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

Wed Mar 26 21:44:55 EDT 2008

Thanks, Tom. 
It would certainly help if, as Bob would remind us, we could see what we are talking about...
In which case I might seem even more ridiculous than usual.

tea

----- Original Message ----
From: "tdmartin2000 at aol.com" <tdmartin2000 at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, March 26, 2008 10:13:34 PM
Subject: Re: [HSF] yikes..... post aortic dissection distal pseudoaneurysm

Tea

I don't follow your math at all- guess that's cause I'm an Aggie. I do know that the natural history of pseudoaneurysms is one of progression and eventual rupture in 100% of cases. I also know that aneurysms and chest pain are a cause for concern and unless you can find another source of the pain then you have to assume it's coming from the aneurysm. Michael has described for us a "symptomatic pt" with chest pain and SOB. He also described mild to moderate AI. I guess you could wait another 6 mo, hope he doesn't die, doesn't develop severe CHF and be in and out of the ER once a month or so and THEN operate on him (assuming he is alive). Or you could sit down and talk to the family and the pt and make sure they know the magnitude of his problem, the natural history of those problems and the opertion or operations (gently dilated rest of the aorta5-6cm) necessary to correct his problems and then let them decide. Everybody is different and makes choices
 different.
But, if I was just treating the aortic pathology alone, I still say he need an operation and that it can be done with very good success.

Tom Martin
U of Florida
Gainesville

-----Original Message-----
From: Tea Acuff <tacuff at swbell.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 26 Mar 2008 12:10 am
Subject: Re: [HSF] yikes..... post aortic dissection distal pseudoaneurysm

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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