1. ASCENDING AORTIC ANEURYSM: TECHNIQUE
MARKO TURINA
University Hospital
Zurich, Switzerland

5. Tension at Coronary Ostia with Graft Inclusion Technique
From Crawford: Diseases of the Aorta

6. GRAFT INCLUSION TECHNIQUE: SUBSTANTIAL SOURCE OF COMPLICATIONS
From Crawford: Diseases of the Aorta

7. Perigraft hematoma after wrap technique

8. Spurious Aneurysm at the Origin of RCA After Graft Inclusion Technique in Composite Graft

9. Spurious Aneurysm of the Aortic Root After Composite Graft: Detachment of the Coronary Orifice

10. COMPOSITE GRAFT IN MARFAN’S DISEASE: False aneurysm at the origin of LMCALA
35 year old male with Marfan, 9 y. after composite graft repair for acute Type A dissection
False aneurysm
True lumen
BS 25
Aortic valve
BS 25
RVOT
Composite graft (compressed)
Courtesy Prof.Jenni, Echocardiography USZ

11. FALSE ANEURYSM AT THE ORIGIN OF LMCA AFTER COMPOSITE GRAFTLA
Leakage into the false aneurysm
True lumen
BS 25
Aortic valve
Composite graft
RVOT

12. Composite Graft with Open Technique

13. Composite Graft with Open Technique

14. Myocardial Protection in Ascending Aortic Surgery Zurich 2003
Systemic hypothermia 280C
Begin with retrograde cardioplegia, cross-clamp and arrest with antegrade perfusion directly into coronaries (except in acute Type A).
Continuos retrograde cold oxygenated 160C throughout procedure.
Warm reperfusion (“hot shot”)

16. Etz C. D. et al.; Ann Thorac Surg 2007;84:1186-1194
Schematic drawing of mechanical (n = 126 patients; 61%) and biologic (n = 80 patients; 39%) valved composite grafts used for aortic root replacement using a modified Bentall technique
Etz C. D. et al.; Ann Thorac Surg 2007;84:
Copyright ©2007 The Society of Thoracic Surgeons

18. BUTTON TECHNIQUE FOR COMPOSITE GRAFT REPAIR

19. From Barbeau et al, Ann Thor Surg 1999

20. Axillary Artery Cannulation: Essential in Arch Procedures and Acute Type A

24. Bavaria et al., Ann Thor Surg 2003

25. Hemiarch Bentall Procedure Subclavian/Innominate Artery Perfusion Technique
Monitor left and right radial, and femoral artery pressure.
Cannulation of subclavian/innominate artery.
Cool patient to 280 C.
Cross clamp innominate and left carotid, block left subclavian artery with balloon, perfuse upper body with 10 ml/kg, and administer antegrade and retrograde CPL.
Perform distal anastomosis first, clamp the graft and resume body perfusion.
Perfrom proximal part of the operation (valve and coronaries).
Re-anastomose proximal and distal graft segment.

27. CABROL’S TECHNIQUE FOR DECOMPRESSION OF PERIGRAFT SPACE J Thorac Cardiovasc Surg 81:309-315, 1981

28. CABROL’S ORIGINAL DESCRIPTION OF CORONARY ANASTOMOSIS J Thorac Cardiovasc Surg 81:309-315, 1981

31. Modifications of Button Technique
Pratali et al, Tex Heart Inst J 2000
Hilgenberg et al, Ann Thor Surg 1996

32. Completion Bentall procedure
Malekan R. et al.; Ann Thorac Surg 2011;92:
Copyright ©2011 The Society of Thoracic Surgeons

33. Two common errors in ascending aortic surgery:
Timid resection of aneurysm (instead of going into arch)
Use too long graft (they all lengthen and distend with time, some up to 20 – 30 % of diameter)

34. Keep you graft short, it expands and lengthens with time!
Figure 7b.  Bentall procedure in a 42-year-old man with a Stanford type A aortic dissection. (a) Preoperative reformatted CT image shows a thin intimal flap in the ascending aorta (arrow). (b) Postoperative reformatted CT image shows the composite graft and mechanical aortic valve used to replace the aortic root, as well as the reimplanted left coronary artery (arrow), which is attached to the composite graft.
Ha H I et al. Radiographics 2007;27:
©2007 by Radiological Society of North America

35. Potential Source of Recurrencies: Distal Anastomosis in Ascending Aorta (Instead in Arch)