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Friday, 24 November 2017

Aortic Surgery

Diseases of the aorta can dangerous and very often one may die even before they get to the hospital. So what causes aortic disease? The commonest cause is atherosclerosis or deposition of cholesterol and other cells in the wall of the aorta and weakening of the wall. This causes the aorta to balloon out at the weak points and tear. When it balloons out it is called an Aneurysm and when it tears it is called a Dissection, the latter is fatal if detected late.

Aortic surgery must be carried out only in centers with good exposure to them. They are high risk procedures but the results are extremely gratifying if done well.

The different procedures are as follows


  1. Ascending aortic replacement
  When the ascending or first part is dilated or torn it can be replaced with synthetic Dacron graft. Depending up the extent this may be done using the heart lung machine on normal temperature or in some cases one may have to freeze the body down to 15 degrees Celsius and perform the operation, this is known as circulatory arrest as the name specifies the circulation is stopped for a period of time. The safe period is 20 minutes at a time.


2. Aortic arch replacement


This is done when the aorta and arteries supplying blood to our brain are both affected by the disease. The entire arch is replaced with synthetic Dacron graft under circulatory arrest. This is a fairly high risk procedure with high incidence of stroke from two causes

a) Most of these patients have significant disease of the blood vessels within the brain and are more prone to strokes the stress of the surgery can predispose to it. These are though mostly white matter infarct.

b) The second is the aorta is very badly diseased and sometime small debris from the diseased aorta can break and go to the brain leading to a stroke.



3. Hybrid aortic arch and descending aortic replacement

  This is a combination of surgery with a stent graft. The ascending aorta that is diseased is replaced and then from above a stent graft is placed into the diseased descending aorta to take care of all the disease in one sitting. It has reduced the risk and morbidity of the operation by half.


4. Endovascular stent graft placement


Instead of an open aneurysm repair, your surgeon may consider a newer procedure called an endovascular aneurysm repair (EVAR, TEVAR, TA-EVAR). Endovascular means that surgery is performed inside your aorta using thin, long tubes called catheters. By entering through small incisions in the groin, the catheters are used to guide and deliver a stent-graft through the blood vessels to the site of the aneurysm. The stent graft is then positioned in the diseased segment of aorta to “reline” the aorta like a sleeve to divert blood flow away from the aneurysm.


This endovascular approach is currently used to treat abdominal and descending thoracic aneurysms, and is being evaluated as a treatment for thoracoabdominal and arch aneurysms. While current results are positive, further research is needed to determine who the best candidates for this type of procedure may be.


The standard surgical treatment for thoracic aortic aneurysms is open-chest aneurysm repair, but surgeons are now able to treat many thoracic and thoracoabdominal (occurring in the lower part of the thoracic aorta and the upper part of the abdominal aorta) aneurysms with a minimally invasive procedure called an endovascular stent graft.


 What is an endovascular stent graft?


Endovascular means that surgery is performed inside your aorta using thin, long tubes called catheters. Through small incisions in the groin, the catheters are used to guide and deliver a stent-graft through the blood vessels to the site of the aneurysm. The stent graft is then deployed in the diseased segment of the aorta and "relines" the aorta like a sleeve to divert blood flow away from the aneurysm.


An endovascular stent graft is a fabric tube supported by metal wire stents (also called a scaffold) that reinforces the weak spot in the aorta. By sealing the area tightly with your artery above and below the aortic aneurysm, the graft allows blood to pass through it without pushing on the aneurysm.


 What are the benefits of endovascular repair?


Endovascular repair of thoracic aneurysms is generally less painful and has a lower risk of complications than traditional surgery because the incisions are smaller. Endovascular aorta aneurysm procedures also allow you to leave the hospital sooner and recover more quickly after your arota repair.


 Who is a candidate for endovascular repair of a thoracic aneurysm?


You may be eligible for endovascular stent grafting if your thoracic aneurysm has not ruptured and the aneurysm is 5 centimeters or more in size.

Your physician can determine if aortic aneurysm repair is the best treatment by performing one or a combination of imaging studies, which may include:

  • High resolution, computed tomography (CT) scan
  • Magnetic resonance imaging (MRI)
  • Angiography (an x-ray of the blood vessels)
  • Transesophageal echocardiography (TEE), to record ultrasound images of your heart from inside your
  • esophagus, or food pipe
  • Intravascular ultrasound

Physical characteristics of the aorta and the aortic aneurysm itself are very important in determining if endovascular repair is the best treatment.


 How is the procedure done?


Your surgeon will make small incisions in the skin above the femoral artery (the large artery that supplies blood to each leg) in the groin. A guide wire is threaded through the artery beyond the area of the thoracic aneurysm.


By using x-ray guidance, your surgeon inserts the device over the guide wire. The stent-graft device is constrained within a catheter to make it easier to deliver the stent-graft through your blood vessels. Once the graft is guided to the thoracic aneurysm site, the catheter is withdrawn, exposing the stent-graft in place. The stent-graft then expands like a spring to fit against the walls of the aorta on either side of the aneurysm, and delivers blood flow through the weakened section.


Once the stent-graft is in place, the blood flows through the graft, avoiding the aneurysm. Over time, the aneurysm typically shrinks due to the blood pressure being diverted away from the aneurysm.


Surgeons are also using fenestrated and branched endografts to treat more complex thoracic aneurysms involving the aortic arch and thoracoabdominal aneurysms (those which involve the aorta both in the chest and the abdomen). Additionally, branched and fenestrated grafts are used to extend thoracic grafts to repair those aneurysms that involve the vessels leading to the intestines or the brain and arms.



For those patients with extensive aortic or multiple aneurysms, the best approach may require a combination of open surgery and endovascular repair. This combined therapy is referred to as a hybrid approach and most often includes what is known as an elephant trunk procedure


 What are the risks of endovascular repair of thoracic aneurysms?


Although endovascular surgery reduces recovery time to a few days, there are still potential risks. The possible complications of endovascular repair include:

  • Leaking of blood around the graft, known as “endoleak”
  • Movement, or migration, of the graft away from its initial placement
  • Stent fracturing

Additional complications that are rare but serious include:

  • Paralysis
  • Delayed rupture of the aneurysm
  • Infection

Your surgeon will discuss the benefits and potential risks of the procedure with you.


The long-term durability of endovascular stent grafting to treat a thoracic aneurysm is yet unknown because this is a fairly new procedure. For this reason, patients who have endovascular repair of their thoracic aneurysms must be monitored closely on a regular basis with examinations and imaging studies.


 How long will it take to recover from endovascular repair of a thoracic aneurysm?


Your hospital stay following endovascular stent grafting is usually 2 to 3 days. While your recovery will take less time than recovering from open-chest thoracic aneurysm surgery, the early restrictions are similar and include:

  • No driving until approved by your physician (usually within 1-2 weeks after the procedure, and no longer taking pain medication)
  • No baths until the groin incisions heal; showers and sponge baths around the incision are permitted
  • Avoid lifting more than 10 pounds for approximately 4 - 6 weeks after the procedure

You will return for a follow-up visit within one month of the procedure. Follow-up imaging tests will take place 1 and 6 months following the procedure to make certain the stent is still functioning and in the proper location. If you aneurysm is shrinking and no problems are found, your subsequent imaging tests will take place yearly.

After you’ve had an endovascular repair of an aneurysm, it is recommended you adopt the same heart-healthy lifestyle led by other heart surgery patients. Your health care team can provide more information



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