ASCENDING AORTIC ANEURYSM: TECHNIQUE MARKO TURINA University Hospital Zurich, Switzerland.

ASCENDING AORTIC ANEURYSM: TECHNIQUE

MARKO TURINA University Hospital

Zurich, Switzerland

Tension at Coronary Ostia withGraft Inclusion Technique

From Crawford: Diseases of the Aorta

GRAFT INCLUSION TECHNIQUE: SUBSTANTIAL SOURCE OF COMPLICATIONS

From Crawford: Diseases of the Aorta

Perigraft hematoma after wrap technique

Spurious Aneurysm at the Origin of RCA After Graft Inclusion Technique in Composite Graft

Spurious Aneurysm of the Aortic Root After Composite Graft: Detachment of the Coronary Orifice

COMPOSITE GRAFT IN MARFAN’S DISEASE:

False aneurysm at the origin of LMCA

Courtesy Prof.Jenni, Echocardiography USZ

35 year old male with Marfan, 9 y. after composite graft repair for acute Type A dissection

Aortic valve

LA

RVOT

True lumenBS 25

False aneurysm

Composite graft (compressed)

BS 25

FALSE ANEURYSM AT THE ORIGIN OF LMCA AFTER COMPOSITE GRAFT

Aortic valve

LA

RVOT

True lumenBS 25

Composite graft

Leakage into the false aneurysm

Composite Graft with Open Technique

Composite Graft with Open Technique

Myocardial Protection inAscending Aortic Surgery

Zurich 2003

• Systemic hypothermia 280C

• Begin with retrograde cardioplegia, cross-clamp and arrest with antegrade perfusion directly into coronaries (except in acute Type A).

• Continuos retrograde cold oxygenated blood @ 160C throughout procedure.

• Warm reperfusion (“hot shot”)

Copyright ©2007 The Society of Thoracic Surgeons

Etz C. D. et al.; Ann Thorac Surg 2007;84:1186-1194

Schematic drawing of mechanical (n = 126 patients; 61%) and biologic (n = 80 patients; 39%) valved composite grafts used for aortic root replacement using a modified Bentall

technique

BUTTON TECHNIQUE FOR COMPOSITE GRAFT REPAIR

From Barbeau et al, Ann Thor Surg 1999

Axillary Artery Cannulation: Essential in Arch Procedures and Acute Type A

http://www.mpoullis.net/bscpb/cpb/blank.htm

Bavaria et al., Ann Thor Surg 2003

Hemiarch Bentall ProcedureSubclavian/Innominate Artery Perfusion Technique

• Monitor left and right radial, and femoral artery pressure.• Cannulation of subclavian/innominate artery.• Cool patient to 280 C.• Cross clamp innominate and left carotid, block left

subclavian artery with balloon, perfuse upper body with 10 ml/kg, and administer antegrade and retrograde CPL.

• Perform distal anastomosis first, clamp the graft and resume body perfusion.

• Perfrom proximal part of the operation (valve and coronaries).

• Re-anastomose proximal and distal graft segment.

CABROL’S TECHNIQUE FOR DECOMPRESSION OF PERIGRAFT SPACE

J Thorac Cardiovasc Surg 81:309-315, 1981

CABROL’S ORIGINAL DESCRIPTION OF CORONARY ANASTOMOSISJ Thorac Cardiovasc Surg 81:309-315, 1981

Modifications of Button Technique

Hilgenberg et al, Ann Thor Surg 1996

Pratali et al, Tex Heart Inst J 2000

Copyright ©2011 The Society of Thoracic Surgeons

Malekan R. et al.; Ann Thorac Surg 2011;92:362-363

Completion Bentall procedure

Two common errors in ascending aortic surgery:

•Timid resection of aneurysm (instead of going into arch)

•Use too long graft (they all lengthen and distend with time,

some up to 20 – 30 % of diameter)

Ha H I et al. Radiographics 2007;27:989-1004

©2007 by Radiological Society of North America

Keep you graft short, it expands and lengthens with time!

Potential Source of Recurrencies: Distal Anastomosis in Ascending Aorta

(Instead in Arch)