Christopher Barreiro, M.D., reviews the history of aortic aneurysm surgery and repair and discusses the standard open surgical techniques used for arch aneurysm repairs and covers aortic pathologies. Dr. Barreiro also highlights cases that include arch aneurysm repair using less invasive hybrid techniques.
All right, so we're gonna get started. So this morning, thank you for having us first of all, and Dr Panettone and I are going to discuss surgical therapies for diseases of the thoracic aorta. I'm gonna first start off by reviewing some of the history of aortic aneurysms and surgery. I'm then gonna focus most of my talk about the standard open surgical techniques that have been used over the last 40 to 50 years. Uh, namely employing stern Artemis cardiopulmonary bypass and circulatory arrest to perform some of these difficult, complicated arch aneurysm repairs. Uh, I'm then going to shift gears a little bit and show a couple of case presentations, Um, that I performed with some of my vascular colleagues, uh, to perform these less invasive hybrid techniques, uh, to achieve the same results as the larger sort of more traditional operations. And then for the second half of the hour, I'm gonna turn it over to Dr Pan Aton. He's going to discuss some of his, uh, aortic practice and the endovascular techniques and trials that he's a part of. And then finally, we're gonna touch on the future of aortic intervention. Uh, namely some of the new and exciting arch branch graft, uh, trials, which allows to achieve the same sort of result at conquering these very complicated arch aneurysms, but at the same time avoiding stern Artemis altogether, which is pretty exciting. So before we get going, I just wanted to start with a short, inspirational video clip. Um, this is, uh this is from the movie City Slickers. In 1991 we might have attracted a larger grand round audience. And if I let everybody know that in slide to I was actually gonna give away the secret to life. Yeah. Do you know what the secret of life is? Know what? This. Your finger. One thing. Just one thing you stick to that and everything else don't mean shit. That's great. But what's the one thing? That's what you got to figure out. Mm. All right. So the point here, being in our pursuit of happiness, it's our job to find the one thing in life that we're passionate about. Which brings me to these two men. So no one can argue that these two surgeons are very passionate about what they do. The gentleman on the left, he is Dr Duke Cameron. Uh, he is a nationally recognized aortic surgeon, especially for his work in Val sparing aortic root replacements, as well as heading the Marfan Center for aortic disease at Johns Hopkins for many years before taking over his current role as the chief of aortic surgery at the Massachusetts General Hospital. And on the right is Dr John L. Cameron. He is, uh, he was the chair of of surgery at Johns Hopkins Hospital for nearly 20 years. Uh, he is a world renowned compatibility, every surgeon performing over 2000 Whipple operations during his career. So these two men found what they were passionate about in life and made it their career. Which brings me to one of my favorite quotes of all time. Choose a career that you love, and you will never have to work a day in your life. Incidentally, also at the one of the highlights of both of these men's careers is that they are largely responsible for the training of myself. Dr Sortino and Dr Kemp. Mhm. As for me, growing up, um, I always knew I wanted to be a surgeon, and it was my upbringing at Hopkins that really made me passionate about aortic surgery. But for those of you who know me, I would be remiss if I didn't also mention my other passion in life, the New York Yankees. So I have to give the disclaimer before I show this clip. It actually has nothing to do with aortic surgery and has no educational value whatsoever. But I just think it's amazing. Okay, hit toward the hole. Jeter backhands from the outfield grass. So for those of you don't know baseball, that is truly magic. Almost as amazing as a total arch replacement. Alright, so now to get down to business. So risk factors for aortic disease age greater than 65. Hypertension hypercholesterolemia, tobacco abuse, atherosclerosis by custody. Aortic valve? Uh, morphology. So about 1% of all people in the world have a bicuspid valve, and it's thought that the turbulent flow through that bicuspid valve is what increases wall tension. It can cause dilation of the sciences of El Salva trauma infection, syphilitic hepatitis, connective tissue disease, such as more fans where a fibrillation fibrillation gene mutation causes the elastic fibers of the vascular media to dilate. So this slide shows some of the aortic pathologies that we encounter. Obviously, aneurysms can occur in any part of the aorta. Um, and it's their location. That sort of dictates the complexity and the repair that's necessary and aneurysms predisposed to dissection, intramural hematoma and penetrating ulcers, which is the reason why we operate on aneurysms. Alright, so now, to talk a little bit about the history of aortic aneurysm and repair, the first written descriptions of the heart the aorta and aneurysms can be found from the Egyptian papyrus back in 15 50 BC The word aneurysm actually comes from the Greek aneurysm a, which means to widen or dilate. Um, and there's been ominous description throughout the centuries of aortic aneurysms. But it wasn't until the mid 18 hundreds, uh, that surgeons first started thinking about ways to fix aneurysms and prevent rupture. Some of the first interventions were focused on ligation of an aneurysm, which obviously renders the downstream vascular bed ischemic can lead to significant complications. As time went on in the late 1800 surgeons continue to think about different ways to intervene on aneurysms to prevent rupture. On the slide On the left, you can see that surgeons were introducing silver wire into aneurysms and then actually passing a current across it to try and reduce coagulation and obliteration of the aneurysm. Surgeons also tried other techniques, such as wrapping aneurysms. They would use cellophane or plastic films to try and wrap an aneurysm to induce a fiber optic or inflammatory reaction to try and prevent rupture. It wasn't until the turn of the century, though, that surgeons first recognize that not only was it important to obliterate an aneurysm, but also to try and maintain the vascular Lumen or patent see in this diagram on the right. Surgeon Rudolph Metis from New Orleans, uh, described a reconstructive technique where he preserved the inner Lumen by placating the aneurysm sac over an inner stylistic tube. And then, in the early 19 hundreds, as we got to mid century, surgeons began thinking about aortic home, a graft replacement of aneurysms. I think the boast in 1951 is credited with the first home, a graft replacement of an abdominal aortic aneurysm, and then in the 19 fifties, with the development of synthetic tube graphs as well as the techniques of cardiopulmonary bypass and circulatory arrest, we came to know the standard techniques that we use today. So this is why we replace aneurysms. Um, as an aneurysm grows, the wall thins out, the tension on the wall increases and and then eventually rupture or dissection can occur. If you look at this bar graph here all the way to the right, it shows the annual rate of complications based on aortic size. The black bar uh, which shows aneurysms that are 4 to 5 centimeters in size. There's about a 5% annual risk of rupture, dissection or death for aneurysms reaching 5 to 6 centimeters. It's about a 7% risk of rupture, dissection or death. And for aneurysms attaining a size greater than six centimeters, it's greater than 15% in a year. So that's pretty significant. And why we don't let aneurysms get to six centimeters and also why the literature is sort of settled on 5 to 5.5 centimeters as the surgical threshold for intervention. So acute aortic dissection are a true emergency. Uh, they're broken up into Type A and Type B based on the Stanford classification. Um, it's estimated that about 20% of all the sections never reached the hospital and for patients that go without treatment. There's a 2 to 3% risk of mortality per hour for the 1st 24 hours after dissection. So this is a very lethal disease for the type A dissection. It is a true cardiac surgical emergency. These are the sections that arise proximal to the take off of the left subclavian. It requires oftentimes stern ami, cardiopulmonary bypass and circulatory arrest for repair and then for Type B two sections. A large majority of them greater than 80% actually can be at least initially treated non operatively with aggressive anti hypertensive management and then eventually, uh, TVR repair down the road. So the goals of a type A dissection repair include reception of the tear initiation site, reestablishing, reestablishing, true loom and flow, false Lumen obliteration and replacement of the disease they order. These are inter operative pictures from a recent dissection that I did a few months ago. On the left, you can see, uh, the stern Artemis incision right down the middle just to orient you. The patient's head is at the top of the screen. You can see down here the epic cardio fat of the heart, which is being pushed down and out of the field due to the very large aneurysm away ascending aorta. And then, of course, the pathetic, demonic, purplish discoloration of the dissection. And then in the picture, on the right, you can see after I have transected the mid ascending aorta, the three layers of the vascular Lumen can be seen. The vascular intimacy is seen here. The media is filled with this fresh thrombosis, and it's being contained by the Outer Adventist cell layer here. And so this is the repair that the patient underwent. They had a root A sending in zone one arch repair under deep, hypothermic circulatory arrest. The picture on the left, uh, basically shows the graph that we sewed in here and on the right, you can see the zones of the aorta. We transected in zone one here and basically replaced everything proximal to that, including a branch graft to the A nominate, which you can see here and for the non surgeons in the audience. One of the critical factors in any dissection repair is your cancellation strategy. And what you can see here on the left is that I've actually sewn an eight millimeter graft here onto the distal in dominant artery right in this area here. And what this allows for is that during a reception and circulatory arrest, we can, uh, simply place a clamp on the base of the nominate artery and continue profuse, oxygenated blood up the right common carotid artery to provide selective integrate cerebral profusion. All right, so I'm gonna change gears from the emergent operation to the more elective aneurysm repairs that we perform. So for patients who have root and approximately a sending aneurysms, we can perform an aortic root replacement, which involves resection of the Sinus tissue as well as re implantation of the coronary buttons. This is a very nice corona CT shot of a root aneurysm. Very focal in nature. You can see that it quickly die. Uh, it quickly tapers down to a more normal caliber at the distal ascending aorta. And this is nice because it allows for cancellation of the arch and then placement of a clamp on the the normal caliber distal ascending to allow for repair without having to use circulatory arrest. So when we perform an aortic root replacement, oftentimes the valve also needs to be replaced. And so we have very nice, readily made, available valved conduits, which have either a mechanical valve or a bio prosthetic valve already integrated into the base of the graft. For those patients who have a competent valve despite a dilated route, um, a valve sparing route operation is also a possibility. And this is the graft called the valve Salva Graft, which I use when doing a valve sparing root replacement, which you can see, uh, in this operative diagram here on the right. Um, so the cartoon on the left basically shows the anatomy a little bit more easily. But basically, what we're doing is we're looking down the barrel of that Val Salva graft, uh, in the center, you can see the normal, uh, native aortic valve in the closed position. The Sinus tissue has been completely resected. The aortic buttons are seen off to the side prior to their re implantation into the graft. Um, and then this future line here is the Hema static layer, which also anchors the graft to the Angelus even more complicated, or the total arch replacements that we perform. And that's due to the to the need to respect all of the aneurysm tissue of the arch as well as the base of the great vessels. And this obviously necessitates a period of circulatory arrest which significantly increases the morbidity of the operation. This is a case of the 72 year old woman who had a sending to breath for a type A resection dissection many years ago. She was initially lost to follow up, but then came back to our aortic clinic. Um, it was found to have a large growing residual arch aneurysm and type B dissection. Mm hmm. And this is the repair that she underwent. So she underwent a reduced anatomy. We cut down on the right axillary artery through a right subclavian, ocular incision. And so an eight millimeter graft for cardiopulmonary bypass. And you can see that here in the diagram, we then, uh, instituted cardiopulmonary bypass and cool the patient down to 18 degrees before, um, initiating our circulatory arrest period and respecting the arch as well as the base of the great vessels. Prior to sowing in our graft, we did first employ a frozen elephant trunk technique which is inserted into the proximal descending thoracic aorta. And I'll show that technique in the next slide. But then the arch and base of the head vessels was then re implanted with a 34 millimeter branch graft. And, as you can see in this diagram during this circulatory arrest period, were able to place a clamp on the base of the nominate artery, which allows for continued profusion of the head. So this is the frozen elephant trunk technique. Um, after we begin our period of circulatory arrest were able to open up the aorta. And under direct vision, we insert basically an anti grade T bar directly into the proximal descending thoracic aorta. By deploying this graph that hopefully provides a seal distantly and then approximately, it allows for a nice landing zone two so two for the arch branch graft that we use. Yeah, these are the inter operative photos from that operation. On the left, you can see the very large, greater than seven centimeter aneurism in the center of the field. Uh, it's so large that it's actually pushing the heart down and out of the way and can be seen way down here. Um, And after a section of this aneurysm, we reconstructed with an ascending and branch arch graft here. And you can say that. See the takeoff of the individual head vessels, the left subclavian here, the left common carotid in the nominate arteries. So so far, I've summarized some of the basic standard traditional open surgical approaches that we use for these very complicated problems. And for those of us who actually perform these operations, it's pretty humbling to think about how we stand on the shoulders of giants to perform these operations. And I just thought this quote from Sir William Osler was very appropriate here from 1900. There's no disease more conducive to clinical humility than aneurysms of the aorta. But what's even more exciting, I, I think, is how we continue to push the envelope. We're still still looking for less invasive ways to tackle these very difficult problems. And so I'm going to change gears and talk and show a couple of cases of some of the less invasive hybrid techniques that we're using to today to try and accomplish the same goal with less morbidity to the patient. And this is why aortic surgery is so exciting and why I think it's sort of the dream job. It sort of sort of makes you feel like a superhero getting for work, Getting ready for work each morning. Honey, What? Where's my super suit? What? Where is my super suit time? All right, So here's the hybrid super suit that we get to wear every day. You gotta love the Incredibles. Alright, So here's a couple of cases that I just wanted to show some of the hybrid techniques that we use. This is actually a case that I did with Dr Rath or a 58 year old woman with, uh, large arch and proximal descending aneurysm. She had multiple comorbidities that significantly increase the risk of cardiopulmonary bypass and circulatory arrest. And her anatomy was unfavorable for a complete endovascular approach. And this is basically the repair that she got. So we still performed a stern anatomy for arch de branching, but she was able to avoid cardiopulmonary bypass. And we did this by placing a side biting clamp on the proximal ascending aorta soda, 12 millimeter bifurcated graft and then sequentially reimplanted the head vessels. And so as not to ever completely interrupt blood flow to the head. And then we're able to come in with a retrograde T bar to cover both the aneurysm as well as the takeoff of all the head vessels. And so this is a very nice repair. Uh, and that again she avoided cardiopulmonary bypass and circulatory arrest, which would have been the standard prior to these newer techniques. This is another patient of Dr rafters who came in with aberrant aortic arch anatomy. She presented with difficulty swallowing and was found to have a right subclavian, that past posterior to the trachea and the esophagus. And you can see that in this axial cut of the C t. Here's the arch and the subclavian passing behind the trachea and the esophagus. And she had compressive symptoms. From this in the cartoon on the right, you can see basically her anatomy here, this right subclavian again, passing posterior to the esophagus and implanting on the posterior arch, just distal to the take off of the left subclavian. And so this is the operation that she received Dr Rath or performed a cervical incision and performed a right subclavian artery to karate transposition. This is the preoperative three D image. So this right subclavian here was implanted into the carotid right here and then the proximal end of the aberrant right. Subclavian was then litigated. Uh, and then we were able to come in with a retrograde sort of zone two T bar, which covered the base of that aberrant right subclavian. Inadvertently, it also covered the left subclavian. But that was taken care of by a laser ministrations and stenting of the proximal left subclavian artery. So sort of a very elegant repair for this problem. And the patient avoided a stern Artemis altogether. So finally, before I turn it over to Dr Pan Aton, I just wanted to highlight some of the aspects of our comprehensive aortic center. We sort of provide one stop shopping for the patients in our multidisciplinary aortic clinic, where they can be seen by a cardiologist, vascular surgeon and a cardiologist. Um, and this allows us to come up with a sort of collaborative approach and, uh, to come up with an operative plan for the patient. We also have a very robust aortic alert program. I think we make it very nice for our community that with one phone call, they can engage a cardiac surgeon, a vascular surgeon, the cardiac surgery Icy charge Nurse, the transfer center as well as Nightingale to try and facilitate the triage, uh, and transfer of patients to definitive care, which is really the main goal with an acute aortic emergency. And then finally, we also have a monthly aortic case conference where any surgeon or physician in the community can put forth uh, complicated aortic case that's gonna need a multidisciplinary approach. I think basically what we're sort of envisioning here is that by providing state of the art comprehensive care for patients with any aortic pathology that hopefully we're gonna put together the infrastructure that's going to help us to develop the reputation not only in the Tidewater community but also in the mid Atlantic region that vcenter is the place to send your patients with an aortic problem, sort of. If you build it, they will come. And this brings me to my last video clip, which you might be able to guess by the quote again. The video clip probably has more to do with baseball than aortic surgery, but it still brings home the point that if we build something special here, hopefully, uh, we're gonna bring the patients the one constant through all the years Ray been baseball. America is ruled by like an army of steamrollers. There's been erased like a blackboard rebuilt and erased again. But baseball has marked the time, this field, this game. It's a part of our past, Ray. It reminds us of all that once was good. It could be again. Oh, people will come, Ray. People will most definitely come. What can I say? I'm passionate about baseball. All right, so I'm gonna end there and turn it over to Dr Pants on.
