ASCENDING AORTIC ANEURYSM: TECHNIQUE MARKO TURINA University Hospital Zurich, Switzerland.
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Transcript of ASCENDING AORTIC ANEURYSM: TECHNIQUE MARKO TURINA University Hospital Zurich, Switzerland.
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ASCENDING AORTIC ANEURYSM: TECHNIQUE
MARKO TURINA University Hospital
Zurich, Switzerland
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Tension at Coronary Ostia withGraft Inclusion Technique
From Crawford: Diseases of the Aorta
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GRAFT INCLUSION TECHNIQUE: SUBSTANTIAL SOURCE OF COMPLICATIONS
From Crawford: Diseases of the Aorta
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Perigraft hematoma after wrap technique
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Spurious Aneurysm at the Origin of RCA After Graft Inclusion Technique in Composite Graft
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Spurious Aneurysm of the Aortic Root After Composite Graft: Detachment of the Coronary Orifice
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COMPOSITE GRAFT IN MARFAN’S DISEASE:
False aneurysm at the origin of LMCA
Courtesy Prof.Jenni, Echocardiography USZ
35 year old male with Marfan, 9 y. after composite graft repair for acute Type A dissection
Aortic valve
LA
RVOT
True lumenBS 25
False aneurysm
Composite graft (compressed)
BS 25
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FALSE ANEURYSM AT THE ORIGIN OF LMCA AFTER COMPOSITE GRAFT
Aortic valve
LA
RVOT
True lumenBS 25
Composite graft
Leakage into the false aneurysm
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Composite Graft with Open Technique
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Composite Graft with Open Technique
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Myocardial Protection inAscending 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 blood @ 160C throughout procedure.
• Warm reperfusion (“hot shot”)
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Copyright ©2007 The Society of Thoracic Surgeons
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
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BUTTON TECHNIQUE FOR COMPOSITE GRAFT REPAIR
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From Barbeau et al, Ann Thor Surg 1999
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Axillary Artery Cannulation: Essential in Arch Procedures and Acute Type A
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http://www.mpoullis.net/bscpb/cpb/blank.htm
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Bavaria et al., Ann Thor Surg 2003
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Hemiarch Bentall ProcedureSubclavian/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.
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CABROL’S TECHNIQUE FOR DECOMPRESSION OF PERIGRAFT SPACE
J Thorac Cardiovasc Surg 81:309-315, 1981
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CABROL’S ORIGINAL DESCRIPTION OF CORONARY ANASTOMOSISJ Thorac Cardiovasc Surg 81:309-315, 1981
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Modifications of Button Technique
Hilgenberg et al, Ann Thor Surg 1996
Pratali et al, Tex Heart Inst J 2000
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Copyright ©2011 The Society of Thoracic Surgeons
Malekan R. et al.; Ann Thorac Surg 2011;92:362-363
Completion Bentall procedure
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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)
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Ha H I et al. Radiographics 2007;27:989-1004
©2007 by Radiological Society of North America
Keep you graft short, it expands and lengthens with time!
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Potential Source of Recurrencies: Distal Anastomosis in Ascending Aorta
(Instead in Arch)