ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC

AORTIC ANEURYSMS

Armando Mansilha MD, PhD, FEBVSJoel Sousa MD

16th National Congress of the Italian Society of Vascular and Endovascular Surgery

Bologna, 2017

I have the following potential conflicts of interest to report:

Receipt of grants/research support

Receipt of honoraria and travel support

Participation in a company sponsored speakers‘ bureau

Employment in industry

Shareholder in a healthcare company

Owner of a healthcare company

I do not have any potential conflict of interest

Disclosure

X

EPIDEMIOLOGY

• True incidence difficult to determine, as many go undiagnosed

• Incidence is reported as increasing, which may reflect advances in imaging techniques

Estimated annual incidence in Olmstead County, Minnesota,

was 10.4 per 100,000 person years

Ascending Aorta

• Several thoracic aortic segments involved

60%

Aortic Arch10%

Descending Aorta40%

Thoracoabdominal Aorta10%

EPIDEMIOLOGY

TREATMENT OPTIONS ?

TREATMENT OPTIONS

ASCENDING AORTIC ANEURYSM

• Supracoronary replacement of the AAo

• Wheat procedure

• David procedure

• Bentall-DeBono procedure

• Cabrol procedure

Supracoronary replacement of the AAo and aortic valve

Replacement of the AAo with direct reimplantation of the coronary arteries and

reconstruction of the aortic valve, and sinutubular junction

Replacement of the AAo and aortic valve with a valved conduit and direct reimplantation of

the coronary arteries

Replacement of the AAo and the aortic valve with a valved conduit and reimplantation of the

coronary arteries via an additional conduit

CARDIAC SURGERY

TREATMENT OPTIONS

Supracoronary replacement of the AAo and aortic valve

Replacement of the AAo with direct reimplantation of the coronary arteries and

reconstruction of the aortic valve, and sinutubular junction

TREATMENT OPTIONS

DESCENDING THORACIC ANEURYSM

1. TEVAR

2. OPEN SURGERY

TREATMENT OPTIONS

“Endovascular thoracic repair reduces perioperative mortality and neurological

morbidity in patients with descending thoracic aortic aneurysms”

1ST CHOICE

1. TEVAR

VASCULAR SURGERY

TREATMENT OPTIONS

2. OPEN REPAIR

CARDIAC SURGERYVASCULAR SURGERY +

TREATMENT OPTIONS

AORTIC ARCH

• Isolated arch aneurysms are a rare entity

• Aortic arch aneurysms are commonly associated with

aneurysms of the adjacent ascending or descending aorta

• The criteria applied are those of ascending or descending

aneurysms depending on whether the arch aneurysm is more

closely related to the ascending or the descending aorta

TREATMENT OPTIONS

ASCENDING AORTA AND ARCH INVOLVEMENT

1. ISLAND PATCH TECHNIQUE 2. Y-GRAFT TECHNIQUE

CARDIAC SURGERY

TREATMENT OPTIONS

ARCH AND DESCENDING THORACIC INVOLVEMENT

• Several treatment options available

• Indications are LESS CLEAR

• Open surgery

• Hybrid techniques (including debranching)

• Total endovascular interventions

TREATMENT OPTIONS

Although, usually performed by CARDIAC SURGERY

1. Elephant trunk2. Frozen elephant trunk

TREATMENT OPTIONS

New endovascular techniques have allowed VASCULAR SURGEONS to treat this vascular

territory

1. Hybrid techniques with SAT debranching 2. Total endovascular replacement with chimneys,

branches and fenestrations

TREATMENT OPTIONS

SO, WHAT TO DO?

• Both endo and open techniques have been develloped

• In patients without CONNECTIVE TISSUE DISORDERS, technique should be chosen accordingly to the patients

physiological status as well as the center’s experience

• In patients with CONNECTIVE TISSUE DISORDERS, OPEN interventions should be favoured over endo procedures

Nonetheless,

PRE AND POST-OPERATIVE PLANNING AND SURVEILLANCE

• PROPER PRE-OPERATIVE ASSESSMENT of the aneurysm is essential,

in order to plan either open or endovascular interventions

• In patients treated with aortic endografts, LIFELONG SURVEILLANCE is

necessary to ensure proper placement of the graft

CONCLUSION

• Depending on the LOCATION of the thoracic aortic aneurysms, DIFFERENT INTERVENTIONS are available

• Patients with CONNECTIVE TISSUE DISORDERS should be offered OPEN SURGERY, whenever possible

• New ENDOVASCULAR interventions have allowed to push the bounderies of arch aneurysm treatment, although solid

evidence is still LACKING

• Proper PRE-OPERATIVE PLANNING and STRICT FOLLOW-UP are essential, either in open or endo interventions

Thoracic aortic aneurysms are COMPLEX PATHOLOGIES which may require a wide variety of

interventions. Patients should be referred to centers where both VASCULAR and CARDIAC

SURGEONS are available, as COOPERATION and JOINT PROCEDURES are often NECESSARY.

ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC

AORTIC ANEURYSMS

Armando Mansilha MD, PhD, FEBVSJoel Sousa MD

16th National Congress of the Italian Society of Vascular and Endovascular Surgery

Bologna, 2017