The document discusses surgical approaches to aortic dissection and aneurysm, emphasizing techniques to prevent aortic rupture and restore normal aortic dimensions. It highlights the effectiveness of various surgical techniques, guidelines for patient management, and outcomes of hybrid procedures. The content underscores the importance of individual treatment strategies based on pathology and surgical risk factors.

1. AORTIC SURGERY
focus on Aortic Dissection & Aneurysm
Dicky A.Wartono ,MD
National Cardiovascular Centre Harapan Kita Jakarta
2014

2. Disclosure : none

3. Principle of Surgery
• Preventing the risk of dissection or rupture by
restoring the normal dimension of the aorta
• Entry tear Exclusion & False lumen thrombosis
• Pathology based level of surgery /
replacement
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
Achneck HE, Rizzo JA, Tranquilli M, Elefteriades JA. Safety of thoracic aortic surgery in the present
era. Ann Thorac Surg 2007;84:1180-1185

4. 2014 ESC Guidelines on the diagnosis and
treatment of aortic diseases

5. 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With
Thoracic Aortic Disease
March 2010

8. 2014 ESC Guidelines on the diagnosis
and treatment of aortic diseases

15. 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With
Thoracic Aortic Disease
March 2010

17. In the case of a normal tricuspid valve, without aortic
regurgitation or central regurgitation due to annular dilation, an
aortic valve-preserving technique 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.

18. 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With
Thoracic Aortic Disease
March 2010

19. • mid & long term result of “valve sparring”
– Severity (>mild)
– Connective Tissue Diseases
– Cuspid repair / pathology
– Bicuspid
– Type A Dissection
David T, Feindel C (1992). "An aortic valve-sparing operation for patients with aortic incompetence and
aneurysm of the ascending aorta.". J Thorac Cardiovasc Surg 103 (4): 617–21; discussion 622
"The Modified David's Reimplantation Procedure". clevelandclinic.org. Retrieved 15 July 2014
David valve-sparing aortic root replacement: Equivalent mid-term outcome for different valve types
with or without connective tissue disorder John-Peder Escobar Kvitting, Fabian A. Kari, Michael P.
Fischbein, David H. Liang, Anne-Sophie Beraud, Elizabeth H. Stephens, R. Scott Mitchell and D. Craig
Miller
J Thorac Cardiovasc Surg 2013;145:117-1275

21. 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease
March 2010
Fischbein, David H. Liang, Anne-Sophie Beraud, Elizabeth H. Stephens, R. Scott Mitchell and D. Craig Miller
J Thorac Cardiovasc Surg 2013;145:117-1275

22. 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

26. 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With
Thoracic Aortic Disease
March 2010

27. In the case of distal dissection 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

28. Extensive repair including graft replacement of the
ascending aorta and aortic arch and integrated
stent grafting of the descending aorta (‘frozen
elephant trunk') was introduced as a single-stage
procedure
Shrestha M, Martens A, Kruger H, Maeding I, Ius F, Fleissner F, Haverich A. Total aortic
arch replacement with the elephant trunk technique: single-centre 30-year results. Eur J
Cardiothorac Surg 2014;45:289-296

32. Arch vessel transposition (debranching) and TEVAR might be considered,
especially when there is reluctance to expose patients to hypothermic
circulatory arrest;
Patients with the underlying diagnosis of acute Type B AD, the risk of
retrograde Type A AD as a direct consequence of the procedure is elevated
Cochennec F, Tresson P, Cross J, Desgranges P, Allaire E, Becquemin JP. Hybrid repair of aortic
arch dissections. J Vasc Surg 2013;57:1560-1567

34. Marana MAI, Alonso VG, Revuelta NC, et al.: Combined treatment, endovascular and surgical treatment of
posttraumatic pseudoaneurysm in the aortic arch. EJVES Extra 2006, 12(9):25-29.
Choi BK, Lee HC, Lee HW, et al.: Successful treatment of a ruptured aortic arch aneurysm using a hybrid
procedure. Korean Circ J 2011, 41:469-473. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Sanchez MJ, Ananian CL, Berkmen T: Embolization of an aortic arch pseudoaneurysm with coils and N-Butyl-
Cyanoacrylate. J Vasc Interv Radiol 2006, 17:1677-1679. PubMed Abstract | Publisher Full Text
Westaby S, Katsumata T, Vaccari G: Arch and descending aortic aneurysms: influence of perfusion technique on
neurological outcome. Eur J Cardiothorac Surg 1999, 15:180-185. PubMed Abstract | Publisher Full Text
Baguley CJ, Sibal AK, Alison PM: Repair of injuries to the thoracic aorta and great vessels. ANZ J Surg 2005,
75(6):383-387. PubMed Abstract | Publisher Full Text
Bouchart F, Bessou JP, Tabley A, et al.: Acute traumatic rupture of the thoracic aorta and its branches. Results of

35. Marana MAI, Alonso VG, Revuelta NC, et al.: Combined treatment, endovascular and surgical treatment of
posttraumatic pseudoaneurysm in the aortic arch. EJVES Extra 2006, 12(9):25-29.
Choi BK, Lee HC, Lee HW, et al.: Successful treatment of a ruptured aortic arch aneurysm using a hybrid
procedure. Korean Circ J 2011, 41:469-473. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
Sanchez MJ, Ananian CL, Berkmen T: Embolization of an aortic arch pseudoaneurysm with coils and N-Butyl-
Cyanoacrylate. J Vasc Interv Radiol 2006, 17:1677-1679. PubMed Abstract | Publisher Full Text
Westaby S, Katsumata T, Vaccari G: Arch and descending aortic aneurysms: influence of perfusion technique on
neurological outcome. Eur J Cardiothorac Surg 1999, 15:180-185. PubMed Abstract | Publisher Full Text
Baguley CJ, Sibal AK, Alison PM: Repair of injuries to the thoracic aorta and great vessels. ANZ J Surg 2005,
75(6):383-387. PubMed Abstract | Publisher Full Text
Bouchart F, Bessou JP, Tabley A, et al.: Acute traumatic rupture of the thoracic aorta and its branches. Results of
We feel that hybrid procedure
may be a valuable therapeutic
alternative when treating this
type of lesion. However, long-term
clinical efficacy and
safety have yet to be
confirmed.

43. The simple ‘clamp and sew’ technique may not be advisable
because the risk of post-operative neurological deficit,
mesenteric and renal ischaemia is significant when the aortic
cross-clamp procedure exceeds 30 minutes
Johansson G, Markstrom U, Swedenborg J. Ruptured thoracic aortic
aneurysms: a study of incidence and mortality rates. J Vasc Surg
2013;21:985-988

44. Acher CW, Wynn MM, Hoch JR, Popic P, Archibald J, Turnipseed WD. Combined use of
cerebral spinal fluid drainage and naloxone reduces the risk of paraplegia in
thoracoabdominal aneurysm repair. J Vasc Surg 1994;19:236-246
Kulik A, Castner CF, Kouchoukos NT. Outcomes after thoracoabdominal aortic
aneurysm repair with hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2011

47. Future
• Single Stage Hybrid Surgery
• Endovascular Complication Surgery
• Aortic Re-operation

48. THANK YOU