ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY … · 2017-11-17 · ROLE OF VASCULAR...
Transcript of ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY … · 2017-11-17 · ROLE OF VASCULAR...
ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC
AORTIC ANEURYSMS
Armando Mansilha MD, PhD, FEBVSJoel Sousa MD
16th National Congress of the Italian Society of Vascular and Endovascular Surgery
Bologna, 2017
I have the following potential conflicts of interest to report:
Receipt of grants/research support
Receipt of honoraria and travel support
Participation in a company sponsored speakers‘ bureau
Employment in industry
Shareholder in a healthcare company
Owner of a healthcare company
I do not have any potential conflict of interest
Disclosure
X
EPIDEMIOLOGY
• True incidence difficult to determine, as many go undiagnosed
• Incidence is reported as increasing, which may reflect advances in imaging techniques
Estimated annual incidence in Olmstead County, Minnesota,
was 10.4 per 100,000 person years
Ascending Aorta
• Several thoracic aortic segments involved
60%
Aortic Arch10%
Descending Aorta40%
Thoracoabdominal Aorta10%
EPIDEMIOLOGY
TREATMENT OPTIONS ?
TREATMENT OPTIONS
ASCENDING AORTIC ANEURYSM
• Supracoronary replacement of the AAo
• Wheat procedure
• David procedure
• Bentall-DeBono procedure
• Cabrol procedure
Supracoronary replacement of the AAo and aortic valve
Replacement of the AAo with direct reimplantation of the coronary arteries and
reconstruction of the aortic valve, and sinutubular junction
Replacement of the AAo and aortic valve with a valved conduit and direct reimplantation of
the coronary arteries
Replacement of the AAo and the aortic valve with a valved conduit and reimplantation of the
coronary arteries via an additional conduit
CARDIAC SURGERY
TREATMENT OPTIONS
Supracoronary replacement of the AAo and aortic valve
Replacement of the AAo with direct reimplantation of the coronary arteries and
reconstruction of the aortic valve, and sinutubular junction
TREATMENT OPTIONS
DESCENDING THORACIC ANEURYSM
1. TEVAR
2. OPEN SURGERY
TREATMENT OPTIONS
“Endovascular thoracic repair reduces perioperative mortality and neurological
morbidity in patients with descending thoracic aortic aneurysms”
1ST CHOICE
1. TEVAR
VASCULAR SURGERY
TREATMENT OPTIONS
2. OPEN REPAIR
CARDIAC SURGERYVASCULAR SURGERY +
TREATMENT OPTIONS
AORTIC ARCH
• Isolated arch aneurysms are a rare entity
• Aortic arch aneurysms are commonly associated with
aneurysms of the adjacent ascending or descending aorta
• The criteria applied are those of ascending or descending
aneurysms depending on whether the arch aneurysm is more
closely related to the ascending or the descending aorta
TREATMENT OPTIONS
ASCENDING AORTA AND ARCH INVOLVEMENT
1. ISLAND PATCH TECHNIQUE 2. Y-GRAFT TECHNIQUE
CARDIAC SURGERY
TREATMENT OPTIONS
ARCH AND DESCENDING THORACIC INVOLVEMENT
• Several treatment options available
• Indications are LESS CLEAR
• Open surgery
• Hybrid techniques (including debranching)
• Total endovascular interventions
TREATMENT OPTIONS
Although, usually performed by CARDIAC SURGERY
1. Elephant trunk2. Frozen elephant trunk
TREATMENT OPTIONS
New endovascular techniques have allowed VASCULAR SURGEONS to treat this vascular
territory
1. Hybrid techniques with SAT debranching 2. Total endovascular replacement with chimneys,
branches and fenestrations
TREATMENT OPTIONS
SO, WHAT TO DO?
• Both endo and open techniques have been develloped
• In patients without CONNECTIVE TISSUE DISORDERS, technique should be chosen accordingly to the patients
physiological status as well as the center’s experience
• In patients with CONNECTIVE TISSUE DISORDERS, OPEN interventions should be favoured over endo procedures
Nonetheless,
PRE AND POST-OPERATIVE PLANNING AND SURVEILLANCE
• PROPER PRE-OPERATIVE ASSESSMENT of the aneurysm is essential,
in order to plan either open or endovascular interventions
• In patients treated with aortic endografts, LIFELONG SURVEILLANCE is
necessary to ensure proper placement of the graft
CONCLUSION
• Depending on the LOCATION of the thoracic aortic aneurysms, DIFFERENT INTERVENTIONS are available
• Patients with CONNECTIVE TISSUE DISORDERS should be offered OPEN SURGERY, whenever possible
• New ENDOVASCULAR interventions have allowed to push the bounderies of arch aneurysm treatment, although solid
evidence is still LACKING
• Proper PRE-OPERATIVE PLANNING and STRICT FOLLOW-UP are essential, either in open or endo interventions
Thoracic aortic aneurysms are COMPLEX PATHOLOGIES which may require a wide variety of
interventions. Patients should be referred to centers where both VASCULAR and CARDIAC
SURGEONS are available, as COOPERATION and JOINT PROCEDURES are often NECESSARY.
ROLE OF VASCULAR SURGERY, CARDIAC SURGERY AND RADIOLOGY IN THE TREATMENT OF THORACIC
AORTIC ANEURYSMS
Armando Mansilha MD, PhD, FEBVSJoel Sousa MD
16th National Congress of the Italian Society of Vascular and Endovascular Surgery
Bologna, 2017