Thoracic aortic disease Kittichai Luengtaviboon 21 January 2011

introduction 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 repair >60 m diameter or > 2x transverse diameter of an adjacent normal aortic segment Symptomatic regardless of size Growth rate of aneurysm > 3 mm/y Circulation 2005;112:

Common thoracic aortic problems in Thailand 1 aneurysm 2 dissection and acute aortic syndrome 3 nonspecific aortitis or Takayasu’s disease 4 aortic trauma 5 aortic infection

Thoracic aortic aneurysm 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

Acute aortic syndrome 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

Indication for surgery in thoracic aortic 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

indication 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 infection 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.

Option for treatment of thoracic aortic 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 for 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 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) 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 descending thoracic aortic 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)

Society of Thoracic Surgeons Recommendations for Thoracic Stent Graft Insertion (summary) Entity/SubgroupClassificationLevel of Evidence Penetrating ulcer/intramural hematoma AsymptomaticIIIC SymptomaticIIaC Acute traumatic IB Chronic traumaticIIaC Acute Type B dissection IschemiaIA No ischemiaIIbC Subacute dissectionIIbB Chronic dissectionIIbB Degenerative descending >5.5 cm, comorbidityIIaB >5.5 cm, no comorbidityIIbC <5.5 cmIIIC Arch Reasonable open riskIIIA Severe comorbidityIIbC Thoracoabdominal/Severe comorbidityIIbC 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.

Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low risk patients: a multicenter comparative trial Joseph E. Bavaria et al J Thorac Cardiovasc Surgery 2007;133: The first completed multicenter trial directed at gaining approval from the US Food and Drug Administration. From Sep 1999 and May 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)

conclusion 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.

Techniques in open repair of thoraic aortic aneurysms Ascending aorta involve root – modified Bentall or David not involve root – replace aorta above sinotubular junction

Aortic 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 replacement 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

Ascending, arch and descending aortic aneurysms Incision – clamshell Canulation ascending aorta, femoral artery venous right atrium

Descending aorta type A or C Incision left posterolateral thoracotomy Use DHCA

Descending aorta type B Incision – left posterolateral thoracotomy Technique clamp and go femoral vein- descending aorta partial CPB shunt left atrio femoral bypass with centrifugal pump