Aortic Arch Pathology

A new minimal invasive technique with in-situ stent-graft fenestration for type A aortic dissection

Background

Aortic surgery successfully improves the prognosis of patients with type A aortic dissection. However, total arch replacement and reconstruction remain challenging. This study presents a new surgical modality, the in-situ stent-graft fenestration (ISSF) technique, for simplifying aortic arch reconstruction and assesses its short-term efficacy and safety in patients with type A aortic dissection.

Methods

Data from 177 patients with type A aortic dissection who underwent aortic arch reconstruction were retrospectively analyzed. Sun's procedure was performed in 90 patients and ISSF was performed in the other 87.

Results

The in-hospital mortality rate was 7.8% in the Sun's procedure group and 3.4% in the ISSF group (p = 0.357). Compared to the Sun's procedure group, the ISSF group had significantly shorter surgical duration, cardiopulmonary bypass time, circulatory arrest time, mechanical ventilation time, and aortic cross-clamp time (p < 0.05). Additionally, intraoperative blood loss was lower in the ISSF group than in the Sun's procedure group (p < 0.05). Patients who underwent ISSF also had a lower incidence of postoperative complications, including lung injury, renal failure, peripheral nerve injury, and chylothorax, than those who underwent Sun's procedure (p < 0.05). During the 6-month follow-up period after surgery, both groups showed significant improvements in the true lumen diameter of the descending thoracic aorta post-operation compared with the pre-operation measurements; meanwhile, the false lumen diameter decreased (p < 0.05).

Conclusions

The ISSF technique appears to be an effective and safe alternative to conventional surgical procedures for patients with type A aortic dissection, with the potential to simplify the procedure, shorten the operation time, and yield satisfactory operative results. However, further investigation is needed to determine its long-term benefits.

Postoperative imaging of thoracic aortic repairs

Imaging plays a crucial role in the postoperative monitoring of thoracic aortic repairs. With the development of multiple surgical techniques to repair the ascending aorta and aortic arch, it can be a daunting challenge for the radiologist to diagnose potential pathologies in this sea of various techniques, each with their own normal postoperative appearance and potential complications. In this paper, we will provide a comprehensive review of the postoperative imaging in the setting of thoracic aortic repairs, including the role of imaging, components of thoracic aortic repairs, the normal postoperative appearance, and potential complications.

Evaluation of Different Cannulation Strategies for Aortic Arch Surgery Using a Cardiovascular Numerical Simulator

Aortic disease has a significant impact on quality of life. The involvement of the aortic arch requires the preservation of blood supply to the brain during surgery. Deep hypothermic circulatory arrest is an established technique for this purpose, although neurological injury remains high. Additional techniques have been used to reduce risk, although controversy still remains. A three-way cannulation approach, including both carotid arteries and the femoral artery or the ascending aorta, has been used successfully for aortic arch replacement and redo procedures. We developed circuits of the circulation to simulate blood flow during this type of cannulation set up. The CARDIOSIM© cardiovascular simulation platform was used to analyse the effect on haemodynamic and energetic parameters and the benefit derived in terms of organ perfusion pressure and flow. Our simulation approach based on lumped-parameter modelling, pressure-volume analysis and modified time-varying elastance provides a theoretical background to a three-way cannulation strategy for aortic arch surgery with correlation to the observed clinical practice.

National Outcomes of Elective Hybrid Arch Debranching with Endograft Exclusion versus Total Arch Replacement Procedures: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

OBJECTIVE

 Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement.

METHODS

 The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models.

RESULTS

 A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p < 0.001) and preoperative dialysis (1.7 vs. 4.7%; p = 0.026), but similar history of stroke (p = 0.91)/cerebrovascular disease (p = 0.52). TAR patients had more concomitant procedures (60 vs. 34.6%; p < 0.0001). TAR patients had lower mortality (6.7 vs. 12.6%; p = 0.02), stroke (6.9 vs. 15%; p = 0.002), paralysis (1.8 vs. 7.1%; p = 0.002), renal failure (4.6 vs. 8.7%; p = 0.045), and STS morbidity (34.2 vs. 42.5%; p = 0.067). Composite mortality, stroke, and paralysis were significantly lower with TAR (11.5 vs. 25.2%; p = 0.0001). After risk adjustment, analysis showed hybrid arch procedures imparted an increased odds of mortality (odds ratio [OR] = 1.91, p = 0.046), stroke (OR = 2.3, p = 0.005), and composite endpoint of stroke or mortality (OR = 2.31, p = 0.0002).

CONCLUSION

 TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.

CT of Postoperative Repair of the Ascending Aorta and Aortic Arch

While many of the classic open surgical repairs are still used to repair the ascending aorta, management of the aortic arch has become more complex via implementation of newer open surgical and endovascular techniques. Furthermore, techniques are often combined in novel repairs or to allow extended anatomic coverage. As such, a framework that rests on understanding the expected postoperative appearance is necessary for the diagnostic radiologist to best interpret CT studies in these patients. After reviewing the imaging appearances of the common components used in proximal aortic repair, the authors present a structured approach that focuses on the key relevant questions that diagnostic radiologists should consider when interpreting CT studies in these patients. For repair of the ascending aorta, this includes determining whether the aortic valve has been repaired, whether the sinuses of Valsalva have been repaired, and how the coronary arteries were managed, when necessary. In repairs that involve the aortic arch, the relevant considerations relate to management of the arch vessels and the distal extent of the repair. In focusing on these questions, the diagnostic radiologist will be able to identify and describe the vast majority of repairs. Understanding these questions will also facilitate improved understanding of novel repairs, which often use these basic building blocks. Finally, complications-which typically involve infection, noninfectious repair breakdown, hemorrhage, problems with endografts, or disease of the remaining adjacent aorta-will be identifiable as deviations from the expected postoperative appearance. Online supplemental material is available for this article. ^©RSNA, 2021.

Mimics of Complications in the Postsurgical Aorta at CT

Various surgical techniques of the aorta result in expected imaging appearances on CT images that resemble complications such as pseudoaneurysm, perigraft abscess, and dissection. Awareness of these techniques, understanding the clinical situation in which they are performed, and familiarity with the typical appearances and locations of these mimics are essential for accurate interpretation. CT imaging techniques such as electrocardiographic gating and inclusion of a precontrast series can help distinguish an expected postsurgical finding from a complication. Information in the medical record, particularly the operative note, can clarify challenging cases with unusual imaging features. This review article provides examples of expected postsurgical findings at CT mimicking complications. © RSNA, 2019.