Cerebral Perfusion
• maintenance of cerebral hypothermia• washout of embolic air or debris• cerebral perfusion and metabolic support.
• Competent cerebral valve n dominant azygos circulation
![Page 29: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/29.jpg)
Retrograde Cerebral Perfusion
![Page 30: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/30.jpg)
* Our Routine• Median sternotomy• Cannulation sites :
– Axillary / Femoral Artery– Right atrial / SVC & IVC
• Myocardial Protection :– Antegrade CPG (Osteal)– Retrograde CPG– Surface cooling– LV venting
• Organ / Brain Protection :– DHCA– ASCP / RSCP– External cooling
![Page 31: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/31.jpg)
![Page 32: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/32.jpg)
![Page 33: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/33.jpg)
![Page 34: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/34.jpg)
![Page 35: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/35.jpg)
![Page 36: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/36.jpg)
![Page 37: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/37.jpg)
![Page 38: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/38.jpg)
Conclusions
• Aortic arch surgery is the most challenging part.
• Aortic arch should be considered in proximal/distal aortic procedures
• Some advancement with few drawback
![Page 39: AORTIC ARCH SURGERY](https://reader035.vdocuments.site/reader035/viewer/2022062522/587ae35f1a28ab542b8b6d1f/html5/thumbnails/39.jpg)
THANK YOU