This document summarizes Dicky Aligheri's experience with hybrid procedures for aortic arch involvement between 2013-2014 at the National Cardiac & Vascular Centre Harapan Kita in Jakarta. It describes several case studies of patients who received treatments like total arch replacement, hemi arch replacement, and the frozen elephant trunk procedure. It also reviews literature on debates around the best surgical strategies for aortic arch pathology and the safety and efficacy of hybrid techniques compared to open surgery.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
my aortic surgery presentation in Solo as an introduction for general practitioner and cardiology resident
Cover the basic diagram of surgical procedures of aorta.
definitely not for surgeon.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Peripheral Angioplasty / Endovascular Management of PVD - PrinciplesSaurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indic...Allina Health
By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
bentall, and 'old' procedures that still valid until present. Bail out for valve sparring & the patology of indonesian most present were best in this procedures
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Peripheral Angioplasty / Endovascular Management of PVD - PrinciplesSaurabh Joshi
This presentation covers the principles of peripheral angioplasty with and explanation of the TASC stratification and selection of appropriate management according to current guidelines. Endovascular management of peripheral vascular disease.
This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
Transcatheter Aortic Valve Replacement (TAVR): Established and Emerging Indic...Allina Health
By Paul Sorajja, MD. The efficacy and safety of transcatheter valve replacement in high-risk, non-operable patients is leading to new valve therapy options for a broader pateint population. "The options we have today to fix problems without opening the chest would have been unimaginable 10 years ago."
bentall, and 'old' procedures that still valid until present. Bail out for valve sparring & the patology of indonesian most present were best in this procedures
cardiovascular diseases- Bahasa indonesia
ALI : Acute Limb Ischemia
DVT: Deep Vein Thrombosis
Aortic Disection
Aortic Aneurysma
kuliah bimbingan penyakit vaskular sistemik
Selective Aortic Arch Perfusion -
Summary by: Jim Manning
Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest.
In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC.
In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.
IMAGES OF A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE IN A 58 YEAR OLD MAN
IMMAGINI DI UN CASO COMPLESSO DI MALATTIA POLINEURISMATICA
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
Does Preoperative Coronary Revascularization Improve Perioperative Cardiac Ou...Guilherme Barcellos
Draft que encontrei de apresentação em 201: Primeiro Encontro de Medicina Hospitalista da Argentina. Slides alguns já traduzidos, outros não - não encontrei versão final. De brasileiros no evento participaram eu, Lucas Zambon e Tiago Daltoé. Boas lembranças! Resgatei agora porque trata de evidência consolidada desde aquela época, e seguimos sobreutilizando o recurso. Ou algo novo que justifique?
Global Hospitals’ Advanced Heart, Lung & Vascular Institute provides all kinds of endovascular procedures including coronary intervention and peripheral intervention, heart surgery, heart bypass surgery as well as heart transplantation surgery in Hyderabad, Chennai, and Bangalore
Aorta in takayasu's arteritis is as brittle as glassRamachandra Barik
Balloon angioplasty of a critically or completely occluded segment of the aorta in Takayasu’s arteritis is challenging because of extensive panarteritis and diffuse fibrosis. In contrast to atheromatous disease, the aorta is left with very little elastic tissue, leading to higher incidence of dissection during intervention. Neither the profile of the angioplasty balloon (compliant vs non-compliant, length, diameter) nor the stent type (covered vs self-expanding) have been defined in performing angioplasty in this situation. We report the case of a 38-year-old female with aortoarteritis. The diseased aorta had diffuse narrowing in its thoracoabdominal part with critical stenosis at the level of the 11th thoracic vertebra. The stenotic segment suffered full-length dissection after balloon dilatation. A self-expanding stent was deployed to contain the dissection. At 12-month follow-up exam, the dissection was healed, without significant lumen loss.
Complication on avf play significant number of hospitalization & morbidity. Despite fistula first campaign are still beneficial for most patient, gathering knowlege to prevent complication are important.
simple word for future doctor. writing & drawing in pure white paper is always fun & feels like nothing to loose even if we knew that it will last almost forever
in endo era. aortic is one of the industrial driven medical proedure & one of the most expensive. Its morbidity are quoet acceptable, but......... surgeon if the best deal behind this awsome techno
Acute type A dissection, is on of the highest mortality cases in cardiovascular surgery. It doubled it incident with concomitant complication such as malperfusion or pericardial tamponade. In this presentation, the patient have both coronary malperfusion and pericardial tamponade
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
1. Hybrid Procedures for
Aortic Arch Involvement
Harapan Kita Experience
2013-2014
Dicky Aligheri, MD FIHA FICA
Cardiac & Vascular Surgeon
National Cardiac & Vascular Centre Harapan Kita
Jakarta 2015
13. 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
14. 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
15. ↵ 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.
16. ACS Vol 2, No 2 (March 2013)
• Pre-existing arch aneurysm
• Primary intimal tear identified on pre-operative CT in
the distal arch or descending thoracic aorta
• Secondary intimal tear in the arch measuring >10 mm
• Clinical signs of visceral or peripheral extremity
malperfusion
• Radiologic signs of potential visceral, renal and
peripheral compromise such as a severely effaced true
lumen in descending thoracic aorta
• False lumen diameter > than 22 mm (20)
• Descending thoracic aorta diameter >35 mm
17.
18.
19.
20. Mostly dissection
Total arch replacement
Hemi arch replacement
Mostly aneurysm
Pathologic exclusion
L-Sc & ARM involvement
21. Mostly dissection
Total arch replacement
Hemi arch replacement
Mostly aneurysm
Pathologic exclusion
L-Sc & ARM involvement
34. Areas of Controversy:
Covering the Left Subclavian Artery
Indications for Left
C-S Bypass or
Transposition
•Always
•Patent IMA or anticipated
•Left vertebral critical to
posterior circulation
•Previous AAA repair
•Internal iliac status
No Consensus
*
*
35. It is still debatable whether a hybrid technique is comparable to total open repair, as the
former strategy is reserved for high-risk patients who are unable to withstand an open repair.
According to the available literature and taking into account the less invasive nature of hybrid
repair, it could be speculated that short-term mortality and morbidity should appear to be
reduced in hybrid repair patients. A recent meta-analysis attempted to elucidate this issue
(53). However, it was based on four non-randomized observational studies, which makes the
analysis prone to selection and patient profile biases. Surprisingly, this study showed that a
hybrid repair did not significantly improve operative mortality, whereas it was associated with
a slight but non-significant increase in permanent neurologic deficits. A non-significant trend
towards increased late mortality was observed in the hybrid group.
A systematic review and meta-analysis of hybrid aortic arch replacement
ACS May 2013
Authors
Konstantinos G. Moulakakis1,2, Spyridon N. Mylonas3, Fotis Markatis1, Thomas
Kotsis3, John Kakisis1, Christos D. Liapis1
36.
37. The chimney-graft technique for preserving
supra-aortic branches: a review
ACS May 2013
Konstantinos G. Moulakakis1,2, Spyridon N.
Mylonas1,2,3, Ilias Dalainas1, George S.
Sfyroeras1, Fotis Markatis1, Thomas Kotsis3,
John Kakisis1, Christos D. Liapis1
The “chimney” technique is a method that requires advanced endovascular skills.
Endovascular aortic arch repair with chimney grafts is associated with a lower
mortality rate compared to totally open and hybrid reconstruction. However, the
stroke rate remains noteworthy. The technique has acceptable short term results.
As there are no available longterm data, it should be approached with a skeptical
view and a reasonable hesitation for a wide embracement of the method.
Compared to fenestrated it has the advantage of avoiding the delay in device
manufacturing and the high cost. Long-term data and larger series are needed to
determine the safety and efficacy of this technique.
40. ACS Vol 2, No 5 (September 2013)
FROZEN
ELEPHANT TRUNK
SURGERY
41.
42.
43.
44. Frozen elephant trunk surgery in type B aortic dissection
ACS Submitted Mar 18, 2014.
45. A systematic review and meta-analysis on the safety and efficacy of the frozen
elephant trunk technique in aortic arch surgery
ACS Vol 2, No 5 (September 2013)
46. A systematic review and meta-analysis on the safety and efficacy of the frozen
elephant trunk technique in aortic arch surgery
ACS Vol 2, No 5 (September 2013)
47. A systematic review and meta-analysis on the safety and efficacy of the frozen
elephant trunk technique in aortic arch surgery
ACS Vol 2, No 5 (September 2013)
48. A systematic review and meta-analysis on the safety and efficacy of the frozen
elephant trunk technique in aortic arch surgery
ACS Vol 2, No 5 (September 2013)
49. Aortic arch replacement with frozen elephant trunk—when not to use it
Authors
Axel Haverich
Authors
Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover
Medical School, Hannover, Germany
Corresponding to: Axel Haverich, MD. Klinik für Herz-, Thorax-, Transplantations-
und Gefäßchirurgie, OE6210, Medizinische Hochschule Hannover, Carl-Neuberg-
Straβe 1, 30625 Hannover, Germany. Email: haverich.axel@mh-hannover.de
Vol 2, No 5 (September 2013)
Hypothesis-driven surgical research in aortic
surgery. Following the initial disrupted
innovation with the introduction of the
elephant trunk technique, two incremental
steps of innovation were driven by
subsequently developed hypotheses
50. Aortic arch replacement with frozen elephant trunk—when not to use it
ACS Submitted Mar 18, 2014.
51. Conclusions
• Aortic arch is the most challenging part.
• Aortic arch should be considered in
proximal/distal aortic procedures
• Some advancement with few drawback
Type of surgery techniques preceding endovascular treatment:
Extra-anatomic bypass, [4-5]:
Carotid-subclavian bypass (Fig. 1 and Fig. 2)
Carotid-carotid bypass (Fig. 3)
Carotid-carotid + carotid-subclavian bypass (Fig. 4 and Fig. 5)
LSA Revascularization
LSA is an important source of blood flow to the left arm but it also plays an important role for the collateral pathways to the cerebellum -via the left vertebral artery (VA)- and the spinal cord -via the left VA to the anterior spinal artery, and collateral perfusion to the left intercostal vessels through the internal mammary and thoracodorsal arteries-.
When revascularization of the LSA is strongly recommended, [6-10]:
Occluded or severely stenosed right VA
Clearly dominant left VA
Discontinuity of the vertebrobasilar system
Presence of a patent left internal mammary artery to coronary artery by-pass graft
A functioning dialysis access fistula in the left arm
In high risk patients for spinal cord ischemia:
patients requiring extensive coverage of the thoracic aorta where critical intercostal arteries originate;
patients who have undergone infrarenal aortic surgery (ligation of lumbar and middle sacral arteries);
patients with compromised hypogastric blood supply
Debranching of epiaortic vessels with sternotomy or ministernotomy [4-5; 11-14]:
Partial debranching: End-to-side graft from ascending aorta to innominate artery and right common carotid artery -> left common carotid artery ± left common carotid artery -> left subclavian artery bypass (Fig. 6)
Partial debranching: Bifurcated end-to-side graft from ascending aorta to innominate artery and left common carotid artery ± left common carotid artery -> left subclavian artery bypass (Fig. 7)
Total debranching: Trifurcated end-to-side graft from ascending aorta to all supra-aortic vessels (Fig. 8)
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
Elephant-trunk and Frozen Elephant-trunk techniques [15-17]:
Aortic arch replacement (± replacement of ascending tract) with elephant trunk technique (Fig. 12): a free-floating extension of the arch prosthesis, the so-called “elephant trunk” (usually 5- to 7-cm long), is left behind in the proximal descending aorta. This technique facilitates subsequent endovascular treatment (TEVAR) on the downstream aorta which, in our experience, could be performed in the same stage, avoiding the requisite thoracotomy or thoracoabdominal incision, mandatory in the traditional second surgical stage.
Aortic arch replacement (± replacement of ascending tract) with frozen technique (Fig. 13). This procedure is adapted from the previous technique, with E®-vita prosthesis placement (Jotec, Hechingen, Germany). E®-vita is a hybrid vascular graft consisting of a conventional tube graft with an endovascular stented graft in the distal end (http://www.jotec.com/english/produkte-hybrid.pml).
Preservasi HLB m branc n sternotomy.. Pitfall !!!!!
Result… endoleak n trombosis
Comclusion… jauh dr ideal.. Kadng mendingan open
Issue LCS coverage
Aneu vs dissect
Result harkita???
Overall, 77.2% of patients were male, with a weighted mean age of 56.5±13.4 years old. Surgical indication was exclusively type A acute dissection in 7 studies (6,11,16,17,20,22,23), while the rest included a combination of acute and chronic type A and type B dissections and aneurysms. Overall, indication was type A acute and chronic dissection in 51.9% and 21.1% of all patients, respectively, and type B acute and chronic dissection in 2.4% and 3.1%, respectively. Aneurysms were the indication for 19.1% of all patients. Marfan’s syndrome was present in 8.6% of patients (range, 2.4-21.2%) in 10 studies (6,10,13-17,19,20,23), while preoperative renal insufficiency/failure was reported in all but two studies (8,17) with a weighted average prevalence of 8.6% (range, 0-20.5%). Other patient demographics reported by more than half of the studies included hypertension, coronary artery disease, cerebral vasculopathies, diabetes, chronic obstructive pulmonary disease, and previous cardiac surgery.
A variety of prefabricated and modified prostheses were utilized (Table 2) by these centers. Aortic valve repair/replacement, Bentall procedure, and coronary artery bypass grafting was performed in 14.7%, 20.0% and 11.9%, respectively, in studies which specifically reported these procedures
Weighted average cardiopulmonary bypass time, myocardial ischemic time, circulatory arrest time, and cerebral perfusion time were 207±63 minutes (range, 108-297 minutes), 122±45 minutes (range, 74-174 minutes), 48±24 minutes (range, 27.2-64 minutes), 52±31 minutes (range, 24-88 minutes), respectively (Figure 3). Significant strong positive linear relationships between mortality and cardiopulmonary bypass time (Spearman’s correlation coefficient, rs =0.812), circulatory arrest time (rs =0.715), and cerebral perfusion time (rs =0.900) were identified, respectively (Figure 4). Moderate positive linear relationships between mortality and myocardial ischemia time (rs =0.572), and between circulatory arrest time and incidence of spinal cord injury (rs =0.474), were identified
Overall, 77.2% of patients were male, with a weighted mean age of 56.5±13.4 years old. Surgical indication was exclusively type A acute dissection in 7 studies (6,11,16,17,20,22,23), while the rest included a combination of acute and chronic type A and type B dissections and aneurysms. Overall, indication was type A acute and chronic dissection in 51.9% and 21.1% of all patients, respectively, and type B acute and chronic dissection in 2.4% and 3.1%, respectively. Aneurysms were the indication for 19.1% of all patients. Marfan’s syndrome was present in 8.6% of patients (range, 2.4-21.2%) in 10 studies (6,10,13-17,19,20,23), while preoperative renal insufficiency/failure was reported in all but two studies (8,17) with a weighted average prevalence of 8.6% (range, 0-20.5%). Other patient demographics reported by more than half of the studies included hypertension, coronary artery disease, cerebral vasculopathies, diabetes, chronic obstructive pulmonary disease, and previous cardiac surgery.
A variety of prefabricated and modified prostheses were utilized (Table 2) by these centers. Aortic valve repair/replacement, Bentall procedure, and coronary artery bypass grafting was performed in 14.7%, 20.0% and 11.9%, respectively, in studies which specifically reported these procedures
Weighted average cardiopulmonary bypass time, myocardial ischemic time, circulatory arrest time, and cerebral perfusion time were 207±63 minutes (range, 108-297 minutes), 122±45 minutes (range, 74-174 minutes), 48±24 minutes (range, 27.2-64 minutes), 52±31 minutes (range, 24-88 minutes), respectively (Figure 3). Significant strong positive linear relationships between mortality and cardiopulmonary bypass time (Spearman’s correlation coefficient, rs =0.812), circulatory arrest time (rs =0.715), and cerebral perfusion time (rs =0.900) were identified, respectively (Figure 4). Moderate positive linear relationships between mortality and myocardial ischemia time (rs =0.572), and between circulatory arrest time and incidence of spinal cord injury (rs =0.474), were identified
Overall, 77.2% of patients were male, with a weighted mean age of 56.5±13.4 years old. Surgical indication was exclusively type A acute dissection in 7 studies (6,11,16,17,20,22,23), while the rest included a combination of acute and chronic type A and type B dissections and aneurysms. Overall, indication was type A acute and chronic dissection in 51.9% and 21.1% of all patients, respectively, and type B acute and chronic dissection in 2.4% and 3.1%, respectively. Aneurysms were the indication for 19.1% of all patients. Marfan’s syndrome was present in 8.6% of patients (range, 2.4-21.2%) in 10 studies (6,10,13-17,19,20,23), while preoperative renal insufficiency/failure was reported in all but two studies (8,17) with a weighted average prevalence of 8.6% (range, 0-20.5%). Other patient demographics reported by more than half of the studies included hypertension, coronary artery disease, cerebral vasculopathies, diabetes, chronic obstructive pulmonary disease, and previous cardiac surgery.
A variety of prefabricated and modified prostheses were utilized (Table 2) by these centers. Aortic valve repair/replacement, Bentall procedure, and coronary artery bypass grafting was performed in 14.7%, 20.0% and 11.9%, respectively, in studies which specifically reported these procedures
Weighted average cardiopulmonary bypass time, myocardial ischemic time, circulatory arrest time, and cerebral perfusion time were 207±63 minutes (range, 108-297 minutes), 122±45 minutes (range, 74-174 minutes), 48±24 minutes (range, 27.2-64 minutes), 52±31 minutes (range, 24-88 minutes), respectively (Figure 3). Significant strong positive linear relationships between mortality and cardiopulmonary bypass time (Spearman’s correlation coefficient, rs =0.812), circulatory arrest time (rs =0.715), and cerebral perfusion time (rs =0.900) were identified, respectively (Figure 4). Moderate positive linear relationships between mortality and myocardial ischemia time (rs =0.572), and between circulatory arrest time and incidence of spinal cord injury (rs =0.474), were identified
Overall, 77.2% of patients were male, with a weighted mean age of 56.5±13.4 years old. Surgical indication was exclusively type A acute dissection in 7 studies (6,11,16,17,20,22,23), while the rest included a combination of acute and chronic type A and type B dissections and aneurysms. Overall, indication was type A acute and chronic dissection in 51.9% and 21.1% of all patients, respectively, and type B acute and chronic dissection in 2.4% and 3.1%, respectively. Aneurysms were the indication for 19.1% of all patients. Marfan’s syndrome was present in 8.6% of patients (range, 2.4-21.2%) in 10 studies (6,10,13-17,19,20,23), while preoperative renal insufficiency/failure was reported in all but two studies (8,17) with a weighted average prevalence of 8.6% (range, 0-20.5%). Other patient demographics reported by more than half of the studies included hypertension, coronary artery disease, cerebral vasculopathies, diabetes, chronic obstructive pulmonary disease, and previous cardiac surgery.
A variety of prefabricated and modified prostheses were utilized (Table 2) by these centers. Aortic valve repair/replacement, Bentall procedure, and coronary artery bypass grafting was performed in 14.7%, 20.0% and 11.9%, respectively, in studies which specifically reported these procedures
Weighted average cardiopulmonary bypass time, myocardial ischemic time, circulatory arrest time, and cerebral perfusion time were 207±63 minutes (range, 108-297 minutes), 122±45 minutes (range, 74-174 minutes), 48±24 minutes (range, 27.2-64 minutes), 52±31 minutes (range, 24-88 minutes), respectively (Figure 3). Significant strong positive linear relationships between mortality and cardiopulmonary bypass time (Spearman’s correlation coefficient, rs =0.812), circulatory arrest time (rs =0.715), and cerebral perfusion time (rs =0.900) were identified, respectively (Figure 4). Moderate positive linear relationships between mortality and myocardial ischemia time (rs =0.572), and between circulatory arrest time and incidence of spinal cord injury (rs =0.474), were identified
TETEP PERLU DHCA
MAHAL EC DEVICE N HYBRID
U MEGA AORTA, TETEP PERLU 2 STEP YG MORTAL N BORBID IDEM CONVENT HYBRID
The advantages of DHCA include:
A bloodless and motionless operative field;
Avoidance of clamping and manipulation of the aorta with reduced risk for brain embolism;
Simplicity and no need for additional perfusion equipment.
The disadvantages of DHCA include:
Limited safe time of circulatory arrest;
Prolonged cardiopulmonary bypass (CPB) time required to cool down and rewarm patients, which may result in an increased occurrence of pulmonary, renal, cardiac and endothelial dysfunction;
Reperfusion injury;
Clotting complications (4).