[HSF] yikes..... post aortic dissection distal pseudoaneurysm

Tea Acuff tacuff at swbell.net
Wed Mar 26 20:46:42 EDT 2008 

I am glad we can agree generally on the problems this case presents. You asnwered well as to what is gained by a delay of a year or so before one is forced to "treat" this patient. If indeed he is quite likely to decompensate, then push ahead. However, for the proponents for early treatment regardless, what do they plan to do (gain) with their up coming year?

tea



----- Original Message ----
From: David Harris <drdharris at yahoo.co.uk>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, March 26, 2008 6:08:21 PM
Subject: RE: [HSF] yikes..... post aortic dissection distal pseudoaneurysm

I am not sure that this patient was `short changed` by
his previous operation. Steve Westerby has good data
on mortality for Type A dissection. Mortality being
increased substantially by unneccessarily replacing
arches and roots in these patients, rather than doing
a quick simple op and giving him a chance to live and
fight another day. 

I agree with Tea. There is good reason to hesitate
before having this op. You only have one chance! If
the patient is the 10%, then he could have had a
wonderful time in a year, blown all his money,
travelled the world, etc. Before dying with a second
scar on his chest.

It looks like the only real indication for this op is
the `pseudoaneurysm` at the isthmus. This was not the
result of short change, but can happen at the distal
anastomosis of any graft. Nevertheless it will have to
be fixed by a big op. The aortic valve in isolation
does not need replacement if the leak is mild. The
descending aorta in isolation is in the borderline
indication for replacement.

A carotid-carotid graft, with stent over the aneurysm
would be a good option. The problem is that thrombus
in the aorta is considered a contra indication for
endovascular repair. Also with a patent subclavian the
risk of endoleak is there. Perhaps this would be the
safest option (depending if aota is small enogh at
this region), and if succesful the descending aorta
could be monitored. Otherwise I think the best would
be a formal thoraco-abdominal repair. Proximal control
will be difficult, and hypothermic arrest will
possibly be needed. In addition with the aortic
regurg, the heart will distend, and an apex vent will
be needed. If hypothermic arrest needed you will also
need to cardioplege the heart. 

Due to technical factors this op will have high
mortality than 10%. Also it is a Crawford II thoraco,
which carries a 15% paraplegia risk in Houston (less
than 5% overall).

If I was the patient I would seriously consider taking
the whisky, wait and see what happens, and only rush
to hospital if I develop severe backache.

This is a case to send to someone doing these cases
regularly.

Dave Harris




--- Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> But Tea in this case the do nothing (medical therapy
> we call it) is particularly lethal. 
>  
> Without access to data, it is difficult to see how
> this 62 year olds life expectancy can be better
> without surgery. Provided he has no comorbidity
> (stroke was presumably related to dissection or
> surgery and is distant) most aortic centers would
> undertake this procedure with a mortality risk of no
> more than 10% (but adding another 10 to 15% though
> if he needs a two stage procedure i.e elephant trunk
> then TAA). I do not know about endovascular
> 'solutions'.
>  
> I do not see what a 3 to 6 month follow-up would
> achieve here as the patient already has
> 'indications' for surgery and his condition cannot
> by definition improve on medical therapy. Unless of
> course we deem that the condition is inoperable or
> that the risks outweigh the benefits - but even then
> what would the follow-up achieve (unless you expect
> to modify either the risk or benefit over the 3 to 6
> month period)?
>  
> This patient was short-changed at his first
> operation. He was fortunate to have his life saved
> for 6 years but was not given a lasting solution -
> while that is preferable to death, more preferable
> would have been a more lasting solution at the first
> surgery. I was at a meeting recently and the theme
> seems to be that because we are treating an often
> lethal condition, any operation that attempts to
> save life is acceptable at whatever outcome. This is
> in preference to driving excellence in this
> procedure and improving outcomes (for example
> demanding we replace the root and arch when
> indicated). So Type A dissection remains one of
> those forgotten diseases - many have their lives
> 'saved' but will in the medium-term have a relapse
> of their vascular disease. Overall I suspect the
> life expectancy of patients with Type A will be much
> better if they all had a complete and durable
> operation (and not just a focus on immediate life
> saving), even if it means transferring patients
> elsewhere (and we should not say that is unsafe - I
> suspect the majority of patients with type A are not
> operated at the first hospital they present) - than
> the present approach where the first surgeon who
> gets hold of it does the best operation they know
> how to do.
>  
> PS - rabies therapy is painful too. Certainly given
> a choice at age 11 I would still chose an arch
> operation at 62 years in preference to 3 weeks of
> intraperitoneal injections at age 11....economists
> call that 'time preference'.
>  
> Ani
>  
>  
> 
> 
> 
> > Date: Tue, 25 Mar 2008 21:10:11 -0700> From:
> tacuff at swbell.net> Subject: Re: [HSF] yikes.....
> post aortic dissection distal pseudoaneurysm> To:
> OpenHeart-L at lists.hsforum.com> CC: > > His now 100%
> mobidity from his first operation, when combined
> with his 10% mortality for the next one equals in
> Mike math, 110%.> > But , Tom, straight up. What do
> you think the likelyhood, knowing only the present
> data, that his chest pain is due to his aorta or an
> easier end point that he will become acutely
> symptomatic within the next 12 mouths? > Wouldn't a
> followup in 3-6 months have prognostic value? What
> are the odds that his current SOB is related to 1-2+
> AI? > > This is a rock from a glass house. I have
> operated myself, probably often enough, where there
> are criteria but after a poor outcome I wonder
> whether there were strong enough. And unlike Ani's
> refusal of the rabies shot our therapy is not only
> painful, but lethal.> > > tea> > > ----- Original
> Message ----> From: "tdmartin2000 at aol.com"
> <tdmartin2000 at aol.com>> To:
> OpenHeart-L at lists.hsforum.com> Sent: Tuesday, March
> 25, 2008 9:54:28 PM> Subject: Re: [HSF] yikes.....
> post aortic dissection distal pseudoaneurysm> > >
> Michael> > Sounds like one of our usual patients. I
> would really need to see the films, but from what
> you describe what this guy needs is a reop with
> removal of his previous graft, AVR or possible root
> or maybe a valve sparing procedure depending on the
> root and valve anatomy, and either an elephant trunk
> or a arch debranching with bypass grafts to the
> innom and carotid, creating a landing zone for a
> future stent graft for the descending. If he has no
> available landing zone near his celiac then an
> thoracoabdominal resection/repair would most likely
> be in his future. At 62, as long as he doesn't have
> any horrible comorbidities, his in hospital survival
> will be in the 90% range.> > Good luck.> > > > Tom
> Martin> > U of Florida> > Gainesville> > >
> -----Original Message-----> From: Michael
> Firstenberg <msfirst at gmail.com>> To:
> OpenHeart-L at lists.hsforum.com> Sent: Tue, 25 Mar
> 2008 3:36 pm> Subject: [HSF] yikes..... post aortic
> dissection distal pseudoaneurysm> > > > > I admitted
> a symptomatic (chest pain and SOB) 62 year/old who
> had an Type I> repair done in 2002. Per the patient,
> he had a very prolonged> post-operative course -
> including a CVA which left him with a significant>
> right sided weakness.. At the time, he had a tube
> graft with resuspension> of the aortic valve, a RCA
> bypass, and a beveled graft to under the arch.> He
> now has a moderate size pseudoaneurysm at the
> isthmus of the underside of> the arch where the
> graft is attached to the native aorta. In the OP
> note> the surgeon describes using a bunch of bioglue
> in that area to get the> dissected layers back
> together. The remainder of his aorta is gently>
> dilated (~5-6 cm) with a chronic hematoma all the
> way down to his> bifurcation.> > On an echo he has
> mild to moderate AI with a good EF.> > We are
> currently thinking a stent graft, but not sure there
> is an> appriopriate landing zone as this is right
> under the head vessels and there> is not much room
> between the LCC and LSC.> > Unfortunately, none of
> the open operations/approaches sound good for this>
> guy.> > (left heart bypass, hypothermia - poss circ
> arrest, TAAA?)> > > any thoughts or pearls which are
> not associated with an 110% M&M?> > > -michael> >
> (one of our experiences vascular surgeons suggested
> lots of beta-blockers> and a good bottle of scotch)>
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Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411            
Fax +27-21-9006412      Mobile +27-83-3309587
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