Radiological Society of North America, RSNA 2013
Refresher Course Program: Vascular Track
RC 112 – Thoracic Aorta: Key Concepts:
Surgical Procedures and
Complications
Surgical Procedures and Complications
Learning objectives – Outline
•Epidemiology / Etiology
•Surgical anatomy of thoracic aorta
•Clinical topics
spectrum of TA aneurysms
Dominik Fleischmann
Department of Radiology
Stanford University
www.stanford.edu / ~dominikf / RSNA /
Thoracic Aortic Aneurysms (TAA)
(from Greek ανευρυσμα, a dilatation)
Incidence:
TAA: 6 / 100,000 (<10% of aortic aneuryms)
Natural history / prognosis
• rupture in 32-68% of untreated pts
rupture mortality 54% (6h), 76% (24h)
• initial size is only independent predictor of
rate of growth and rupture
< 5 cm diameter 'low risk'
< 2.75cm/m2 BSA: less than 4% annual risk
Atherosclerotic (degenerative)
Aneurysm
surgical procedures
pre- / postoperative imaging
www.stanford.edu / ~dominikf / RSNA /
Thoracic Aortic Aneurysms (TAA)
Etiology and associated conditions
•atherosclerotic
•genetic (congenital wall defect)
Marfan's
Bicuspid aortic valve
•chronic dissection
•infectious ('mycotic', syphilis)
•vasculitis
•post-traumatic
very
common
rare
75 y o woman
w. atherosclerotic
aneurysm of the
thoracic aorta
(normal root)
Descending TAA
1
BAV disease
33 yo woman
Marfan's Disesase
gated chest
(bicuspid aortic valve disease)
Aortic root aneurysm
Thoracic Aortic Aneurysms (TAA)
Thoracic Aortic Aneurysms (TAA)
Etiology and associated conditions
Etiology and associated conditions
Marfan's
Bicuspid aortic valve
very
common
•chronic dissection
•infectious ('mycotic', syphilis)
•vasculitis
•post-traumatic
rare
Surgical Procedures and Complications
Learning objectives – Outline
•Epidemiology / Etiology
•Surgical anatomy of thoracic aorta
•Clinical topics
•atherosclerotic
•genetic (congenital wall defect)
Marfan's
Bicuspid aortic valve
aortic root
aneurysms
•chronic dissection
•infectious ('mycotic', syphilis)
•vasculitis
•post-traumatic
rare
Thoracic Aorta
Surgical Anatomy
Transverse Arch
Aortic
Isthmus
Descending Aorta
Transverse Aorta
Ascending Aorta
Aortic Root
Ao. Root
•atherosclerotic
•genetic (congenital wall defect)
Aortic spindle
(ductus bump)
spectrum of TA aneurysms
surgical procedures
pre- / postoperative imaging
www.stanford.edu / ~dominikf / RSNA /
* Sino-tubular Junction
# Sinuses of Valsalva
2
Thoracic Aorta
Transverse Arch
Surgical Anatomy
Descending Aorta
Transverse Aorta
Transverse Aorta
Ascending Aorta
Ascending Aorta
Aortic Root
Ao. Root
Descending Aorta
Aortic Root
Arch
* Sino-tubular Junction
# Sinuses of Valsalva
* Sino-tubular Junction
# Sinuses of Valsalva
• 73 y/o retired RN
Thoracic Aorta
Surgical Anatomy
Transverse
Ao. Root
Thoracic Aorta
Surgical Anatomy
Transverse Arch
ascending aortic aneurysm
Descending Aorta
Transverse Aorta
Aortic Root
• Sinotubular junction
• Sinuses of Valsalva
Ao. Root
Ascending Aorta
Ao. Root
aortic valve
coronary ostia
Sino-tubular Junction
Sinuses of Valsalva
Aortic Anulus
• Aortic anulus
* Sino-tubular Junction
# Sinuses of Valsalva
• 73 y/o retired RN
ascending aortic aneurysm
MIP (thin-slab) centered at valve
• 73 y/o retired RN
ascending aortic aneurysm, root dilatation
MIP (thin-slab) centered at valve
3
Preoperative and post-operative Aorta:
3D measurements and documentation
• 3D thoracic Aorta
•
VR (candy-cane view)
• Measurements
•
•
•
•Epidemiology / Etiology
•Surgical anatomy of thoracic aorta
•Clinical topics
MIP (5mm) ~ a-p
MIP (5mm) ~ lat.
(MPR othogonal)
• Coronary Anatomy
•
spectrum of TA aneurysms
VR
• Sinuses + valve
•
•
•
Surgical Procedures and Complications
Learning objectives – Outline
surgical procedures
VR 'transparent'
MinIP (inverted)
3 Chamber view
pre- / postoperative imaging
www.stanford.edu / ~dominikf / RSNA /
Thoracic Aorta
Transverse Arch
Surgical Options
Aortic Root
• anulo-aortic ectasia (>27)
• aortic root aneurysm
• anulo-aortic ectasia
• aortic root aneurysm
if SOV, STJ (>40 mm)
Ao. Root
Aortic Root
SOV, STJ
Transverse Arch
Ao. Root
Thoracic Aorta
Surgical Terminology
• Sinus of Valsalva aneu.
(peds./congenital; in adults
inflammatory)
* Sino-tubular Junction
# Sinuses of Valsalva
Thoracic Aorta
Surgical Options
Transverse Arch
* Sino-tubular Junction
# Sinuses of Valsalva
41 yo man
Marfan's
• Anuloplasty
• Composite graft

Contains valve
Coronary reimplant.

ANTICOAGULATION

Ao. Root
Aortic Root
• Valve Sparing Surgery
* Sino-tubular Junction
# Sinuses of Valsalva
4
Thoracic Aorta
Surgical Options
Transverse Arch
Valve Sparing Aortic Root Procedures
Tirone David- I “Reimplantation” Technique
Aortic Root


Ao. Root
• Anuloplasty
• Composite graft
Contains valve
Coronary
reimplantation
• Valve Sparing Surgery
Resect sinuses down
to valve insertions
 Preserve (resuspend)
native valves
 Coronary reimpl.

* Sino-tubular Junction
'Yacoub'
# Sinuses of Valsalva
Surgical
procedure
41 yo man
Marfan's
Estimate
correct anulus diameter (d):
d=(hleaflet1.35) *
e.g. 18mm leaflet: 24mm anulus
*mod. from David & Feindel (1992): d=[(hleaflet2)x0.67]+(2Aowall)
Thoracic Aorta
Surgical Options
Transverse Arch
Aortic Root - synthetic
• Composite graft
• Valve Sparing Surgery
bioprosthetic
• pulm. Autograft
Ao. Root
POST-OP
(Ross Procedure)
• Homograft (cadaver)
• Xenograft (porcine)
5
32 y/o man, st.p. remote Ross (pulm.-to-aortic autograft)
Thoracic Aorta
Surgical Options
Transverse Arch
bioprosthetic
• pulm. Autograft
J Thor Cardiovasc Surg 2005
• Composite graft
• Valve Sparing Surgery
Ao. Root
Aortic Root - synthetic
(Ross Procedure)
• Homograft (cadaver)
• Xenograft (porcine)
Decellularized cryopreserved
aortic homograft
Thoracic Aorta
Thoracic Aorta
Transverse Arch
Surgical Options
Aortic Root - synthetic
Aortic Root
• Composite graft
• Valve Sparing Surgery
Ascending Aorta
• pulm. Autograft
Ao. Root
bioprosthetic
• tube graft
Transverse Aorta
Descending Aorta
Transverse Arch
Ao. Root
Surgical Options
(Ross Procedure)
• Homograft (cadaver)
• Xenograft (porcine)
Medtronic 'Freestyle'®
porcine root graft
Thoracic Aorta
Surgical Options
Transverse Arch
Surgical Options
Aortic Root
Ascending Aorta
Ascending Aorta
• tube graft
• tube graft
Transverse Aorta
• arch reconstruction w
Ao. Root
Aortic Root
island / peninsula for
supraaortic vessels
island / peninsula for
supraaortic vessels
• limbed graft
Descending Aorta
Transverse Aorta
• arch reconstruction w
Transverse Arch
Ao. Root
Thoracic Aorta
* Sino-tubular Junction
# Sinuses of Valsalva
• limbed graft
* Sino-tubular Junction
# Sinuses of Valsalva
Descending Aorta
* Sino-tubular Junction
# Sinuses of Valsalva
6
Thoracic Aorta
Surgical Options
Transverse Arch
Aortic Root
Transverse Aorta
• asc.+arch reconstr.
+ elephant trunk
Ao. Root
Ascending Aorta +
Descending Aorta repair
anticipated
* Sino-tubular Junction
# Sinuses of Valsalva
52 y/o woman with giant cell arteritis
52 y/o woman with giant cell arteritis
aortic root, ascending, arch and descending aneurysm
st.p. freestyle root, ascending and total arch repair, + elephant trunk
52 y/o woman with giant cell arteritis
52 y/o woman with giant cell arteritis
st.p. freestyle root, ascending and total arch repair, + elephant trunk
st.p. freestyle root, ascending and total arch repair, + elephant trunk
perfusion limb
(graft)
elephant
trunk
7
30 y/o woman, Marfans, chronic dissection, TAAA
Post-op Evaluation
62 y/o man
• s/p remote repair of
ascending ao
• s/p enlarging
pseudoaneurysm of
transverse aorta –
• recent surg. revision
Aneurysm
opened
 assess aortic graft
surgical site
descending TA, viewed from left lateral thoracotomy
Post-op Cardiac Evaluation
Left ventricular
pseudoaneurysm
(at cannulation
site for air
evacuation after
cardiocirc.
bypass)
Pseudoaneurysm of the aorta after surgical repair
Post-surgical Imaging
• know procedure:
leaks/dehiscence always at anastomosis
• non-contrast scan:
felt pledgets, strips, calcifications
• ECG gating:
if root involved, cine may be helpful
s/p Ross procedure (pulmonary-to-aorta autograft)
suspected leak/pseudoaneurysm on TEE
diastole
systole
8
Surgical Procedures and Complications
Summary
•Epidemiology / Etiology
•Surgical anatomy of thoracic aorta
•Clinical topics
spectrum of TA aneurysms
Radiological Society of North America, RSNA 2013
Refresher Course Program: Vascular Track
Thank you ...
DC Miller
RS Mitchell
M Fischbein
surgical procedures
pre- / postoperative imaging
www.stanford.edu / ~dominikf / RSNA /
www.stanford.edu / ~dominikf / RSNA /
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