Today let's discuss some of the various ways aneurysms and dissections of the aortic arch can be repaired with some images!
Recall the basic anatomy of our beloved vessel:
The aorta is an elephant trunk-like vessel that has an ascending part that connects right to the heart, then an arch and a descending part that goes down the body.
Also important noting is that at the top of the aorta, three very important "great" vessels come off including the brachiocephalic (innominate), left common carotid, and left subclavian, and are very important for supplying blood to the top half of your body including the brain.
Depending on where one develops their aneurysm or dissection, different repair techniques can be deployed:
Hemiarch repair: this is one of the most common approaches for management of acute aortic dissection that include the ascending aorta without involvement of the great vessels. Here the surgeon cuts away the diseased tissue and sutures in a new Dacron synthetic graft.
2. Total Arch Replacement: in some patients aortic disease may extend beyond the ascending aorta and involve the transverse arch (the part of the vessel where it starts to curve. In this situation, a larger section of aorta is cut out and the great vessels are sewn back into the graft body to feed the brain.
3. Elephant Trunk: in a subset of complex patients, aortic disease includes both the transverse aortic arch as well as some tissue in the lower (Descending part) of the aorta. These patients are difficult to manage surgically as the lower part of the aorta is difficult to visualize in class surgery through the chest. In the Elephant Trunk approach, a 2-stage repair is organized:
1 - First the diseased aortic arch is cut out and replaced with new synthetic graft. However, the surgeon will leave behind some "Extra" free-floating graft in the aorta to prepare for stage 2:
2 - Elephant trunk that was left behind in stage 1 can be controlled and used for extension of the graft.
Note - there is a modification of the elephant trunk technique called the Frozen Elephant Trunk which can be done in just one stage. Here, the surgeon replaces the damaged ascending aorta, followed by the immediate deployment of a stent graft through the open aortic arch in the same operation.
And that's a wrap for this week! Try to familiarize yourself with these surgery descriptions and images. Visualize what the benefits and utilities of each kind would be! And remember to join us next week as we discuss some hybrid arch repair strategies to manage aortic disease!
Until then, enjoy the summer my friends and remember to always - Think Aorta!
Adham
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