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Surgical treatment for aortic arch aneurysms
- 1. Lenox Hill Heart and Vascular Institute of New York Surgical Treatment for Aortic Arch Aneurysms Konstadinos A Plestis, MD Associate Professor Director of Aortic Surgery Department of Thoracic and Cardiovascular Surgery Lenox Hill Hospital, NY
- 2. Lenox Hill Heart and Vascular Institute of New York Hemiarch
- 3. Lenox Hill Heart and Vascular Institute of New York Total Arch
- 4. Lenox Hill Heart and Vascular Institute of New York Types of Cerebral Injury during Arch Surgery Focal embolic Diffuse ischemic
- 5. Lenox Hill Heart and Vascular Institute of New York METHODS OF CEREBRAL PROTECTION Deep hypothermic circulatory arrest HCA Griepp 1975 Retrograde cerebral perfusion RCP Ueda 1990, Takamoto 1992, Safi 1993 Antegrade cerebral perfusion ACP Debakey 1957, Frist 1986, Bachet 1991, Kazui 1992
- 6. Lenox Hill Heart and Vascular Institute of New York Griepp, et. al. JTCVS, 1975 Deep Hypothermic Circulatory Arrest
- 7. Lenox Hill Heart and Vascular Institute of New York Suppression of Metabolism with HCA at Different Temperatures Mezrow et al, JTCVS 1994 McCullough et. al. Ann Thorac Surg, 1999
- 8. Lenox Hill Heart and Vascular Institute of New York 0 20 40 60 80 100 120 37 30 25 20 15 10 0 5 10 15 20 25 30 35 40 45 % CMRO2 SAFE HCA Duration of HCA Min %CMRO2 Temperature °C Actual Q10 directly calculated in 37 Adult patients during DHCA What is the LIMIT of “SAFE” HCA? McCullough et. al. Ann Thorac Surg, 1999
- 9. Lenox Hill Heart and Vascular Institute of New York Temporary Dysfunction Duration Grade 1 simple confusion short Grade 2 confusion + lethargy short Grade 3 confusion + agitation short Grade 4 overt psychosis long Grade 5 psychosis, parkinsonism long Cognitive Function and Temporary Neurological Dysfunction
- 10. Lenox Hill Heart and Vascular Institute of New York DHCA > 25 minutes Advanced age Neuropsychological impairment in fine motor and memory functions Temporary Neurologic Dysfunction
- 11. Lenox Hill Heart and Vascular Institute of New York Selective Antegrade Cerebral Perfusion
- 12. Lenox Hill Heart and Vascular Institute of New York Neurological Outcome after Thoracic Aortic Surgery Effect of Cerebral Protection Method on Stroke, 0 5 10 15 20 HCA HCA+ACP Transient Permanent Stroke [%] Transient Permanent Hagl et. al. JTCVS, 2001
- 13. Lenox Hill Heart and Vascular Institute of New York Neurological Outcome after Thoracic Aortic Surgery TND by Cerebral Protection Method 0 10 20 30 40 50 60 70 HCA HCA+ACP TND [%] * * p = 0.05 OR 0.33 Hagl et. Al. JTCVS, 2001
- 14. Lenox Hill Heart and Vascular Institute of New York
- 15. Lenox Hill Heart and Vascular Institute of New York
- 16. Lenox Hill Heart and Vascular Institute of New York Srategies to Minimize Cerebral Injury in Arch Surgery Minimize particulate embolization Axillary cannulation Avoid manipulation of diseased vessels Trifurcation graft Aspirate cerebral vessels prior to resuming cerebral perfusion
- 17. Lenox Hill Heart and Vascular Institute of New York
- 18. Lenox Hill Heart and Vascular Institute of New York • 22F – 26F • wire-reinforced • right angled • flexible cannula
- 19. Lenox Hill Heart and Vascular Institute of New York Pre-operative Aneurysm
- 20. Lenox Hill Heart and Vascular Institute of New York
- 21. Lenox Hill Heart and Vascular Institute of New York Srategies to Minimize Cerebral Injury during Aortic Arch Surgery Optimize implementation of HCA Trifurcation graft (arch first technique) EEG, SSEP INVUS Head packed in ice Antegrade selective cerebral perfusion
- 22. Lenox Hill Heart and Vascular Institute of New York OPTIMAL PARAMETERS FOR SELECTIVE CEREBRAL PERFUSION Temperature: 10º-15ºC Pressure: 50-70 torr pH management: alpha stat Hematocrit: 30%
- 23. Lenox Hill Heart and Vascular Institute of New York Re-Operative Complex Aortic Arch Repair Konstadinos A Plestis, MD Director, Aortic Surgery Lenox Hill Hospital Lenox Hill Heart and Vascular Institute of New York
- 24. Lenox Hill Heart and Vascular Institute of New York Case presentation 53 yr male s/p AVR (bioprosthesis)- 2006 s/p Type A Aortic Dissection – 2007 Aortic Root Replacement bioprosthetic composite valve graft reimplantation of the right and left main coronary arteries (Cabrol) Lenox Hill Heart and Vascular Institute of New York
- 25. Lenox Hill Heart and Vascular Institute of New York Bovine Aortic Arch L Main Cabrol Lenox Hill Heart and Vascular Institute of New York
- 26. Lenox Hill Heart and Vascular Institute of New York True Lumen False Lumen Left Subclavian Right Cabrol Left Cabrol Lenox Hill Heart and Vascular Institute of New York
- 27. Lenox Hill Heart and Vascular Institute of New York True Lumen Thrombus Lenox Hill Heart and Vascular Institute of New York
- 28. Lenox Hill Heart and Vascular Institute of New York Celiac axis SMA True lumen Lenox Hill Heart and Vascular Institute of New York
- 29. Lenox Hill Heart and Vascular Institute of New York • Right subclavian artery and right femoral vein cannulation • Re-redo median sternotomy on bypass • Deep Hypothermic Circulatory Arrest at 20° C Lenox Hill Heart and Vascular Institute of New York
- 30. Lenox Hill Heart and Vascular Institute of New York Surgical Strategy • Trifurcation graft to innominate, left carotid and left subclavian arteries • Antegrade selective cerebral perfusion • Fenestration of the descending aorta • Elephant trunk (Stage I) Lenox Hill Heart and Vascular Institute of New York
- 31. Lenox Hill Heart and Vascular Institute of New York
- 32. Lenox Hill Heart and Vascular Institute of New York • 66 yo Female • S/P Right Nephrectomy • Severe retrosternal chest pain
- 33. Lenox Hill Heart and Vascular Institute of New York CT Angiogram: Ascending: 8 cm Arch: 5.4 cm Descending: 8cm. Abdominal: 11.7 cm.
- 34. Lenox Hill Heart and Vascular Institute of New York Distal Arch
- 35. Lenox Hill Heart and Vascular Institute of New York Ascending Descending
- 36. Lenox Hill Heart and Vascular Institute of New York Descending
- 37. Lenox Hill Heart and Vascular Institute of New York Supraceliac Aorta
- 38. Lenox Hill Heart and Vascular Institute of New York Abdominal Aorta
- 39. Lenox Hill Heart and Vascular Institute of New York Ascending Aorta Abdominal Aorta
- 40. Lenox Hill Heart and Vascular Institute of New York Thoracoabdominal Aneurysm
- 41. Lenox Hill Heart and Vascular Institute of New York • Aortic Valve Repair • Replacement of Ascending/ Arch Aorta •(Stage I – Elephant Trunk) • Reimplantation of Brachiocephalic, left Carotid and left Subclavian •(Trifurcation graft) •DHCA, ACP, SSEP, EEG
- 42. Lenox Hill Heart and Vascular Institute of New York Elephant Trunk
- 43. Lenox Hill Heart and Vascular Institute of New York Elephant Trunk Graft
- 44. Lenox Hill Heart and Vascular Institute of New York •Replacement of type I TAAA (stage II ET) •Reimplantation of Celiac, SMA, Left Renal Artery (trifurcation graft) •Perfusion of Celiac, SMA, and Left Renal with cold blood •DAP, CSF drainage, SSEP, MEP
- 45. Lenox Hill Heart and Vascular Institute of New York Trifurcation graft
- 46. Lenox Hill Heart and Vascular Institute of New York Celiac SMA Left Renal
- 47. Lenox Hill Heart and Vascular Institute of New York Left renal
- 48. Lenox Hill Heart and Vascular Institute of New York Distal Anastomosis
- 49. Lenox Hill Heart and Vascular Institute of New York • 70 yo Female • S/P Type A - Aortic dissection repair (‘96) • Severe retrosternal chest pain
- 50. Lenox Hill Heart and Vascular Institute of New York CT Angiogram: Ascending Aorta = 5.0 cm. Aortic Arch = 6.0 cm. Descending Aorta = 3.4 cm.
- 51. Lenox Hill Heart and Vascular Institute of New York Brachiocephalic Artery Left Common Carotid Artery Left Subclavian Artery
- 52. Lenox Hill Heart and Vascular Institute of New York False Lumen of Dissection Brachiocephalic Artery Left Subclavian Artery Left Common Carotid Artery
- 53. Lenox Hill Heart and Vascular Institute of New York False Lumen Brachiocephalic Artery Left Subclavian Artery Left Common Carotid Artery
- 54. Lenox Hill Heart and Vascular Institute of New York False Lumen True Lumen
- 55. Lenox Hill Heart and Vascular Institute of New York False lumen True Lumen
- 56. Lenox Hill Heart and Vascular Institute of New York Ascending Aorta False LumenTrue Lumen
- 57. Lenox Hill Heart and Vascular Institute of New York False Lumen True Lumen
- 58. Lenox Hill Heart and Vascular Institute of New York True Lumen False Lumen False Lumen
- 59. Lenox Hill Heart and Vascular Institute of New York •Bilateral Anterior Thoracotomy •Replacement of Ascending/ Arch/ Descending with a 22 mm Dacron graft. •Reimplantation of Brachiochephalic, Left Carotid, Left Subclavian with a trifurcation graft. •DHCA, ACP, EEG,SSEP
- 60. Lenox Hill Heart and Vascular Institute of New York Trifurcation Graft
- 61. Lenox Hill Heart and Vascular Institute of New York Descending Aortic Graft Ascending Aortic Graft
- 62. Lenox Hill Heart and Vascular Institute of New York Trifurcation
- 63. Lenox Hill Heart and Vascular Institute of New York Trifurcation Graft Origin
- 64. Lenox Hill Heart and Vascular Institute of New York Ascending Aortic Graft Brachiocephalic branch of graft Left Carotid
- 65. Lenox Hill Heart and Vascular Institute of New York Aortic Graft Arch Trifurcation Branches: • Brachiocephalic • Left CCA • Left Subclavian
- 66. Lenox Hill Heart and Vascular Institute of New York False Lumen Graft Distal End of GraftGraft
- 67. Lenox Hill Heart and Vascular Institute of New York Arch Replacement 9/05-9/11 N=157 Pts Hemiarch 100 Total Arch 57
- 68. Lenox Hill Heart and Vascular Institute of New York Etiology Acute Dissection 17 17% 8 14% Chronic Dissection 19 19% 18 32% Medial degeneration 48 48% 24 42% Atherosclerosis 6 6% 7 17% Hemiarch Total Arch
- 69. Lenox Hill Heart and Vascular Institute of New York Demographics HTN 80 80% 47 82% ASHD 1 9 19% 15 26% COPD 24 24% 9 16% Cerebrovascular 12 12% 10 18% disease Hemiarch Total Arch
- 70. Lenox Hill Heart and Vascular Institute of New York Operative Variables Root 57 57% 13 23% Redo 33 33% 21 37% Elective 60 60% 31 54% Hemiarch Total Arch
- 71. Lenox Hill Heart and Vascular Institute of New York Operative variables Right Axillary 33 33% 50 88% cannulation RCP 44 44% 4 7% ACP 15 15% 44 77% Hemiarch Total Arch
- 72. Lenox Hill Heart and Vascular Institute of New York Trifurcated Graft Arch Replacement Mortality 8 8% 2 4% Stroke 5 5% 2 4% TIA 1 1% 2 4% TND 4 4% 4 7% Hemiarch Total Arch
- 73. Lenox Hill Heart and Vascular Institute of New York Conclusions Total Aortic Arch replacement with the trifurcation graft has led to simplification of the technical aspects of the operation The technique is very versatile and can be used in all the anatomical circumstances The mortality and neurologic morbidity of arch replacement have improved significantly with the aid of antegrade and retrograde cerebral perfusion techniques
- 74. Lenox Hill Heart and Vascular Institute of New York Thank you