Thoracic aortic diseaseThoracic aortic diseaseKittichai Luengtaviboon

21 January 2011

introductionintroduction

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.

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.

Indication for TAA repairIndication for TAA repair

>60 m diameter or > 2x transverse diameter of an adjacent normal aortic segment

Symptomatic regardless of sizeGrowth rate of aneurysm > 3 mm/y

Circulation 2005;112:1663-1675.

Common thoracic aortic problems Common thoracic aortic problems in Thailandin Thailand

1 aneurysm2 dissection and acute aortic syndrome3 nonspecific aortitis or Takayasu’s

disease4 aortic trauma5 aortic infection

Thoracic aortic aneurysmThoracic aortic aneurysm

Classification – anatomical ascending – root, tubular part arch descending type A,B and C thoraco abdominal Crawford 1-4Etiology atherosclerotic hereditary chronic dissection others – infection, trauma, inflammatory

Acute aortic syndromeAcute aortic syndrome

There are three common types acute aortic dissection intramural hematoma penetrating aortic ulcerCommon etiologic factors hypertension older age atherosclerosis genetic disorder – Marfan, Ehler Danlos,

Turner, Loeys Dietz

Indication for surgery in thoracic Indication for surgery in thoracic aortic diseseaseaortic disesease

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

indicationindication

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

Thoracic aortic infectionThoracic aortic infection

4 types, most common due to infected aortitisGold standard open resection with insitu graft

replacementTEVAR 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.

Option for treatment of thoracic Option for treatment of thoracic aortic diseasesaortic diseases

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

TEVAR evidence based

support its use in descending aorta

Recommendations for open surgery Recommendations for open surgery for ascending aortic aneurysmfor ascending aortic aneurysm

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)

Recommendation for aortic arch Recommendation for aortic arch aneurysmaneurysm

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)

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 of treatment of Recommendation of treatment of descending thoracic aortic descending thoracic aortic aneurysmaneurysm

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)

Society of Thoracic Surgeons Recommendations Society of Thoracic Surgeons Recommendations for Thoracic Stent Graft Insertion (summary)for Thoracic Stent Graft Insertion (summary)

Entity/Subgroup Classification Level of Evidence

Penetrating ulcer/intramural hematoma

Asymptomatic III C

Symptomatic IIa C

Acute traumatic   I B

Chronic traumatic IIa C

Acute Type B dissection

Ischemia I A

No ischemia IIb C

Subacute dissection IIb B

Chronic dissection IIb B

Degenerative descending

>5.5 cm, comorbidity IIa B

>5.5 cm, no comorbidity IIb C

<5.5 cm III C

Arch

Reasonable open risk III A

Severe comorbidity IIb C

Thoracoabdominal/Severe comorbidity IIb C

Note: Table 15 in full-text version of TAD Guidelines. Reprinted from Svensson et al. Expertconsensus document on the treatment of descending thoracic aortic disease using endovascular stentgrafts. Ann Thorac Surg. 2008;85:S1– 41.

Endovascular stent grafting versus open Endovascular stent grafting versus open surgical repair of descending thoracic aortic surgical repair of descending thoracic aortic aneurysms in low risk patients: a multicenter aneurysms in low risk patients: a multicenter comparative trialcomparative trial

Joseph E. Bavaria et alJ 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)

conclusionconclusion

Perioperative mortality and morbidity were significantly less with TEVAR

Overall stroke rate was similarReintervention 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.

Techniques in open repair of Techniques in open repair of thoraic aortic aneurysmsthoraic aortic aneurysms

Ascending aorta involve root – modified Bentall or David not involve root – replace aorta above

sinotubular junction

Aortic archAortic arch

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

Total arch replacementTotal arch replacement

Incision – median sternotomyCannulation arterial – ascending aorta, right

subclavian, left common carotid, femroal A

venous – right atriumTechnique of arch replacement island – arch first individual arch branch

Ascending, arch and descending Ascending, arch and descending aortic aneurysmsaortic aneurysms

Incision – clamshellCanulation ascending aorta, femoral artery venous right atrium

Descending aorta type A or CDescending aorta type A or C

Incision left posterolateral thoracotomyUse DHCA

Descending aorta type BDescending aorta type B

Incision – left posterolateral thoracotomyTechnique clamp and go femoral vein- descending aorta partial

CPB shunt left atrio femoral bypass with

centrifugal pump