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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)