P177. Institutional Experience of Post-Dissection Repair Aortic Root Pseudoaneurysms and an Algorithm for Treatment
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
University of Colorado Anschutz
Denver, CO
United States - Contact Me
Adam Carroll is a current PGY-3 surgical resident at the University of Colorado. Adam attended medical school at the University of Colorado and has been involved in research with the cardiothoracic surgery department throughout medical school and residency. He has interest specifically in endovascular and transcatheter aortic interventions, as well as neurologic outcomes in aortic research. He is currently in the aortic surgery research labaratory in the Department of Cardiothoracic Surgery at the University of Colorado. He plans to pursue a career in cardiothoracic surgery following his general surgery residency.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objective:
Aortic root pseudoaneurysms (PSA) are recognized complications after arch surgery for type A dissection, often related to the dehiscence of suture lines and cannulation sites. Management of PSA is complex due to the necessity to operate in a prior surgical field and the potential proximity of the pseudoaneurysm to the posterior sternal table. While open repair allows for definitive treatment, endovascular repair has been employed as an alternative. Furthermore, in our experience, surveillance may be a viable strategy in select patients. We describe our institutional experience with post-dissection aortic root pseudoaneurysms and propose an algorithm for treatment.
Methods:
A prospectively maintained institutional database was used to identify patients over the last 10 years who presented with aortic root pseudoaneurysms after arch surgery for aortic dissection. We describe the temporal relationship of their presentation to their index surgery, subsequent management strategy and outcomes. Based on our institutional experience we developed an algorithm for treatment.
Results:
In total, 31 patients were identified who had a root pseudoaneurysm post aortic-dissection repair. The majority of these patients underwent open surgical repair (27, 87.1%), with two having recurrence of their pseudoaneurysms following. In most cases open repair was selected due to concomitant pathology, with the majority of patients undergoing adjunct hemiarch (3, 11.1%), or total arch (18, 66,7%). Given the significant scar tissue present, pulmonary artery repair after iatrogenic injury was frequently required (7, 25.9%), with high rates of open chest (7, 25.9%) post-operatively due to coagulopathy (7, 25.9%). Notable post-operative complications included stroke (4, 14.8%), prolonged ventilation (4, 14.8%), and mortality (3, 11.1%).
Six patients were selected for endovascular management; three patients with a remote history of dissection, and three patients with a prior root replacement within the year prior to intervention, two of whom were from the above cohort. Four patients underwent successful endovascular repair; two with a transfemoral approach, and two with a transapical approach. In both unsuccessful attempts, the PSA tract was unable to accessed via either approach. Following successful endovascular repair, post-operative course was uncomplicated with minimal hospital stay. One procedure was converted to open and underwent successful open root replacement, and the other had a stable PSA at two years until he was lost to follow-up. Currently one patient is being surveyed for their PSA, who wanted to avoid further intervention and had a small root PSA, with stable imaging at three years. Based on our experience we developed an algorithm for treatment of aortic root pseudoaneurysm post aortic-dissection (Figure 1).
Conclusions:
Management of aortic root PSA carries a high risk of morbidity and mortality. Patients are typically complex, and due to a re-operative field are at high risk of bleeding and coagulopathy. In general, in the setting of isolated root pseudoaneurysm, we recommend an endovascular approach first to minimize morbidity. If unsuccessful, or in the setting of other pathology that can not be managed with an endovascular approach, open root replacement can be performed in suitable candidates. In select patients with stable, small pseudoaneurysms, close surveillance may be considered.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Elizabeth Devine (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
Aortic root pseudoaneurysms (PSA) are recognized complications after arch surgery for type A dissection, often related to the dehiscence of suture lines and cannulation sites. Management of PSA is complex due to the necessity to operate in a prior surgical field and the potential proximity of the pseudoaneurysm to the posterior sternal table. While open repair allows for definitive treatment, endovascular repair has been employed as an alternative. Furthermore, in our experience, surveillance may be a viable strategy in select patients. We describe our institutional experience with post-dissection aortic root pseudoaneurysms and propose an algorithm for treatment.
Methods:
A prospectively maintained institutional database was used to identify patients over the last 10 years who presented with aortic root pseudoaneurysms after arch surgery for aortic dissection. We describe the temporal relationship of their presentation to their index surgery, subsequent management strategy and outcomes. Based on our institutional experience we developed an algorithm for treatment.
Results:
In total, 31 patients were identified who had a root pseudoaneurysm post aortic-dissection repair. The majority of these patients underwent open surgical repair (27, 87.1%), with two having recurrence of their pseudoaneurysms following. In most cases open repair was selected due to concomitant pathology, with the majority of patients undergoing adjunct hemiarch (3, 11.1%), or total arch (18, 66,7%). Given the significant scar tissue present, pulmonary artery repair after iatrogenic injury was frequently required (7, 25.9%), with high rates of open chest (7, 25.9%) post-operatively due to coagulopathy (7, 25.9%). Notable post-operative complications included stroke (4, 14.8%), prolonged ventilation (4, 14.8%), and mortality (3, 11.1%).
Six patients were selected for endovascular management; three patients with a remote history of dissection, and three patients with a prior root replacement within the year prior to intervention, two of whom were from the above cohort. Four patients underwent successful endovascular repair; two with a transfemoral approach, and two with a transapical approach. In both unsuccessful attempts, the PSA tract was unable to accessed via either approach. Following successful endovascular repair, post-operative course was uncomplicated with minimal hospital stay. One procedure was converted to open and underwent successful open root replacement, and the other had a stable PSA at two years until he was lost to follow-up. Currently one patient is being surveyed for their PSA, who wanted to avoid further intervention and had a small root PSA, with stable imaging at three years. Based on our experience we developed an algorithm for treatment of aortic root pseudoaneurysm post aortic-dissection (Figure 1).
Conclusions:
Management of aortic root PSA carries a high risk of morbidity and mortality. Patients are typically complex, and due to a re-operative field are at high risk of bleeding and coagulopathy. In general, in the setting of isolated root pseudoaneurysm, we recommend an endovascular approach first to minimize morbidity. If unsuccessful, or in the setting of other pathology that can not be managed with an endovascular approach, open root replacement can be performed in suitable candidates. In select patients with stable, small pseudoaneurysms, close surveillance may be considered.
Authors
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Elizabeth Devine (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions
(1) University of Colorado Anschutz, Denver, CO
Presentation Duration
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