presentation will give a idea about management of thoracoabdominal aortic aneurysm, including detail of investigation and treatment options available today.
This is a recreation of a presentation that I created in the early 2000s for a nursing inservice about femoral vascular access site complications. Post cardiac catheterization and post interventional radiology patients were a new patient population for these nurses.
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
Indications and timing of intervention in congenital heart diseaseRamachandra Barik
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Ventricular septal defect (VSD) is the most common congenital heart defect (excluding bicuspid
aortic valve); its prevalence varies from 3 to 5/1,000 live births.9,10 Clinical manifestations depend on the size of
the defect and the pulmonary and systemic vascular resistances. Some of the small and moderate sized VSDs
can close spontaneously. In the historic series of Dr. Paul Wood, 52% of patients with large VSD developed
irreversible pulmonary vascular disease with the onset in infancy in four-fifths of them.11 Commonest site of
VSD is perimembranous (80%), the other sites are outlet or sub-pulmonary (5%-7%), inlet (5%-8%), and
muscular (5%-20%).
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mmÃ3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Mediastinal injury includes cardiac, thoracic aorta, pulmonary vessels and SVC injury. Pelvic includes pelvic fracture. GI injury includes upper and lower GI injuries. Abdominal vascular includes abdominal aorta, IVC and other named vascular injury.
This is a recreation of a presentation that I created in the early 2000s for a nursing inservice about femoral vascular access site complications. Post cardiac catheterization and post interventional radiology patients were a new patient population for these nurses.
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
Indications and timing of intervention in congenital heart diseaseRamachandra Barik
Â
Ventricular septal defect (VSD) is the most common congenital heart defect (excluding bicuspid
aortic valve); its prevalence varies from 3 to 5/1,000 live births.9,10 Clinical manifestations depend on the size of
the defect and the pulmonary and systemic vascular resistances. Some of the small and moderate sized VSDs
can close spontaneously. In the historic series of Dr. Paul Wood, 52% of patients with large VSD developed
irreversible pulmonary vascular disease with the onset in infancy in four-fifths of them.11 Commonest site of
VSD is perimembranous (80%), the other sites are outlet or sub-pulmonary (5%-7%), inlet (5%-8%), and
muscular (5%-20%).
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mmÃ3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Mediastinal injury includes cardiac, thoracic aorta, pulmonary vessels and SVC injury. Pelvic includes pelvic fracture. GI injury includes upper and lower GI injuries. Abdominal vascular includes abdominal aorta, IVC and other named vascular injury.
Trans catheter intervention is emerging field in cardiac intervention. due to complex anatomy of mitral valve understanding of anatomy and three dimensional imaging is most important aspect of successful intervention and could be life saving in high risk surgical candidate
DEFINITION:
An aortic aneurysm is an enlargement (dilation) of the aorta to greater than 1.5 times normal size.
1)Abdominal aortic aneurysm:
2)Thoracic aortic aneurysm:
1)Hardening of the arteries ( Atherosclerosis).
2)Genetic conditions:
Aortic aneurysms in younger people often have a genetic cause âpeople who are born with Marfan syndrome.
3)Other medical conditions: Inflammatory conditions ,such as giant cell arteritis.
4)Problems with your hearts aortic valve:
Some times people who have problems with the valve.
5)Untreated infection: Such as syphilis or salmonella, and HIV.
6)Traumatic injury: Rarely ,some people who are injured in falls or motor vehicle crashes develop thoracic aortic aneurysms.
RISK FACTORS-1)Age
2)Male gender
3)Hypertension
4)Coronary artery disease
5)Family history
6)High cholesterol
7)Lower extremity
8)Carotid artery disease.
9)Previous stroke
10)Tobacco use
11)Excess weight.
SIGN & SYMPTOMS-
THORACIC AORTIC ANEURYSM.
âĸConstant boring pain, which may occur only when the patient is in the supine position.
Dyspnea, cough( parpoxysmal and brassy).
Hoarseness , stridor ,weakness or completer loss of the voice( aphonia).
Dysphagia.
Dilated superficial veins on chest ,neck, neck or arms.
Edematous areas on chest wall.
Cyanosis
Unequal pupils.
1.Patients complaints of â heart beatingâ in abdomen when lying down or a feeling of an abdominal mass or abdominal throbbing.
2.Cyanosis and mottling of the toes if aneurysm is associated with thrombus.
DIAGNOSTIC MEASURE-Chest x.ray , CT angiography ( CTA), and transesophageal electrocardiography( TEE) , are done to reveal abnormal widening of the thoracic aorta.
Abdominal aortic aneurysm : Pulsation of pulsatile mass in the middle and upper abdomen , duplex ultrasonography or CTA is used to determine the size ,length and location of the aneurysm.
Dissecting aneurysm : Arteriography ,CTA,TEE duplex ultrasonography and magnetic resonance angiography ( MRA).
COMPLICATION
âĸRupture of an aneurysm is the most serious complication.
âĸIf rupture occurs into the retroperitoneal space , bleeding may be controlled by surrounding anatomic structures, preventing exsanguination and death.
MEDICALMANAGEMENT
âĸThe goal of both medical and surgical management is to prevent aneurysm rupture.
âĸEarly detection and prompt treatment are essential .
âĸConservative therapy of small asymptomatic AAAâs ( 4-5.5) is the best practice.
This consists of risk factor modification ( ceasing tobacco use , decreasing B.P, optimizing of aneurysm size using ultrasound ,CT, or MRI.
âĸGrowth rates may be lowered with B- adrenergic blocking agents ( eg. Propranolol) , Statins ( eg. Simvastatin) and antibiotics( eg. Doxycycline).
SURGICAL MANAGEMENT-Surgical repair is recommended in patients. with asymptomatic aneurysm 5-5 cm in diameter or larger.
âĸSurgical procedure are
1)Open aneurysm repair (OAR)
2)Endovascular graft procedure
Aortic Aneurysm: Diagnosis, Management, Exercise Testing, And TrainingJavidsultandar
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An aortic aneurysm is a balloon-like bulge in the aorta, the large artery that carries blood from the heart through the chest and torso.
Aortic aneurysms can dissect or rupture:
The force of blood pumping can split the layers of the artery wall, allowing blood to leak in between them. This process is called a dissection.
The aneurysm can burst completely, causing bleeding inside the body. This is called a rupture.
Dissections and ruptures are the cause of most deaths from aortic aneurysms.
Stanford Type A Aortic Dissection: a Complex Disease for Patients and Cardiot...Crimsonpublisherssmoaj
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Acute type A aortic dissection is a catastrophic event in which blood exits the vascular lumen and dissects the media, creating a false lumen. Surgery is the best possible treatment but it is complex. The surgical team needs to understand the anatomy and physiopathology before dealing with the repair. While there are just a few surgical solutions for the repair of the dissected ascending aorta, debate is still ongoing about the best surgical option for the disease involving the arch and the descending aorta. Late reoperations are relatively common on the aortic valve and/or the distal aorta after primary repair. Results are excellent in specialized centers with high volume and complexity. Lifelong follow-up is required in survivors.
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)
Infective Endocarditis- surgical indication & principle of surgeryDhaval Bhimani
Â
this presentation is to give idea about surgical indication for Infective Endocarditis and what are the principle of surgery for infective endocarditis.
Neurocognitive function in on pump vs off pump CABGDhaval Bhimani
Â
CABG(coronary artery bypass grafting) is most common operation done in cardiac surgery, this presentation will give idea about neurocognitive dysfunction in on pump vs off pump CABG.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
How many patients does case series should have In comparison to case reports.pdfpubrica101
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Pubricaâs team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
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According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
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The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
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This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patientâs body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
The Importance of Community Nursing Care.pdfAD Healthcare
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NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Global launch of the Healthy Ageing and Prevention Index 2nd wave â alongside...ILC- UK
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The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.Â
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctorsâ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
 Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratoryÂ
 to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
4. ANATOMIC PRINCIPLES
ī´ Arises distal to the origin of Left SCA.
ī´ TAA span the diaphragmatic hiatus at the level of Tl2
and introduce important considerations for pleural entry,
peritoneal access, and diaphragmatic conservation for
aortic repair.
ī´ In addition, phrenic nerve localization and preservation
are imperative within the pericardium as it crosses the
left atrium and terminates distally on the abdominal
surface of the diaphragm.
5. ī´ The critical vascular zone of the spinal cord from T4 to Ll vertebral levels is
characterized by the least prominent blood supply and is the zone at which
interference with the circulation is most likely to result in paraplegia.
ī´ The artery of Adamkiewicz is the largest anterior medullary feeder for the
supply of the lumbar cord and arises from the lower intercostal or lumbar
artery on left in 65% to 80% of cases between T6 and 14 levels.
ī´ The lower intercostal and lumbar artery supplying the artery of
Adamkiewicz should be preserved or reconstructed to maintain blood
supply to the lumbar spinal cord to minimize the risk of spinal cord injury.
ī´ Perfusion through medullary arteries maintains spinal cord blood supply
proximal to the aortic cross-clamp and determines postoperative
neurologic function.
6. ī´ Visceral branches are located on the ventral aorta as the celiac
axis, superior mesenteric, inferior mesenteric, and paired or
multiple renal arteries.
ī´ The anterior spinal artery is a principal component of the extensive
intraspinal and paraspinous collateral blood supply to the anterior
spinal cord, with 75% of all segmental arteries providing direct
anterior spinal artery-supplying branches.
ī´ This extensive collateral network imparts a responsibility to define
dominant intercostal and lumbar arteries for each individual patient
to guide operative planning for reconstruction and preservation of
blood supply to the spinal cord.
7. IMAGING, option available ??
ī´ Determined by following factors
1. patient-related factors
âĸ hemodynamic stability
âĸ renal function
âĸ contrast allergy
2. institutional capabilities ( technologic capability, expertise).
CT-induced contrast nephropathy and magnetic resonance (MR) associated gadolinium
nephrogenic systemic fibrosis are principal considerations for patients with borderline
kidney function (serum creatinine > 1.8 to 2.0 mg/dl).
8. Chest X- Ray
ī´ specificity for acute aortic pathology of
86% in prospective study of patients
undergoing evaluation for acute thoracic
aortic disease.
ī´ However, it is insufficient to definitely
exclude thoracic aortic aneurysm in high-
risk patients and lacks anatomic detail
necessary for directed treatment.
9. CT angiography
(CTA)
ī´ CTA is accepted as the primary
diagnostic imaging modality for the
thoracic aorta with a demonstrated
accuracy of92% for all-inclusive
abnormalities of the thoracic aorta and
has an established efficacy in the
prediction of the need for hypothermic
circulatory arrest during surgical repair.
ī´ Image acquisition should include
ascending aorta, aortic arch,thoracic
branch vessels and femoral vessels to
determine aneurysm extension and to
guide potential endovascular access.
10.
11. MR angiography (MRA)
ī´ provides similar advantages to CTA without the limitations of radiation exposure or
iodinated contrast.
ī´ Phase-contrast techniques and two-dimensional time-of-flight modalities have
increased the application of MRA in the setting of thoracic aortic aneurysm and
dissection, with beneficial applications in the determination of flow dynamics within
the false channel.
ī´ First-line adoption of this imaging modality in the setting of thoracic aortic
aneurysm remains limited by institutional capabilities and the time required for
acquisition.
ī´ In addition to providing insight regarding aortic size and anatomic aneurysm
characteristics, both CTA and MRA guide the selection of safe sites for arterial
cannulation and cross clamp application.
18. Principle of medical therapy
ī´ The main aim of medical therapy in this condition is to reduce shear stress on the
diseased segment of the aorta by reducing blood pressure and cardiac
contractility.
ī´ Cessation of smoking is important, as studies have shown that self-reported
current smoking induced a signiīŦcantly faster expansion (by approximately 0.4
mm/year).
ī´ Moderate physical activity probably prevents the progression of aortic
atherosclerosis but data are sparse.
ī´ To prevent blood pressure spikes, competitive sports should be avoided in patients
with an enlarged aorta.
19. ī´ It is mechanistically logical that medical therapy to reduce dP/dt and to control
blood pressure would be beneficial for the treatment of all patients with thoracic
aortic aneurysms.
ī´ In a randomized study of adults with Marfan syndrome, Shores et al found that
treatment with propranolol (versus no b-blocker therapy) over 10 years resulted in
a significantly slower rate of aortic dilatation, fewer aortic events, and lower
mortality.
ī´ There is some early experimental evidence to suggest that oxidative stress may
play a role in the pathogenesis of atherosclerotic thoracic aortic aneurysms and
that perhaps statin therapy and angiotensin II receptor blocker therapy may
potentially have a protective effect.
20. ī´ Once b- blocker therapy is maximized (or in the event that b-blockers are
contraindicated or not tolerated), any persistent hypertension should be treated
with other antihypertensive agents to bring the blood pressure down to a low-
normal range, eg, a systolic pressure of 105 to 120 mm Hg
ī´ Patients should be informed of the typical symptoms of acute aortic dissection.
Moreover, patients should be instructed that should they ever experience the
abrupt onset of significant chest, neck, back, or abdominal pain, they should
present immediately to an emergency department for evaluation.
ī´ In addition, patients should be instructed to inform the emergency physician of the
existence of a thoracic aortic aneurysm and explain explicitly that their physician
recommends an urgent CT scan of the chest (or transesophageal
echocardiography or MRI if a CT is contraindicated) to rule out acute aortic
dissection or rupture.
21.
22. ENDOVASCULAR REPAIR TECHNIQUE
ī´ Thoracic endo vascular aortic repair aims at excluding an aortic lesion (i.e.
aneurysm or FL after AD) from the circulation by the implantation of a membrane-
covered stent-graft across the lesion, in order to prevent further enlargement and
ultimate aortic rupture.
ī´ Careful pre-procedural planning is essential for a successful TEVAR procedure.
ī´ Contrast-enhanced CT represents the imaging modality of choice for planning
TEVAR, taking ,3 mm âslicesâ of the proximal supra-aortic branches down to the
femoral arteries.
ī´ In situations involving important aortic side branches (e.g. left subclavian artery),
TEVAR is often preceded by limited surgical revascularization of these branches
(the âhybridâ approach). Another option is a surgical de-branching or the use of
fenestrated and branched endografts or the âchimney techniqueâ. An alternative
may be a single, branched stent-graft.
23.
24. ī´ In high-risk patients, preventive cerebrospinal īŦuid(CSF)drainage can be
beneīŦcial, as it has proven efīŦcacy in spinal cord protection during open
thoraco-abdominal aneurysm surgery.
ī´ Reversal of paraplegia can be achieved by the immediate initiation of CSF
drainage and pharmacological elevation of blood pressure to >90 mm Hg
mean arterial pressure.
ī´ Hypotensive episodes during the procedure should be avoided.
ī´ Follow up Ct scan to be done after 1 week to rule out endoleak.
25.
26. ī´ Type I and Type III
ī´Endoleaks are regarded as treatment failures and warrant
further treatment to prevent the continuing risk of rupture.
ī´Type II
ī´Endoleaks are normally managed conservatively by a âwait-and-
watchâ strategy to detect aneurysmal expansion, except for
supra-aortic arteries.
ī´Types IV and V
ī´Endoleaks are indirect and have a benign course. Treatment is
required in cases of aneurysm expansion.
28. Anaesthesia and monitoring
ī´ General anaesthesia
ī´ Double lumen endotracheal tube.
ī´ Monitoring :-
ī´ Large-bore peripheral access, central venous pressure monitoring, continuous
arterial pressure assessment, pulse oximetry, and foley catheter are imperative to
guide intraoperative resuscitation and support.
ī´ Transesophageal echocardiography, continuous electrocardiographic monitoring,
and a pulmonary artery catheter provide additional adjuncts for intraoperative
cardiac evaluation and are routine in our institution.
ī´ Femoral artery access is needed with cardiopulmonary bypass to maintain
balanced pressures.
29. ī´ Temperature monitoring is achieved at two access sites to estimate
cerebral (blood, esophageal, tympanic membrane, nasopharynx) and
visceral (bladder, rectal) temperatures.
ī´ Cerebrospinal fluid (CSF) drainage is the principal modality for spinal cord
protection , due to the established benefit and low-risk of this protective
strategy.
ī´ Motor-evoked potential (MEP) and somato sensory evoked potential
(SSEP) monitoring may be applied in addition to CSF drainage for spinal
cord protection and monitoring.
30. Incision and Exposure: Thoracic
Aneurysms
ī´ An extended posterolateral thoracotomy is performed to expose the entire
length of the thoracic aorta.
ī´ The latissimus dorsi and a minimal portion of the serratus anterior muscles
are divided.
ī´ Aneurysms of the upper or middle thoracic aorta are accessed through a
single intercostal space, which may be facilitated by division of one of the
ribs posteriorly.
ī´ Two separate sites of entry through the fourth interspace and the seventh
or eighth interspace for more extensive descending thoracoabdominal
aneurysms can be obtained and recommended.
ī´ The fourth interspace is critical to proximal clamp application.
31.
32.
33. ī´ The thoracic duct and adjacent lymph vessels should be avoided. Intraoperative
lymph leaks should be immediately repaired.
ī´ The identification of the esophagus may be augmented by the direct palpation of
the nasogastric tube or transesophageal echocardiography scope to avoid
inadvertent injury.
ī´ FOR thoracoabdominal aneurysm-
ī´ Incision is started posterolaterally over the ribs of the seventh, eighth, or ninth
interspace dependent on the proximal extent of the aneurysm.
ī´ The incision is then advanced across the ninth interspace at the costal margin to
curve inferiorly to run parallel and left-lateral to the midline and rectus sheath.
ī´ The abdominal muscles are divided and the peritoneum is preserved. Special care
is needed at the lateral edge of the rectus abdominis muscle where the peritoneum
and transversalis fascia are closely apposed to the abdominal wall.
34. ī´ The diaphragm may be taken down with a
curved incision along the costal margin with
care to preserve a 3-cm rim along the
posterior aspect of the rib.
ī´ The tendinous center of the diaphragm is
then conserved when anatomically feasible
to improve postoperative respiratory recovery
and weaning time.
ī´ This limited phrenotomy technique allows
passage of the graft through the natural
hiatus of the diaphragm.
ī´ The incision is continued down to the crura,
and the left crus may be divided to expose
the aorta beneath.
ī´ A radial diaphragmatic incision may also be
utilized.
35. ī´ Progressive retraction of the peritoneum and its contents will facilitate exposure of
the retroperitoneum and a self-retaining retractor is necessary.
ī´ The aorta is located medial to the iliopsoas muscle.
ī´ Mobilization of the left kidney from the bed of the psoas muscle may provide
additional exposure.
ī´ Importantly, this step is deferred in patients with a retroaortic left renal vein.
Anterior visceral branches are identified and sharply dissected with attention to
mobilization should reimplantation or bypass be required.
ī´ Dissection is performed proximal and distal to the aneurysmal segment of aorta
and each site is tapped in preparation for cross-clamping.
36. Hemodynamic Support during Aortic
Cross-Clamping
ī´ Proximal aortic cross-clamp application induces a significant
increase in cardiac afterload.
ī´ Sudden afterload reduction following clamp release is
associated with an acute relative hypovolemia and systemic
hypotension.
37. Strategy:-
ī´ Approach to cross-clamp application and distal aortic perfusion involves active
distal aortic perfusion with femoral-to-femoral bypass for all but type IV and V
aortic aneurysms, for which we can minimize supraceliac clamp times with no
active distal perfusion.
ī´ maintenance of distal aortic blood pressure is imperative and is achieved through
the titration of pharmacologic agents and pump flow rates to maintain optimal
perfusion.
ī´ Infusion of nitroglycerine, trimethaphan, or sodium nitroprusside prior to the
application of the aortic cross-clamp may be performed to lower systolic blood
pressure to 70 to 80 mmHg.
38. ī´ Sodium bicarbonate, calcium, and rapid volume infusion may be initiated prior to
unclamping to prevent acute hypotension.
ī´ Vasopressor agents may also be utilized to augment these resuscitative measures
to maintain blood pressure upon clamp release.
ī´ Progressive clamp application and release over a period of 2 to 4 minutes may
blunt the imposed physiologic insult and hemodynamic response.
ī´ In assessment of end-organ ischemia, cross-clamp time is measured from the first
click of clamp application until its complete release.
39. Extracorporeal Circulation
ī´ Extracorporeal circulation support provides after load reduction and
continuous end-organ perfusion during the aortic cross-clamp period.
ī´ Techniques for the maintenance of extracorporeal circulation include
ī passive aorto-aortic shunt,
ī left atriofemoral bypass, and
ī femorofemoral cardiopulmonary bypass.
40. Spinal Cord Protection
ī´ Central to methods of cord protection is an understanding of the axial network and
the supplying segmental, subclavian, and hypogastric arteries and the protective
effect of permissive hypothermia on neural tissue.
ī´ This collateral network may increase flow through alternative routes when another
is reduced; however, this network may also result in steal that will result in
decreased nutrient flow to the cord.
ī´ Steal may occur secondary to the absence of visceral and iliac artery perfusion,
during the cross-clamp period, or as a result of pharmacologically induced
arteriovenous shunting when bleeding intercostals into an excluded aortic
segment.
41. ī´ liberal use of multi head
perfusion cannulae and
pediatric coronary sinus
catheters for the maintenance
of perfusion to the visceral and
subclavian aortic branches and
dominant intercostal arteries,
respectively.
42. ī´ The detection of potentially reversible delayed paraplegia may be achieved by
MEP and SSEP monitoring with immediate assessment of function postoperatively.
ī´ The adoption of the following provocative techniques for reduction of spinal cord
ischemic-induced injury has resulted in a significant decrease in the incidence of
paralysis following open repair that is dependent on the extent of repair.
ī´ 15% for type I,
ī´ 30% for type II,
ī´ 7% for type III, and
ī´ 4% for type Iv.
43. Predictors of delayed neurologic deficit
ī´ emergent operative status,
ī´ prolonged aortic cross-clamp time,
ī´ level of cross-clamp, hypogastric artery exclusion,
ī´ aortic rupture,
ī´ preoperative renal dysfunction,
ī´ prior abdominal aortic aneurysm repair,
ī´ acute dissection, and
ī´ extent II involvement.
44. Strategies
īļ Distal aortic perfusion.
īļ Lower body pressure monitoring is imperative to maintain appropriate cord
perfusion which may necessitate flow rates as high as 3 to 3.5 L/min.
īļ Intrathecal vasodilators and topical cooling.
īļ Experimental porcine studies have established the protective effect of
intrathecal administration of vasodilators during the aortic cross-clamp period.
This technique dilates spinal arteries and prevents spasm and may be
combined with local cooling of the cord with 4°C saline to extend the potential
aortic cross-clamp time.
īļ Topical cooling of the spinal cord is associated with increases in CSF pressure;
however, this technique has proven to be a protective adjunct in the reduction
of postoperative paralysis and paraplegia.
45. īļ Cerebrospinal fluid drainage.
īļ In randomized prospective study, the incidence of paraplegia or
paraparesis was reduced with CSF drainage from 13.0% to 2.6%, P =
0.03.
īļ CSF pressure is maintained < 10 mmHg with mean perfusion
pressures of 85 to 90 mmHg to enhance spinal cord perfusion.
īļ Lumbar drains are generally removed on postoperative day 2 in
patients without neurologic deficit.
īļ Preference in high-risk patients is to leave the lumbar drain inplace for
72 hours, while in select low risk patients one can consider removal at
24 hours.
46. īļ Reattachment of intercostal and lumbar arteries.
īļ acceptable rates of paralysis and paraplegia following sacrifice without
reimplantation of as many as 15 intercostal and lumbar arteries during
thoracoabdominal aneurysm reconstruction.
īļ Prompt ligation of nonimplanted intercostal arteries is recommended to
avoid steal from the cord circulation.
īļ While multimodality approaches have implemented complete intercostal
reimplantation.
47.
48.
49. īļ Hypothermia.
īļ Moderate (29 to 32°C) to profound (20%) hypothermia is associated with
improved outcomes following thoracoabdominal and descending aortic
operations.
īļ The proposed mechanism of hypothermia-induced protection involves the
reduction of excitatory neurotransmitter release, decreased free oxygen radical
production, decreased postischemic edema, and stabilized central nervous
system blood flow.
50. īļ Pharmacologic agents.
īļ Mannitol (0.25 to 1.0 g/kg), high-dose barbiturates, methylprednisolone (30
mg/kg), calcium-channel blockers, adenosine 2A agonist, naloxone, and local
anesthetic agents have a demonstrated efficacy in experimental models of
spinal cord ischemia and multimodality clinical protocols.
īļ The proposed mechanism of spinal cord protection involves decreased spinal
cord edema and improved free oxygen radical scavenging
īļ Minimizing aortic cross-clamp times.
55. HYBRID APPROCH
ī´ Hybrid techniques that incorporate open and endovascular repair
techniques provide a promising approach to treatment in patients with
complex thoracic aortic aneurysms with or without concomitant dissection.
ī´ In patients with descending thoracic aortic aneurysms with proximal
extension into the aortic arch, we can successfully performed open arch
debranching and revascularization of branch vessels, followed by TEVAR
of the arch and descending thoracic aorta.
ī´ Similaraly, TAAA extending and involving viseral vessel, hybrid approch
can be tried.
56.
57.
58. SPECIAL FEATURES OF
POSTOPERATIVE CARE
ī´ Particular attention is paid to maintaining adequate ventricular preload by
volume infusions.
ī´ Amount of chest drainage is closely monitored.
ī´ close attention to pulmonary subsystem management is mandatory in
thoracotomy involving cases.
ī´ Prompt initiation of cerebrospinal
ī´ fluid drainage may, in some instances, reverse the neurologic deficit, and if
a drain is not already in place, it should be inserted when signs of spinal
cord ischemia develop postoperatively.
ī´ Avoiding prolonged periods of hypotension is also essential to
ensure optimal spinal cord perfusion.
59. FOLLOW-UP RECOMMENDATIONS
ī´ The current standard for postoperative endovascular and open
descending thoracic and thoracoabdominal aortic aneurysm
repair involves
ī´ physical examination,
ī´ Repeat imaging with CTA chest and chest radiography at 1, 6, and 12 months.
ī´ The initial interval to postoperative evaluation may be modified as determined by
the immediate in-hospital postoperative course.
60.
61. Literature rerview
ī´What to look for
1. In hospital mortality
2. Morbidity
3. Type of different strategy developed over years.