Natural History

TAR has been long considered a surgical emergency. This concept is primarily based on the historical study by Parmley et al. 2 in 1958, who reported autopsy findings in 296 nonpenetrating TARs among Korean War victims. Remarkably, the analysis of Parmley et al. estimated that 85 of the victims died on the scene from free aortic rupture of those who survived at least for 1 h, 30 died within 6 h, 49 within 24 h, and 90 within 4 months. The impressive negative natural history of TAR victims gave...

FollowUp

The principal aim of follow-up is to propose surgery before aortic dissection has occurred. The aortic diameter is the principal predictor of aortic rupture or dissection 35 . In a large retrospective study gathering thoracic aortic aneurysms from different aetiologies, the risk for rupture or dissection was 6.9 per year, and death, rupture, or dissection was 15.6 per year for a size greater than 6.0 cm. The odds ratio for rupture increases 27-fold compared with lower values 36 . Similarly,...

Medical Treatment

The concept of pharmacological treatment and medical support of acute aortic dissection introduced by Wheat et al. 27 in 1984 was first proposed by Aronstam et al. 28 for the treatment of traumatic rupture of the aorta. This attitude was confirmed by several groups in the ensuing years 29, 30 . Walker et al. 31 in an extensive review of the literature found 64 patients medically treated waiting for aortic surgery. Stulz et al. 35 in 1991 did not observe any death among patients treated in a...

Introduction

Intramural aortic hematoma (IAH) and penetrating aortic ulcers (PAU) are part of the so-called acute aortic syndrome (AAS). This new cardiovascular syndrome embraces a heterogeneous group of patients with a similar clinical profile that includes classic aortic dissection, IAH and PAU (Fig. 27.1) 1 . The physiopathologi-cal mechanism that precipitates the appearance of each of these entities is different and the natural history of the last two aortic lesions is not well known. Currently, we know...

Current Therapeutic Strategy

The prevalence and the gravity of the lesions associated with the aortic rupture (Table 32.1) in our series are in accordance with data recently published. It is to be noted that no patient died from hemorrhage. Six deaths out of ten (60 ) were directly related to an associated lesion, five being possibly worsened by full hepariniza-tion during CPB two cases of intracerebral hematoma following a major head injury and three cases of respi Table 32.4. Comparison of mortality and paraplegia rates...

Medical Therapy

Medical therapy has been developed based on the assumption that aortic dilation and dissection are favoured by the repeated aortic stretch secondary to blood ejection by the left ventricle. Therefore, it was initially aimed at decreasing dp dt and the rebound wave. The use of beta-blockers in this setting was rein forced by the observed benefit on turkeys prone to aortic dissection 26 . However, invasive haemodynamic measurements performed in patients scheduled for aortic surgery (and hence...

Incision

The choice of incision primarily depends on the exact procedure planned, taking into consideration exposure, morbidity of the incision itself, and the options to minimize neurologic complications. As a rule, a median sternotomy provides excellent exposure for any procedure involving the proximal or total arch. A left pos-terolateral thoracotomy in the fourth or fifth intercostal space provides excellent exposure for a distal arch procedure, especially if additional surgery is necessary on the...

Trauma

Despite advances in surgical and reanimation techniques, surgery is still associated with significant morbidity and mortality rates ranging between 8 and 15 depending on whether circulatory assistance to maintain satisfactory perfusion of the distal aorta is used or not 25 . The postoperative paraplegia rate without circulatory assistance can be as high as 19 and increases significantly when the aorta is clamped for more than 30 min 26 . With circulatory assistance, the rate is about 2 25...

Diagnosis

The infectious attack of the aorta can be visualized thanks to the imaging examinations. Standard chest X-rays find aortic aneurysms, shown by opacities of different size in the mediastinum. These opacities are the same density as the rest of the aorta. X-rays at different angles will show the topography of the aneurysm 44 . A computed tomographic scan with contrast injection is the most useful examination to define the precise location of the arterial attack. It initially shows an...

Technique of Measurement

Aortic root diameter can be measured using echocardiography, a computed tomography (CT) scan, or MRI. Transthoracic echocardiography remains the preferred investigation because of easy accessibility and good visualisation of the aortic root in most patients. However, in some patients, mainly as a result of chest deformation, it may be difficult to obtain a reliable aortic diameter using transthoracic echocardiography, in which case alternative techniques should be used (CT or MRI). Whichever...

Clinical Presentation

Despite the severe nature of the injury the clinical signs are ambiguously meager. In the diagnosis of acute TAR, it is imperative to maintain a high index of suspicion of the likelihood of this lesion in victims of high-speed-deceleration injuries, whether or not there is external evidence of thoracic injury. The signs of aortic rupture are not specific and when head, facial, orthopedic, and visceral lesions coexist, their own clinical features attract the attention of the physician. Chest...

Evolutive Risk Factors

The assessment of evolutive risk factors will determine the therapeutic strategy. The evolution must be assessed with repeated imaging controls, principally a CT scan ner. Screening at the end of the first week, 1 and 6 months, 1 year and yearly thereafter until complete normal restitution seems a reasonable and safe protocol. An intermediate control can be necessary in the case of modifications. At the chronic phase, MRI can be proposed as an alternative. The choice of the imaging modality...

Type of Replacement

The type of replacement has been the subject of continuing controversy. After the introduction of the deep hypothermic circulatory arrest, orthotopic tubular replacement of the aortic arch became the standard, at Fig. 10.6. Schematic drawing of ascending and partial arch replacement. The exact level of the distal anastomosis has little or no impact on morbidity or mortality Fig. 10.6. Schematic drawing of ascending and partial arch replacement. The exact level of the distal anastomosis has...

Neonatal and Early Childhood Thoracic Aorta Abnormalities and Their Current Surgical Treatment

Artrip 36.1 Introduction 353 36.2 Aortic Coarctation 353 36.2.2 Occurrence 353 36.2.3 Clinical Presentation and Diagnosis 354 36.2.4 Surgical Treatment 355 36.2.5 Surgical Results 357 36.2.6 Interventional Approach to Coarctation . . . 357 36.3 Interrupted Aortic Arch 357 36.3.2 Occurrence 358 36.3.3 Clinical Presentation and Diagnosis 358 36.3.4 Surgical Treatment 358 36.3.5 Surgical Results 359 36.4 Vascular Rings 359 36.4.1 Anatomy and Embryology 359 36.4.2...

Experiments on the Hemodynamics of True Lumen Collapse

An in vitro study at Stanford created two aortic dissection phantoms to investigate the causative factors for true-lumen collapse and to develop effective treatments 13, 14 . One phantom was compliant and opaque (Fig. 3.1), and the other was rigid and transparent (Fig. 3.2). The rigid, transparent phantom was created to allow visual observation of the true lumen along the length of the aorta. Each phantom had the following physical features to model a Stanford type B aortic dissection an aortic...

Length of Coverage

An unanswered technical question concerns the length of aortic coverage necessary to achieve dissection healing. The key is to cover the proximal entry site to reduce pressure in the false lumen and consequently shrink the total aortic diameter and improve flow in the true lumen expanding the later, resolving ischemic complications or malperfusion syndromes. Given our results and those of others, it seems that complete thrombosis of the false lumen is necessary to reduce the overall aortic...

Cerebral Protection

Cerebral protection is of central importance in surgery of the aortic arch 10, 11 . Historically the first approach to be utilized was antegrade perfusion of the supraaortic vessels in order to completely avoid interruption of cerebral blood flow. Although this made the first replacements of the arch possible, it never gained wide acceptance. The concept of hypothermic circulatory arrest was based on the early investigations of Bigelow 12 and others 13, 14 , who found that decreased body...

Intimal Lesion

By definition there is always an intimal lesion in the APU. In IMH, intimal lesions most often represent ostial disruptions (mainly of intercostal arteries) called ulcerlike projections. They are more frequent on the descending aorta than on the ascending aorta. Their onset during the course of the disease is a predictor of worse outcome 4 . Different thresholds of size and depth have been proposed. In the study by Ganaha et al. 5 , the cutoff was a diameter of 20 mm and a depth of 10 mm. The...

Physiopathology

IAH was described by Krukenberg 4 in 1920 as a dissection without intimal tear. IAH has been defined as a novel variant of classic aortic dissection characterized by the absence of an entrance tear. It is, therefore, a noncommunicating type of dissection (Fig. 27.2) 5 . Here, the false lumen is created by a hemorrhage into the aortic media, most likely after rhexis of the vasa vasorum that penetrate the outer half of the aortic media from the adventitia and arborize at this level. Fig. 27.2....

Stenting and Fenestration

For a few years, new therapies have been available percutaneous stenting and fenestration 7 . They represent an alternative to surgical treatment especially in some high-risk patients, in the case of an involved descending aorta aneurysms, dissection and traumatic rupture of the isthmus, asacute as in chronicle phases. Fenestration is particularly useful in aortic dissection. During the procedure, TEE can easily identify true and false lumen. An immediate evaluation of treatment can be assessed...

Pathology

According to the study of Parmley et al. 2 , the lesion may be classified as (1) intimal hemorrhage, (2) intimal hemorrhage with laceration, (3) medial laceration, (4) complete laceration of the aorta, (5) false aneurysm formation, and (6) periaortic hemorrhage. The intimal hemorrhage may have an intact endothelian layer or may be associated with circumscribed laceration of the endothe-lial and internal elastic lamina of the intima. Recent reports indicate that intimal hemorrhage with or...

Endovascular Treatment

Today, endovascular treatment is mainly available for the descending aorta. It relies on stent-grafts. Their main use is to provide protection from the risk of rupture in the case of an intimal lesion. The landing zone must include a sufficient proximal and distal area of normal aortic wall. It seems preferable to use completely covered stent-grafts, without bare stents or hooks. Given the intima fragility, it seems unwise to use a modeling balloon to complete the stent-graft deployment. Up to...

Frequency for FollowUp

Currently the recommended follow-up for aortic root measurement is once a year, when the aortic dilation is moderate. However, when the diameter comes to values close to surgical threshold, a 6-month interval follow-up is usually proposed. Similarly, when the aortic diameter appears to increase, the confirmation of the measurement using another technique is necessary and repeated measurements at 2-month intervals may be performed to confirm the evolution of the diameter and the indication for...

References

Fabian TC, Richardson JD, Croce MA, Smith JS, Rodman G Jr, Kearney PA. Prospective study of blunt aortic injury multicenter trial of the American Association for the surgery of trauma. J Trauma 1996 42 374-383. 2. Von Oppell VD, Dunne TT, De Groot MK, Zilla P. Traumatic aortic rupture twenty year metanalysis of mortality and risk of paraplegia. Ann Thorac Surg 1994 58 585593. 3. Kipfer B, Leupi F, Schuepach P, Friedli D, Althaus U. Acute traumatic rupture of the thoracic aorta immediate or...

Timing of Treatment

Stent-graft placement could become, in the near future, the standard treatment for most cases of complicated or uncomplicated aortic dissection mostly because the operative mortality rate approaches 70 if we wait for complications to occur. Another argument in favor of early endovascular treatment is the evolution of aortic morphology with time following dissection. In acute type B dissections, an isolated tear is more frequent and usually no thrombus is present in the false lumen, while in...

Results

Hospital mortality mainly depends on the urgency of the operation, age, and the presence and degree of atherosclerosis. Elective arch replacement is possible with a mortality rate of 2-6 . In patients over the age of 80 years, mortality may be as high as 8-15 . In Fig. 10.9. Computed tomography of the chest after total arch replacement with an elephant trunk. The graft extension can be seen easily there is the of beginning thrombosis of the aortic lumen around the trunk We commonly perform...

Diagnostic Investigations

A computed tomography (CT) scan of the chest will be available for almost all patients at the time of referral. It gives almost all the information necessary regarding the aorta itself, i.e., diameters, extension of the aneurys-matic process, and anatomical relationship with neighboring structures including the chest wall. If not already available, a CT or an MRI scan should be available before every operation performed on an elective basis. It is of vital importance when planning any aortic...

Traumatic Aortic Injuries

If performed by a trained physician, TEE is able to assume diagnosis of traumatic aortic injury and to indicate the precise type and emergency of treatment. Classically, subadventitial disruption requires surgical treat- Fig. 4.23. Stenting procedure for aneurysm of the descending aorta (two stents), a After deployment of the first stent (arrow), uncovered aneurysm (AN), b Color Doppler image of aortic flow, c Guidewire (arrow), d After deployment of the Fig. 4.23. Stenting procedure for...

Operative Techniques

The purpose of endografting for the treatment of aortic dissection is to close the entry tear located in the descending thoracic aorta, which usually does not have large branches contributing to type II endoleak. Therefore, the device could be simple compared with that used for the treatment of abdominal aortic aneurysms. Although some devices are already commercially available in western countries, so-called first-generation endografts, Fig. 20.4. An axial computed tomography (CT) image shows...

Surgical Treatment

Surgical treatment is based on the currently validated techniques of replacement of the pathologic segment. The basic principle is to realize prostheto-aortic sutures in areas of normal wall, sometimes reinforced by a Teflon banding according to the fragility of the aortic wall. The sealing of the suture can be completed by the use of biological glues (cf. previous chapters). Because of an older age, and a greater frequency of comorbidities 5 , the surgical risk is higher in patients with IMH...

Microbiology

Before the era of antibiotics, the most common germs were Streptococcus and syphilis 19 . Since the introduction of antibiotics and their significant use, the nature of responsive germs has changed. Currently, the commonest bacteria in the thoracic aortitis are the grampositive cocci which occur in 60 of cases (Table 25.1). Among them, Staphylococcus aureus represents, according to studies, between 30 and 50 of all aortitis cases. Streptococcus is the second commonest bacterium found. It is...

Conclusions

Replacement of the aortic arch for degenerative aneu-rysms is a standardized procedure which can be performed with a low risk. Both operative technique and cerebral discussion are still the subject of controversial discussion. In many patients standard arch replacement using hypothermic arrest yields excellent results. Technical modifications should be kept in mind to be able to apply an individualized approach to patient and aortic pathology in difficult situations. 1. Cooley DA, Mahaffey DE,...

Prognosis Indication for Treatment

The prognosis of these aneurysms largely depends on their tendency to rupture or originate acute dissection. Some information exists on the spontaneous prognosis of true aneurysms 6, 8 , even though the data is very limited compared with the prognostic information on coronary heart or valve disease. On the basis of the information available it seems to be clear that these aneu-rysms tend to grow in size and rupture or dissect with increasing frequency once a diameter of approximately 5 cm has...

Aortic Anomaly in Marfan Syndrome

Aortic dissection and dilatation are mainly observed on the proximal part of the ascending aorta in patients with Marfan syndrome this portion of the aorta is submitted to maximal haemodynamic stress, and is the richest in elastic fibres as well as in fibrillin 1. However, haemodynamic studies have clearly demonstrated that the entire aortic wall properties are altered 15, 16 , even when the aortic diameter is within normal values 17 . Although less common, aortic dissection of the descending...

Indications for Surgery

The indications for surgery are based on the appreciation of the risk of aortic dissection. Factors associated with increased risk are First of all, the aortic diameter at the level of the sinuses of Valsalva (maximal diameter) 35 (cf. supra). The risk increases dramatically after 60 mm, although aortic dissection may occur when the aorta is of normal size 37 . Indications for surgery have been proposed in the past when the aortic diameter was 60 mm. With the progress in surgery, the limit of...

Conclusion

TEE is a recognized and accurate method for diagnosis of all thoracic aortic diseases. This technique does not expose the patient to radiation or injection of toxic contrast agent. TEE can be performed at the bedside and in critical circumstances. In addition, it provides determinant data concerning left ventricular function, volumes and associated valve abnormalities. It requires a trained medical team. Nevertheless, aortic diseases need a regular follow-up. In that case, MRI offers the...

Management Strategy

IMH usually appear on aortas with little atheroma lesions, oppositely to APU. So, evolution towards a frank dissection is frequent in the case of IMH, by media splitting, whereas in the case of UPA, fibrous changes of the aortic wall due to atheroma limit the extension of the dissecting process. Evolution towards localized dissection can be completely silent 1, 2 . Association of persistent or recurrent pain, evolving serous or hemorrhagic effusion, and dynamic instability constitute a syndrome...

Dissection

Despite the frequency of acute aortic dissection, there are few large series published on the outcomes of dissections and most are long retrospective multicenter studies confounded by inconsistent methods of treat ment and data collection. The IRAD study, a prospective multicenter registry has now been created to address some of these concerns. This study 7, 8 provides better understanding of the clinical profile and outcomes of patients with acute type B aortic dissection, helping clinicians...

Vasa vasorum

In normal circumstances, the intima and the inner part of the aortic media are avascular. It is important to point out that the vasa vasorum are present in the medial layer only when this layer has more than 29 lamellar units and, in such cases, they will only be found in the region of the medial layer that is beyond these 29 units 6 . The region of the medial layer corresponding to the 29 subintimal units is an avascular area and one may presume that the nutrients flow via transintimal...

Acute Traumatic Aortic Rupture Stent Graft Repair

Herv Rousseau, Jean Phillipe Bolduc, Camille Dambrin, Bertrand Marcheix, Guillaume Canevet, B. Leobon, C. Cron, Philippe Otal, Jean-Michel Bartoli, Gerard Fournial 33.1 Introduction 331 33.2 Pathophysiology 331 33.3 Conventional Treatment 331 33.4 Concept of Delaying Repair 332 33.6 Our Therapeutic Strategy 332 33.8 Potential Limitations 336

Anatomy

Coarctation encompasses a variety of obstructive lesions of the aorta. Bonnet 6 was the first to recognize distinct anatomical subsets of coarctation and classify them into an adult and an infantile type. The adult type depicts a discrete obstructive lesion just distal to the left subclavian artery, whereas the infantile type depicts a diffuse narrowing of the aortic isthmus (Fig. 36.1). Terms such as preductal and postductal are employed to describe the lesion in relation to the ductus...

Pathogenesis

This lesion may be generated by many different types of sudden-deceleration injury, including car and motorcycle collisions, falls from a height, blast injuries, airplane and train crashes, and skiing and equestrian accidents. In a demographic analysis of 144 patients with aortic rupture, Hunt et al. 6 reported motor vehicle crashes in 83 of cases, motorcycle crashes in 4.9 of cases, pedestrian injuries in 7 of cases and falls in 2.1 of cases. The use of the seat belt has partially modified the...

Balloon Angioplasty for Native Coarctation

Following the first documented treatment of balloon an-gioplasty for recurrent coarctation 13 , this technique was applied to native coarctation in a critically ill neo-nate 25 and led to several clinical studies 26-28 . The greatest limitation of balloon angioplasty for the treatment of native coarctation is the occurrence of aortic aneurysms 28 . Patients treated for coarctation by surgical correction or stent implantation are also susceptible to aneurysms 9, 29 , but there is an increased...

Aneurysms

Symptoms, etiology, underlying pathology and TTE evaluation of left ventricular function or valvular dysfunction are necessary for treatment discussion. TEE provides determinant data about the site, involvement of collateral branches, mechanisms of complications, periaortic extension and diameters. The purpose of this chapter is not to define the dimension cutoff point for indication of surgery but to evaluate the ability of TEE for monitoring of aortic diameters. TEE allows measurement of...

Risk Factors

The risk factors are mainly marked by those of atherosclerosis male sex, age, tobacco smokers, hypertension, diabetes mellitus, dyslipidemia 9, 11, 12 . Congenital anomalies of the aorta (coarctation of the aorta, ductus arteriosus) also represent risky situations 14 . The immune statute of the patient also seems to play a role with probably an increased risk in the event of immune system depression mainly caused by diabetes mellitus, treatments (corticosteroids, immunosuppressive treatments)...

Results of Endografting

Nienaber et al. 29 should be credited as being first to objectively prove the efficacy of endografting for the treatment of chronic aortic dissection. They treated 24 patients with chronic aortic dissection 12 patients with endografting and 12 patients with surgical graft replacement. Endografting was associated with no mortality or morbidity, whereas conventional surgery was associated with four deaths and five serious adverse events in their series. Although the number of the patients and the...

The New Wave of Elephant Trunk Technique

11.1 The Conventional Elephant Trunk Technique . . . 125 11.2 The Frozen Elephant Trunk Technique 126 11.3 Own Experience Employing the Frozen Elephant Trunk Technique Using a Hybrid Prosthesis with a Stented and a Nonstented End 126 11.3.1 Patients and Surgery 126 11.3.2 Results and Follow-Up 128 11.4 Comment 128

Surgical Treatment of Chronic Descending Aortic Dissection

18.1 Introduction 181 18.2 Indications for Surgery 181 18.3 Surgical Techniques 182 18.3.1 Access 182 18.3.2 Thoracic Approach 182 18.3.3 Thoracoabdominal Approach 184 18.3.4 Abdominal Approach 184 18.4 Adjunctive Procedures 184 18.5 General Considerations Pitfalls During Surgery . 185 18.6 Additional Surgical Techniques 185 18.6.1 Descending Thoracic Postdissection 18.6.2 Thoracoabdominal Aneurysms 186 18.7.1 Stroke 186 18.7.3 Renal Failure 186 18.7.4 Visceral Ischemia 187 18.7.5 Pulmonary...

Occurrence

Coarctation occurs in 20-60 per 100,000 live births and represents 5-8 of all congenital cardiovascular lesions 11, 13 . It is an isolated lesion 82 of the time and is approximately twice as common in male 14 . The reported frequency of important associated cardiac malformations depends on the patient population studied. Fig. 36.1. Top Illustration and angiogram of an adult-type coarctation with a typical shelflike lesion distal to the left subclavian artery. The large arterial vessels present...

PAU Versus Rupture of Vasa Vasorum

Although these aortic lesions (IAH and PAU) are phy-siopathologically different, in some cases it may be difficult to differentiate between them. Mohr-Kahaly et al. 5 identified 15 patients with IAH by transesophageal echocardiography (TEE) and analyzed the amount of aortic atherosclerosis of these patients. Atherosclerotic lesions were detected in 11 patients (mild in eight, moderate in two, and severe in one) there were no atherosclerotic plaques in the remaining four patients. Accordingly,...

Marfan Syndrome and the Importance of Familial Screening

Marfan syndrome is a polymorphic disease with large interfamilial and intrafamilial variability, complete penetrance and dominant autosomal transmission. Neo mutation may be responsible for 25 of the recognised cases. International criteria have been defined 3 , with the aim of limiting overdiagnosis. To be diagnosed positive, a patient has to show major or minor features in at least three systems, including three major criteria. The criteria are less stringent for patients with a family...

Conventional Surgical Treatment

Surgical approach is made through a left postero-lateral thoracotomy in the fourth intercostal space, which allows access to the descending thoracic aorta as well as the heart and the trunk of the pulmonary artery. The goal of the surgical treatment is to clamp the aorta proximally and distally to the lesion, open the tear and repair it. This treatment leads to two types of discussion firstly, how to repair the lesion (direct repair or graft interposition) and, secondly, how to protect the...

Aortic Regurgitation

Aortic regurgitation may be related to different mechanisms. The first mechanism, aortic dilatation, particularly of the sino-tubular junction, leads to an increase in aortic orifice area and central, axial, aortic regurgitation. In this case the aortic regurgitation is roughly proportional to aortic dilatation. This is rare when the aortic diameter is lower than 40 mm, and is the rule when the aortic diameter is greater than 60 mm. The second mechanism which can be responsible for aortic...

Descending Thoracic Aortic Aneurysms

Aneurysms of the thoracic aorta represent a potentially life-threatening situation. Surgical resection and interposition with a vascular prosthesis have long been considered the standard treatment despite the substantial risks of the procedure. The use of an endovascular stent graft to treat thoracic aortic aneurysms emerged a decade ago propelled by the desire to reduce surgical risks and induce remodeling of the diseased aorta by initiating a natural healing process after exclusion and...

Aortic Dissection

Diagnosis accuracy of TEE allows an efficient classification of type (A and B) and risk stratification. The involved ascending aorta requires surgical treatment. Uncomplicated type B may be treated medically 2 . An-giography may have severe adverse effects in this disease. CT sensitivity (more than 90 ) and specificity (more than 85 ) are comparable to those of TEE for diagnosis 16 . CT provides determinant data about extension to arch emergent vessels. MRI global accuracy nearly reaches 100 16...

Stent Implantation

The use of stents has recently been applied to the treatment of coarctation for the same minimally invasive reasons that prompted the popularity of balloon angioplasty in this patient population. Stenting works by stretching and scaffolding rather than tearing the aorta and this likely accounts for the observed lower short-term instances of aneurysms and recoarctation as compared with those from balloon angioplasty alone. The popularity and enthusiasm resulting from studies conducted over the...

Endovascular Treatment Strategies for Coarctation of the Aorta

Taylor, Jeffrey A. Feinstein 37.1 Introduction 363 37.2 Endovascular Treatments for Coarctation of the Aorta 363 37.2.1 Balloon Angioplasty for Recurrent Coarctation 363 37.2.2 Balloon Angioplasty for Native Coarctation 364 37.2.3 Stent Implantation 366 37.2.4 Immediate and Intermediate-Term Outcomes After Stenting 366 37.2.5 Complications Associated with Stent Implantation 367 37.2.6 Indications for Stent Implantation 368 37.3 Comparing Treatment Modalities 369...

Summary

Although further follow-up is mandatory, endografting for the treatment of chronic type B aortic dissection is seemingly a superior alternative to surgical graft replacement in terms of short and midterm results, even if first-generation endografts are used. To expand indication more sophisticated devices such as branched or fenestrated endografts should be necessary. Acute aortic dissection. Lancet 1998 2 827-828. Blum U, Voshage G, Lammer J, Beyersdorf F, Tollner D, Kretschmer G, Spillner G,...

Identification of the True and False Lumens

Identification of the true and false lumens is crucial in the endovascular treatment of aortic dissection. The true and false lumens behave differently. In most acute aortic dissection, the false lumen is prone to ectasia and is at risk of rupture, and the true lumen is prone to collapse and is at risk of compromise of its branch arteries. Numerous steps in the endovascular treatment of dissection require real-time knowledge of which lumen the guidewire, the diagnostic catheter, and treatment...

Transesophageal Echocardiography for Diagnosis and Treatment of Aortic Diseases

4.1 Introduction 4.2 Transesophageal Echocardiography for Diagnosis of Aortic Diseases 33 4.2.1 Aortic 4.2.1.1 Intimal 4.2.1.2 Intimal 4.2.1.3 True and False Lumens 36 4.2.1.4 Aortic 4.2.1.5 Aortic Branches 37 4.2.1.6 Periaortic 4.2.17 4.2.2 Intramural 4.2.3 Penetrating Aortic Ulcer 41 4.2.4 Aortic 4.2.4.1 Atherosclerotic Aneurysms 41 4.2.4.2 Dystrophic Aneurysms 41 4.2.4.3 Aneurysm of the Sinus of Valsalva 41 or Inflammatory Diseases 42 4.2.4.5 Aneurysms and Infectious Diseases 42 4.2.5...

Absence of Entrance Tear

In the literature 17, 18 and in our own experience, some patients with AAS have been initially diagnosed of IAH, and later, at surgery, a tiny intimomedial entrance tear with a clotted false lumen has been identified (Figs. 27.3, 27.4). In these cases, the false channel not been decompressed by a reentrance tear and an immediate thrombosis of the false lumen occurred consequently there would be no possibility of detecting flow within the aortic wall. These observations raise the question of the...

Type A

Surgery remains the only treatment option for hemody-namically unstable patients with type A lesions. Medical treatment of type A IMH without an intimal tear, bed rest with antihypertensive treatment to minimize the risk of evolution towards frank dissection, can only be conceived in the case of important comorbidity and in the absence of menace of rupture. Supportive medical treatment with frequent follow-up imaging studies and timed surgical repair in cases with complications must remain the...

Prevalence Symptoms

While the exact prevalence of aortic arch aneurysms is unknown, they are less frequent than aneurysms of the ascending or the infrarenal aorta 5 . This is due to the fact that aneurysms of the aortic arch may easily be overlooked in the course of cardiologic diagnostic studies, and an arch aneurysm is rarely diagnosed on a rou- Fig. 10.1. Typical computed tomography of the chest with contrast in a 65-year-old patient with a true proximal aortic aneurysm. The main involvement is in the ascending...

The Conventional Elephant Trunk Technique

Anatomy determines that the proximal segment of the descending aorta is less accessible via median sternotomy than the aortic arch. Therefore most surgeons prefer a multiple-stage approach to treat combined lesion of the aortic arch and the descending aorta. The introduction of the elephant trunk technique by Borst et al. 4 in 1983 has greatly facilitated surgery on this kind of pathology. The basic principle of the Borst operation for the replacement of the aortic arch resides in the...

Pregnancy

Pregnancy is associated with an increased risk of aortic dissection combining the figures of the different series reported, a risk of around 4 can be calculated in women for each pregnancy. In these series, most of the women were unaware of the diagnosis, and were not receiving beta-blockers. The recommendation is to advise the risk of pregnancy as acceptable when the ascending aorta is less than 40 mm in diameter, and to advise against pregnancy when it is above 40-45 mm. Beta-blockers should...

Of Abdominal Aortic Dissection

Renal, mesenteric, or spinal cord malperfusion approximately doubles the mortality of patients with acute aortic dissection 2 . Most of these malperfusion syndromes arise as complications of the dissection path through Fig. 23.3. A single lumen is prominent at the level of the aortic crura near the diaphragm in the same patient as in Fig. 23.2. Careful tracing of this lumen back to the heart shows that it is the false lumen, and that the true lumen is completely collapsed and nearly invisible....

Outcome

12.3.1 Immediate Results and In-Hospital Course Single-branched stent-graft placement was technically successful in 86 (30 35 patients), double-branched in 67 (2 3 patients), and triple-branched in 70 (7 10) of patients (Fig. 12.8). The procedure was terminated before completion in nine patients, either because of a complication (one patient) or because the stent-graft did not pass through the delivery sheath used (eight patients). There were three deaths in the perioperative period. The causes...

Management of the Horizontal Aorta with the Inoue Branched Stent Graft

Kanji Inoue, Hiroaki Hosokawa, Kenichi Abe, Takeshi Kimura 12.1 Introduction 133 12.2 Materials and Methods 133 12.2.1 Inoue Branched Stent-Graft 133 12.2.2 Inoue Stent-Graft Delivery System 134 12.2.3 Aortic Arch Reconstruction with Single-Branched Stent-Grafts 134 12.2.4 Aortic Arch Reconstruction with Double-Branched or Triple-Branched Stent-Grafts 135 12.2.5 Countermeasure Against Distal Embolization 135 12.2.6 Patients and Anatomic Criteria for Endovascular Repair 136 12.3.1 Immediate...

Emergence of Endografting

Endovascular repair including percutaneous fenestra-tion and stenting had been performed mainly for the treatment of visceral or leg ischemia before endograft-ing became clinically available. Its safety and efficacy have been reported by several investigators 30, 31, 37 . On the other hand, endografting was initiated for the treatment of abdominal aortic aneurysms and it is now a good alternative to surgical graft replacement for both abdominal and thoracic aortic aneurysms 2, 4 . Application...

Clinical Presentation and Diagnosis

The neonate with coarctation may have severe heart failure with acidosis, tachypnea and a profound diaphoresis with feeding. Depending on the patency of the ductus arteriosus and the severity of the coarctation, differential cyanosis may be present. Severe obstruction at the isthmus and ductus arteriosus requires intravenous infusion of prostaglandin Ex in the neonate. This relaxes the ductal tissue, lowering the resistance of flow through the aorta, improving ventricular function....

Intraparietal Hemorrhage

IAH has also been documented at autopsy. Necropsy series have demonstrated that in some patients (5-13 ) with dissection the entrance tear is not evident 20-22 . On histologic analysis, a hematoma disrupting the aortic media is well documented (Fig. 27.5). In our experience, this hematoma is most often intramedial, but occasionally it is subadventitial (between the media and the adventitia). A subadventitial hematoma might have a greater risk of aortic rupture. This intramedial or...

In Acute Aortic Syndrome

Maria Cristina Porciani and Magdi Yacoub 5.1 Introduction 5.2 Biochemical Markers 5.2.1 Smooth Muscle Myosin Heavy Chains 57 5.2.2 Soluble Elastin Fragments 58 5.2.3 C-Reactive 5.2.6 Matrix Metalloproteinases 61 5.2.7 Other Biochemical Markers 62 5.3 Genetic Markers 5.3.1 Genes Associated with Syndromic or Non-syndromic Monogenic Disorders Presenting Aortic Aneurysms or Dissections 63 5.3.2 Polymorphic Mutations in Genes Predisposing to 5.4 Prospective New Tools to Identify New Biochemical and...

Iatrogenic Aortic Injuries

Iatrogenic injuries correspond to class 5 of the new classification. They are rarely observed in current cathe-terization procedures. They occur principally during in-traluminal manipulation intra-aortic balloon pumping, stenting, balloon inflation for treatment of coarctation. Severe atheroma increases the risk. The main injuries are dissection (anterograde or retrograde) and systemic embolism. TEE is determinant to detect them during these high-risk catheterizations or after the event. During...

Immediate and Intermediate Term Outcomes After Stenting

In 1991 O'Laughlin et al. 45 reported the first use of a Palmaz iliac artery stent to reduce the pressure gradient across a coarctation in the thoracic aorta (5025 mmHg) of a 12-year-old patient previously treated using balloon angioplasty. Subsequent case reports documented successful deployment of stents for palliative treatment of patients with severe coarctation that had been treated by surgery 46 , balloon angioplasty 47 or both 44 . Larger studies then emerged with six to 54 patients 9,...

Cerebrospinal Fluid Drainage

Drainage of CSF during aortic procedures was introduced to prevent the rise in CSF pressure (and consequent reduction in spinal perfusion pressure) that often occurs during aortic cross-clamping or in the early postoperative period. With this technique, a catheter is inserted into the lumbar spinal canal, and small amounts of spinal fluid (up to 50 ml prior to aortic clamping, 50 ml during aortic clamping and a maximum of 20 ml h in the postoperative period) are withdrawn on an intermittent...

Problems Encountered During and After Stent Graft Treatment of Aortic Dissection

21.1 Introduction 209 21.2 Materials and Methods 209 21.2.1 Patients 209 21.2.4 Procedures 210 21.3 Problems During the Procedure 211 21.3.1 Stent-Graft Migration 211 21.3.2 Complications Related to the Size of the Stent-Graft 211 21.3.3 Appearance of a Hidden Intimal Tear 21.3.4 Type I Endoleak 212 21.4 Problems During the Follow-Up 212 21.4.1 Postimplantation Syndrome 212 21.4.2 Neurologic Complication 214 21.4.3 Persistent Type I Endoleak 214 21.4.4 Type II Endoleak 215 21.4.5 Progressive...

Management of Aortic Hematomas and Ulcers Evaluation Scoring

Jean-Fran ois Heautot, Vincent Tran Dinh, Bertrand De Latour, Jean-Philippe Verhoye 29.1 Introduction 297 29.2 Therapeutic Principles 297 29.2.1 Medical Treatment 297 29.2.2 Surgical Treatment 297 29.2.3 Endovascular Treatment 298 29.3 Evolutive Risk Factors 298 29.3.1 Clinical Risk Factors 298 29.3.1.1 Difficulties in Blood Pressure Control . 298 29.3.1.2 Persistent or Recurrent Pain 298 29.3.2 Anatomo-radiologic Risk Factors 298 29.3.2.2 Aorta Diameter 298 29.3.2.3 Hematoma Thickness 298...

The FollowUp and Its Warnings

Guillaume Jondeau, Gabriel Delorme, Olivier Milleron and Jessica Wilson 6.1 Introduction 6.2 Positive Diagnosis of Marfan Syndrome, and the Importance of Familial Screening 71 6.3 Aortic Anomaly in Marfan Syndrome 72 6.4 Exercise Limitation 6.5 Medical 6.6.1 Technique of Measurement 75 6.6.2 Frequency for Follow-Up 76 6.6.3 Indications for Surgery 76 6.6.3.1 Aortic 6.6.3.3 Neonatal Marfan Syndrome 77 6.7 Conclusion

Classification

As in classic aortic dissection, patients with IAH are divided in two groups according to Stanford classification type A, when the involved segment is the ascending aorta and type B when it is confined to the descending aorta. In the meta-analysis done by Marajet al., type A IAH was commoner than type B (57 type A vs 43 type B), but in our experience type B is commoner than type A. From a surgical and prognostic standpoint we use the following classification if the affected segment is the...

Of Branch Artery Obstruction

The Michigan classification of branch artery obstruction 15 is based on the anatomical relationship of the dissection flap to the branch artery in question (Fig. 23.4). It is an intuitively appealing classification because this anatomic distinction forms the basis of distinct treatment strategies. The causes of obstruction may be distinguished as follows Mixed static and dynamic obstruction - Related to dissection thrombosis, embolism - Unrelated to dissection atherosclerosis, fibromus-cular...

Conventional Treatment

Since the classic study of Parmley et al. 2 in 1958, the extremely high death rate of patients with acute blunt rupture of the thoracic aorta has led surgeons to repair the aortic tear as quickly as possible. But despite advances in surgical and reanimation techniques, surgery is still associated with significant morbidity and mortality rates 1, 8 . The overall death rate reported by Von Oppell et al. 8 in a meta-analysis of articles including 1,492 hemodynamically stable patients who reached...

For the Thoracic Aortic Arch

Inoue et al. 11 published their results with the use of a branch stent-graft for the thoracic aorta in 1999. Since then, little has happened in this field, most likely owing to the obvious problems associated with the deployment of branch stent-grafts in such a complex area as the aortic arch. Attempts have been made to create a modular system for the arch by using a standard stent-graft placed across the subclavian artery and then puncturing a hole from the subclavian arteries into the aortic...

Discussion

With the advances in stent-graft technique and technology EVAR is today applied in more complex anatomy. This is particularly true for the aortic arch, where a combination of open surgical repair techniques, including either extraanatomical bypasses or bypasses from the ascending aorta to the supraaortic vessels, or a total replacement of the aortic arch, may be necessary in order to find a less traumatic solution when applying EVAR in this area. It is an evolving field and it has been Fig....

Type B

Medical management is recommended for type B APU 16 . Stent-grafts permit a higher degree of protection against rupture than medical therapy alone. Because APU affect older persons, one must consider the patient's age, overall physical condition, and anticipated life expectancy in the decision to use operative treatment. If patients tolerate medical management without clinical deterioration, they may continue conservative follow-up care with reasonable safety 10 . This medical treatment is...

Regional Cooling

Direct cooling of the spinal cord has been applied in both the laboratory and the clinical setting, and has the theoretical advantage of deep cooling of the spinal cord whilst avoiding the drawbacks of profound systemic hy pothermia. Cooling of the spinal cord has been achieved in the experimental or clinical setting by direct perfusion of intercostal arteries with cold blood 61 , indirect perfusion by infusing cold blood into the clamped aneurysm 74 , retrograde perfusion through hemiazygous...

Vasodilators

Although dopamine dilates renal arterioles, increases renal blood flow, and has anti-aldosterone activity, its role as a renal protecting compound is questionable. Low-dose dopamine (0.5-3 p,g kg min) did not show any benefit in preventing renal failure in surgical patients, presumably because it has a mixed specificity for DA1 receptors, DA2 receptors and -adrenergic receptors 19 . Fenoldopam, a highly selective DA1 receptor agonist, has a similar vasodilating profile as dopamine. In patients...

The Frozen Elephant Trunk Technique

The complications that may be attributed to the elephant trunk itself and the cumulative risks of the staged approach are drivers for change towards new procedures and implants, which allow for risk reduction in the surgical treatment of large aortic aneurysms. Extensive one-stage repair techniques performed through a clamshell incision or through the left chest bear remarkable technical challenges and risks, too 17, 19, 28, 35 . They may therefore be limited to selected patients. A new wave of...

Surgical Techniques

Surgical access is dependent on the extent of the aortic replacement. Figure 18.1 schematically depicts the different TAAs and TAAAs. Table 18.2 summarizes the surgical access for the corresponding aneurysms. Figure 18.2 depicts a giant post-type B dissection thoracic aneurysm. Figure 18.3 shows a perforation of the aortic wall and only thrombus in the false lumen prevented free rupture. Figure 18.4 illustrates the implanted polyester graft. It is obvious that the majority of type B, C and D...

Traumatic Rupture of the Aortic Isthmus

Traumatic aortic injuries are becoming more frequent. They are related to the increase of blunt chest trauma owing to motor vehicle accidents. Falls from a elevated site represent the second cause. The mechanism consists in a sudden deceleration that submits the aortic wall to high shearing forces. The aortic isthmus, at the junction between the mobile arch and the fixed descending part, is especially exposed. Supraaortic arteries (8 ) and ascending and descending (3 ) aorta are less frequently...

Info

Triple-branched stent-graft for treatment of aortic arch aneurysm. a Computed tomography (CT) image demonstrates a huge transverse aortic arch aneurysm. b CT image obtained after stent-graft placement shows complete exclusion of the aneurysm Fig. 12.9. Triple-branched stent-graft for treatment of aortic arch aneurysm. A CT image demonstrates a transverse aortic arch aneurysm. B CT image obtained 2 years after stent-graft placement shows aneurysm shrinkage Fig. 12.10. Aortograms in a...

Malperfusion

In the past creating a surgical reentry was the treatment of choice for malperfusion, but actually endovascular catheter-based interventions are the primary option 12 . Surgeons dealing with aortic problems should, however, keep themselves abreast of the technique of creating a surgical reentry because endovascular interventions might fail or be unsuccessful. Of course it can be performed at any aortic level it was most frequently used at the level of the upper abdominal aorta in order to...

Physiopathology of Ischemic Complications of Aortic Dissections

Williams, Bora Peynircioglu 23.1 Introduction 239 23.2 Identification of the True and False Lumens 239 23.3 Importance of Abdominal Aortic Dissection 240 23.4 Classification of Branch Artery Obstruction 241 23.5 Diagnosis of Branch Artery Obstruction 242 23.6 Setting Priorities and Avoiding Pitfalls 243

Comment

In Sect. 11.3 we described our approach that allows for definite treatment of lesions of the aortic arch and beyond during a single-stage procedure by using a hybrid prosthesis, which combines the features of a stent graft and a conventional vascular prosthesis. The stented distal segment of the hybrid prosthesis is implanted into the descending aorta through the opened aortic arch under fluoroscopic control, while the proximal non-stented segment is used for conventional replacement of the...

Treatment Results

Most reports of endograft treatment of penetrating ulcers consist of single case reports or small-series patients embedded in large series of mixed thoracic aortic disease, from which it is difficult to elicit general principles of patient selection and anatomical features predictive of treatment failure. The Stanford group has published the results of endograft treatment of its first 26 patients with penetrating ulcers with or without intramural hemorrhage 3 . Treatment was between 1993...

To Identify New Biochemical and Genetic Markers

At the moment very few genetic and biochemical markers have been detected in TAAs, while many biochemical markers and few genetic markers have been found in AAAs these last markers are similar to those found in atherosclerosis. The fact that TAA has a different molecular background from that found in AAA or atherosclerosis is in part explainable by the fact that the aortic wall has a different structural protein composition that can contribute to the different pathologies. To address the...

Concept of Delaying Repair

During the early 1970s, Akins et al. 10 began to delay the repair of blunt aortic tears in selected patients with associated major injuries. Before the aortic repair, they were treated with antihypertensive drugs and no rupture of the traumatic false aneurysm was reported. Similarly, in 1995, Pate et al. 6 reported no rupture of pseudo-aneurysm of the thoracic aorta in 41 patients whose arterial pressure was maintained below 140 mmHg and who underwent delayed repair of the aortic tear between...

Gravity Score

On the basis of the analysis of literature, the authors suggest a gravity score based on two clinical items and four radiological items to compose a gravity score. Each item is weighted by its severity in terms of prediction of risk. Persistent or recurrent thoracic pain in spite Increase of IMU thickness or APU depth The lowest score is 0 and the maximum score is 8. If the score is more than or equal to 3, prediction of rupture is high and treatment (type A surgical, type B en-dovascular) is...

True and False Lumens

The true lumen is generally smaller than the false one but presents a systolic expansion 7 . Color Doppler imaging presents an aspect of aliasing owing to the high velocity of systolic anterograde flow (Fig. 4.7). The false lumen is larger and presents a systolic compression. Blood velocity is lower and, sometimes, results in a constitution of the spontaneous echo contrast effect. It appears as dynamic smokelike echos with slow swirling movements that are markers of blood stasis. So, a thrombus...

With Open Stent Graft Placement

This technique is recommended when concomitant heart surgery is performed, including coronary bypass, graft replacement with or without aortic valve remodeling in the ascending aorta due to aneurysm formation or type A dissection, or when there is a type A dissection continuing into the descending thoracic aorta 5, 6, 7 . In these situations a stent-graft may be placed from the distal aortic arch under hypothermic cardiopulmo-nary arrest and guided either fluoroscopically or by transesophageal...

Complications Associated with Stent Implantation

Recoarctation following stent implantation may occur as a result of neointimal hyperplasia or patient growth. Some amount of neointimal hyperplasia occurs after non-drug-eluting stent implantation in all vascular beds 59 , but is typically inconsequential in comparison to the diameter of the aorta 9 . Stent overexpansion has been correlated with the severity of neointimal hyperplasia in the aorta and other vascular beds 60, 61 . Recoarctation resulting from patient growth in cases of stent...