Surgical treatment of thoracic aortic aneurysms. Personal experience.
U RubertiAttilio OderoA ArpesaniGiorgetti PlM CugnascaRampoldiAnguissola GbAlessandro MorbidelliR ScorzaS Selva
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A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.Keywords:
Thoracic aorta
Bentall procedure
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Saccular aneurysm
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Objective To evaluate the role of Doppler ultrasonic examination in diagnosing thoracic aorta aneurysm and dissection. Methods Twenty cases of thoracic aorta aneurysm or dissection were diagnosed by ultrasonography and identified by surgery and cardiovasography.The images,pathological and clinical data were synthetically studied. Results Among 20 cases,there were 7 cases of aneurysm (35%) and one of pseudoaneurysm (5%) located on the arch and descending aorta,7 cases of aneurysm (35%) and 5 cases of dissection (25%) on the ascending aorta.One case was misdiagnosed.The diagnostic accuracy was 95%. Conclusions Ascending aorta aneurysms were usually seen in Marfan′s syndrome,while all aneurysms on the arch and descending aorta were caused by atherosclerosis.For patients suffering from dissection,color Doppler ultrasonography had special value in detection of true-false lumen and finding of break site on the endomebrane.
Thoracic aorta
Descending aorta
Pseudoaneurysm
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Digital subtraction angiography
Thoracic aortic aneurysm
Thoracic aorta
Image subtraction
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Bentall operation was performed for the ascending aortic dissection in the patient of a 70-year old man, who had undergone aortic valve replacement (AVR) for aortic valve regurgitation 7 years ago. At the AVR, the diameter of the ascending aorta was 50 mm on CT. During the follow up period after AVR, the ascending aorta was gradually developed to 95 mm in diameter without any symptoms. During the reoperation, entry was recognized on the prior aortotomy reinforced with felt-strips and the intimal flap was thickened. These situations suggested that the aortic dissection might be occurred just or early after AVR, and the reinforcement of aortotomy using felt-strips and AVR could not prevent progression of aortic root enlargement and dissection. From some previous reports about ascending aortic dissection after AVR, an adequate surgical treatment for a dilated ascending aorta (40-50 min) should be required at the same time of AVR.
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__Abstract__
Aortic disease represents one of the major causes of morbidity and mortality in the
industrialized society. Approximately 2% of all deaths are caused by aortic aneurysm and
dissections [1]. Aneurysms are defined as a local widening of the artery with more than
50 percent of the normal diameter [2]. An aneurysm can result in a fatal aortic rupture or
in an aortic dissection, which is a tear in the wall of the artery that causes blood to flow
between the layers of the wall and forces the layers apart [3]. Dissections involving the
ascending aorta, Stanford type A dissections, have a mortality rate of 1-2% per hour and
should be immediately treated surgically [4], while dissections occurring in the descending
aorta are usually treated medically and have an in-hospital mortality of about 10% [5].
However, an acute aortic dissection may also result in a rupture and with thoracic aortic
rupture mortality is very high, approximately 94 to 100%. Both diseases have principles and
techniques of surgical treatment in common. Surgery of aneurysms of the ascending aorta
and arch, the descending aorta, and the thoracoabdominal aorta has been associated with
a reduced operative mortality of respectively 2.9%, 3.0% and 11.9% between 1995 and
2004 [6]. However, the diagnosis of aneurysms and dissections is at the moment limited
to computed tomography and echocardiography, usually in late and severe stages of the
diseases. The main mechanisms by which these diseases occur are largely unknown. It is
thought that aneurysm formation is the result of changes in the extracellular matrix (ECM)
of the aortic wall and signaling pathways of the vasculature [3]. However, more insight into
the molecular mechanisms leading to aneurysm formation is required in order to identify
predisposing factors and new detection protocols for earlier detection of aortic aneurysms.
Descending aorta
Thoracic aorta
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In order to assess the respective values of two-dimensional echocardiography (2D echo) and computed tomography (CT) in the evaluation of aneurysms of the thoracic aorta, 14 patients with angiographically proven aneurysms of the thoracic aorta (three of which were dissecting aneurysms) were studied. The entire thoracic aorta was visualized in 10/14 patients by 2D Echo and in all patients by CT. An intimal flap was recognized by 2D echo in each case with a dissection whereas such a recognition was never possible with CT. CT identified calcification of the wall of an huge aneurysm of the ascending aorta in one case and a thrombotic stratification in the lumen of the descending thoracic aorta in another case; both abnormalities were missed by echocardiography probably because of inappropriate gain setting. In conclusion, 2D Echo and CT are both useful in the evaluation of aneurysms of the thoracic aorta: 2D echo appears to be superior in the recognition of an intimal flap due to dissection whereas CT allows a better recognition of the configuration, extension and tissue modifications of the aneurysm.
Thoracic aorta
Thoracic aortic aneurysm
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Thus far the only reported successful surgical efforts in cases of dissecting aneurysm of the thoracic aorta have been procedures which mimic nature's occasional cure and divert the false channel back into the aortic lumen. DeBakey, Cooley, and Creech have demonstrated that good results can be obtained by dividing the thoracic aorta in the area of dissection and repairing it in such a way as to close the inner and outer coats of the distal segment, leaving a window between the two proximally. They described one case in which a dissecting aneurysm was partially resected with suture of the homograft to the approximated inner and outer walls of the distal aorta and to the aorta above proximal to the site of dissection. Occasionally a patient survives a more or less limited dissection with a persistent aneurysm. It is the purpose of this communication to describe such a case treated by
Thoracic aorta
Thoracic aortic aneurysm
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Between 1969 and 1990, 119 patients underwent operations for aneurysmatic disease of the thoracic aorta in our department: 63 patients suffered from an aneurysm of the ascending aorta, 32 from an acute dissection (26 Type A, 6 Type B), 2 from an isolated aneurysm of the arch, 10 from an aneurysm of the descending aorta and 12 had a traumatic rupture of the aorta. The death rate due to operations for aneurysms of the thoracic aorta and acute type A dissections was clearly lowered. In case of an acute type A dissection emergency intervention is indicated; in acute type B dissection primarily conservative treatment.
Thoracic aorta
Descending aorta
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Objective To review the surgical results of aortic dissecting aneurysm. Method from June 1992 to June 1998,15 patients with aortic dissecting aneurysm underwent surgical treatment. The procedures performed included 6 Cabrol operation, 4 Bentall procedure, one of closure of dissection with aortic valvular plasty and 4of deviation bypassing the dissected aorta. Results There was 1 postoperative death with a mortality of 6 6%. The cause of death was leakage of the anastomosis of left coronary in Bentall procedure. Conclusion The modification of Cabrol operation could improve surgical outcome of type II aortic dissection aneurysm. A selfblood infusion system bypass is created in case of hemostatic failure between right atrium and aneurysmal sac sewn around the dacron graft. For type IIIa aortic dissection aneurysm, a dacron graft was implanted between ascending aorta and abdominal aorta to bypass the dissected aorta, the results are encouraging.
Bentall procedure
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Descending aorta
Thoracic aorta
Thoracic aortic aneurysm
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