1. Surgical Management of
Aortic Arch Pathology
Dicky Aligheri, MD
Cardiac & Vascular Surgeon
National Cardiac & Vascular Centre Harapan Kita
Jakarta 2014
2. Mr ES, 55yo
Chest & Back Pain 24h before admissions
Heavy smokers, uncontroled hipertension
3.
4. Mr HR, 65yo
Chest & Back Pain 4d before
admissions
Uncontroled hipertension,
DM
History (+) 6 month
5.
6.
7. In the case of distal extension to the aortic arch, an limited but
open distal anastomosis with the aortic arch or a hemiarch
replacement should be performed
Kallenbach K, Kojic D, Oezsoez M, Bruckner T, Sandrio S, Arif R, Beller CJ, Weymann A, Karck M.
Treatment of ascending aortic aneurysms using different surgical techniques: a single-centre
experience with 548 patients. Eur J Cardiothorac Surg 2013;44:337-345.
2014 ESC Guidelines on the diagnosis and treatment of aortic diseases
8. Interact Cardiovasc Thorac Surg. 2015
Jan;20(1):120-6. doi:
10.1093/icvts/ivu323. Epub 2014 Oct
3.
Is extended arch replacement
justified for acute type A aortic
dissection?
In [patients undergoing surgery, for acute type A aortic dissection] does
[aggressive initial treatment with total arch repair] result in [reduced mortality
and improved closure of the distal false lumen]?
Medline 1950 to December 2013
We conclude that a more extensive surgical strategy can be justified when it is
based on circumstances, on the individual patient's clinical condition, and on
the anatomical and pathological features of the dissection
9. ↵ Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based
medicine in cardiothoracic surgery: best BETS. Interact CardioVasc Thorac Surg 2003;2:405-
9.
↵ Ohtsubo S, Itoh T, Takarabe K, Rikitake K, Furukawa K, Suda H, et al. Surgical
results of hemiarch replacement for acute type A dissection. Ann Thorac Surg
2002;74:S1853-6. discussion S1857–3. ↵ Tan ME, Dossche KM, Morshuis WJ, Kelder
JC, Waanders FG, Schepens MA. Is extended arch replacement for acute type A aortic
dissection an additional risk factor for mortality? Ann Thorac Surg 2003;76:1209-14.
↵ Shiono M, Hata M, Sezai A, Niino T, Yagi S, Negishi N. Validity of a limited
ascending and hemiarch replacement for acute type A aortic dissection. Ann Thorac Surg
2006;82:1665-9
↵ Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined with stented
elephant trunk implantation: a new ‘standard’ therapy for type a dissection involving
repair of the aortic arch? Circulation 2011;123:971-8.
↵ Easo J, Weigang E, Holzl PP, Horst M, Hoffmann I, Blettner M, et al. Influence of
operative strategy for the aortic arch in DeBakey type I aortic dissection: analysis of the
German Registry for Acute Aortic Dissection type A. J Thorac Cardiovasc Surg
2012;144:617-23.
↵ Zhang H, Lang X, Lu F, Song Z, Wang J, Han L, et al. Acute type A dissection
without intimal tear in arch: proximal or extensive repair? J Thorac Cardiovasc Surg
2014;147:1251-5.
14. Mostly dissection
Total arch replacement
Hemi arch replacement
Mostly aneurysm
Pathologic exclusion
L-Sc & ARM involvement
15. Mostly dissection
Total arch replacement
Hemi arch replacement
Mostly aneurysm
Pathologic exclusion
L-Sc & ARM involvement
16. Schafer, PWHardin, CA. The use of temporary polyethylene shunts to
permit occlusion, resection and frozen homologous graft replacement of
vital vessel segments. Surgery. 1952;31:186
17. Cooley, DAMahaffey, DEDeBakey, ME.
Total excision of the aortic arch for
aneurysm. Surg Gynecol Obstet.
1955;101:667.
DeBakey, MECrawford, ESCooley,
DAMorris, GC. Successful resection of a
fusiform aneurysm of aortic arch with
replacement by homograft. Surg Gynecol
Obstet. 1957;105:657.
Creech, ODeBakey, MEMahaffey, DE.
Total resection of the aortic arch.
Surgery. 1956;40:817
18. • Griepp and colleagues' introduction of
hypothermic circulatory arrest (HCA) was a
major advance that greatly enhanced the
safety of arch-replacement procedures
• he use of cerebral perfusion was reconsidered
by Frist and colleagues
27. Antegrade selective cerebral perfusion
• prolonged safe time of cerebral protection
• moderate hypothermia and reduced CPB time
• improved cerebral cooling and maintenance of
hypothermia
• independent control of cerebral and systemic circulations
• technically more complicated
• additional equipment required
28. Retrograde Cerebral Perfusion
• maintenance of cerebral hypothermia
• washout of embolic air or debris
• cerebral perfusion and metabolic support.
• Competent cerebral valve n dominant azygos
circulation
38. Conclusions
• Aortic arch surgery is the most challenging
part.
• Aortic arch should be considered in
proximal/distal aortic procedures
• Some advancement with few drawback
Aortic arch anatomy and the landing zones dictate the type of arch hybrid repair. In a type I arch hybrid, the great vessels are debranched to enable Z0 stent grafting, followed by concomitant antegrade or delayed retrograde TEVAR. For arch aneurysm without a good proximal Z0, but an adequate Z3/Z4 distal landing zone, type II arch hybrid repair is performed involving not only great vessel debranching, but creation of a proximal Z0 by reconstructing the ascending aorta. More complex aortopathies such as mega-aorta syndrome require type III arch hybrid repair
