a simplified introduction on aortic surgery from cardiothoracic point of view targeted for the undergraduate 6th year medical school

2. Disclosures

3. Learning Objectives
At the end of this lecture you should understand:
1. Anatomy of different segments of the Aorta
2. Different pathologies affecting the Aorta
3. Strategy in management of different pathologies
4. Surgical procedures for Aorta

4. Segments of the ascending and descending aorta. rPA = right pulmonary artery.
Authors/Task Force members et al. Eur Heart J 2014;35:2873-2926
© The European Society of Cardiology 2014. All rights reserved. For permissions please email:
journals.permissions@oup.com.

5. Pathology
• Aortic dissection
• Aortic aneurysm
• Traumatic aortic transection

6. Aortic dissection
• Def.: blood leaves aortic lumen via an “intimal tear” ,separating the inner
from the outer layers of the media creating a “false lumen”

7. Pathology

8. Classification
• Time of presentation:
• Acute: within 14 days
• Chronic: after 2 months
• Subacute: between 14 days and 2 months
• Site:
• Stanford classification
• Debakey classification

9. Stanford Classification
Emergency surgery is indicated for acute Stanford type A and Debakey type I and type II dissections

10. • Pathogenesis is not well understood, several theories might explain it
• Cystic medial degeneration :oldest theory, only in minority of patients (lost ground)
• Penetration of atherosclerotic ulcer (uncommon)
• Intramural hematoma :from bleeding vasa vasorum into the media
• Risk factors include,
• Age
• Hypertension
• CT disorders
• Iatrogenic and trauma
• High cardiac output status

11. • Clinical presentation may be in the form of severe “tearing pain” from chest
through to the back, sudden death, asymptomatic or as a complicated
dissection.
• Complications :
• Arch vessel occlusion
• Myocardial ischemia
• Hemopericardium,hemothorax
• Severe aortic valve incompetence
• Upper,lower limb,mesenteric or renal ischemmia
• CVS or paraplegia

12. Diagnosis of type A dissection
• History,clinical picture,ECG,CXR,ECHO ,etc……
• Imaging
• The primary role is to differentiate between type A dissection (emergency)and type
B
• As a rule centers planning to refer suspected acute type A dissection should use
the imaging modality in which they have most expertise with minimum delay.
• Aortography used to be the gold standard till recently
• CT angiography 90% sensitivity and specificity

13. Chest X-Ray

14. CT chest

15. CT chest

16. MRI
Stanford type B

17. Management
• Medical treatment has no rule in acute type A dissection
• In the acute setting it is usually safest to focus on treating the
immediately life-threatening complication
• The main variable to think about are
1. Extent of the resection (root or arch replacement needed ??)
2. Cannulation strategy
3. Need for circulatory arrest
4. Can aorta be clamped ?
5. Myocardial protection ,cerebral and spinal protection ,use of DHCA
6. Venting

21. Arch repair Hybrid approach

22. Type B dissection
• Medical treatment is superior
• Surgical approach is for complicated cases
• Until recently,
Endoluminal stenting

27. Permanent localized dilatation of an artery by at least 50% compared to normal

28. Thank you