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

Thu Mar 27 07:35:50 EDT 2008

This is a brief comment even for you, Bill.

tea

----- Original Message ----
From: "wftjrtyler at aol.com" <wftjrtyler at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, March 27, 2008 6:17:53 AM
Subject: Re: [HSF] yikes..... post aortic dissection distal pseudoaneurysm

In a message dated 3/26/2008 10:19:36 P.M. Central Daylight Time,  
tdmartin2000 at aol.com writes:

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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Michael,Send him to Gainesville(if Tom's not huntin' 'gators)......bill  
turner

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