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

Fri Mar 28 01:41:03 EDT 2008

Tea

My thesis does not concern aortic surgery or surgical specialization per se but management of surgical emergencies. In the traditional model the belief was that the first doctor who sees a patient with a life threatening condition should exert therapy and that this therapy is better than death. For example this could mean you - a cardiac surgeon - performing a cesarean section on a patient in obstructed labor rather than moving the patient to the maternity hospital. This is the way surgery was practiced historically - indeed in Africa where I trained, doctors straight out of medical school would regularly perform surgical 'emergencies' without surgical training on the premise that that in emergency any doctor is better than none.

While we do not have data for aortic dissection, there are examples from other areas of surgery. For example, the treatment of ruptured abdominal aorta (due to aneurysm). In the 1970s and 1980s where such patients presented to an emergency room the treatment would be to find a surgeon - any surgeon - to open the belly and apply a clamp to safe life. The result is that many patients got operated by general surgeons who had no elective vascular practice. Most of these patients died - about a third survived. Whereas in the hands of vascular surgeons the reverse was the case - two thirds survived. A study performed in Oxford, UK compared two strategies - immediate operation by on call local surgeon to transfer to a vascular surgeon (locally or elsewhere) and found that transferring patients to a specialist had far better survival (considering all cause deaths including those who died during surgery). This is the model adopted in most countries today and it is thankfully rare to have non-vascular surgeons operating on this condition. Several other examples exist in emergency surgery, another being the use of emergency burr-holes in patients with suspected extradural hemorrhage which has been superceded by immediate referral to a neurosurgery center.

I think the same needs to be extended to type A dissection if we are to improve the outcomes for patients with this condition. I am not an aortic surgeon so do not make this argument from an expert-based view, but I have seen several patients die in the hands of non-aortic 'specialists' with this disease - at least five for example because of unnecessary delay in operating by requesting repeat imaging, several because of hemorrhage etc and also I have seen many referred to our aortic center with mid-term complications such as in michaels patient. Roberto might help but I think they have a model not too dissimilar to what I suggest in Liepzig and they receive dissections from a very large catchment area allowing them to deliver high level therapy with excellent outcomes for a disease that on a global scale continues to have a high surgical mortality.

Ani

> Date: Thu, 27 Mar 2008 07:11:21 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] yikes..... post aortic dissection distal pseudoaneurysm> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani wrote:> "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"> > > That is the theory, but large centers see many of the complications (whatever that presentage 10-90%, it makes a hugh difference) and us little guys almost never see these problems. Is this like the simple AVR data verses root cause I can? Is there any good data or just Kodak moments? If the latter, we shouldn't make light of "saving lives", nor assume only the referal centers are making a positive difference in peoples live. > > I believe our difference on this point, Ani, since we have it in many contexts is largely epistemological and not data or factual. I will try to address this philosophical issues in a few postings as i think we (collectively) spend a huge amount of time stumbling over this issue, when we might could avoid error if we at least predict the dead ends that we think ourselves into. Again this is not an argument that i am "correct" about any particular subject which in this posting happens to be aortic surgery. > > tea> > ----- Original Message ----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: openheart-l at lists.hsforum.com> Sent: Wednesday, March 26, 2008 5:58:33 AM> Subject: RE: [HSF] yikes..... post aortic dissection distal pseudoaneurysm> > 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)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim>> -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _________________________________________________________________> Win 100’s of Virgin Experience days with BigSnapSearch.com> http://www.bigsnapsearch.com_______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and> disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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