Thoracic aortic disease surgery

2010 ACCF/AHA Guideline Recommendations: Evaluation and Management of Acute Thoracic Aortic Disease (DO NOT EDIT)

Recommendation for Surgical Intervention for Acute Thoracic Aortic Dissection

Class I

"1. For patients with ascending thoracic aortic dissection, all of the aneurysmal aorta and the proximal extent of the dissection should be resected. A partially dissected aortic root may be repaired with aortic valve resuspension. Extensive dissection of the aortic root should be treated with aortic root replacement with a composite graft or with a valve sparing root replacement. If a DeBakey Type II dissection is present, the entire dissected aorta should be replaced. (Level of Evidence: C) "

2010 ACCF/AHA Guideline Recommendations: Surgical and Endovascular Treatment by Location of Aortic Disease (DO NOT EDIT)

Recommendations for Open Surgery for Ascending Aortic Aneurysm

Class I

"1. Separate valve and ascending aortic replacement are recommended in patients without significant aortic root dilatation, in elderly patients, or in young patients with minimal dilatation who have aortic valve disease. (Level of Evidence: C) "

"2. Patients with Marfan, Loeys-Dietz, and Ehlers-Danlos syndromes and other patients with dilatation of the aortic root and sinuses of Valsalva should undergo excision of the sinuses in combination with a modified David reimplantation operation if technically feasible or, if not, root replacement with valved graft conduit. (Level of Evidence: B)"

Recommendations for Descending Thoracic Aorta and Thoracoabdominal Aortic Aneurysms

Class I

"1. For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended. (Level of Evidence: B) "

"2. For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible. (Level of Evidence: B)"

"3. For patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present. (Level of Evidence: C)"

"4. For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure is recommended. (Level of Evidence: B)"

Recommendation for Symptomatic Patients with Thoracic Aortic Aneurysm

Class I

"1. Patients with symptoms suggestive of expansion of a thoracic aneurysm should be evaluated for prompt surgical intervention unless life expectancy from comorbid conditions is limited or quality of life is substantially impaired. (Level of Evidence: C) "

Recommendations for Asymptomatic Patients with Ascending Aortic Aneurysm

Class I

"1. Asymptomatic patients with degenerative thoracic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, or pseudoaneurysm, who are otherwise suitable candidates and for whom the ascending aorta or aortic sinus diameter is 5.5 cm or greater, should be evaluated for surgical repair. (Level of Evidence: C) "

"2. Patients with Marfan syndrome or other genetically mediated disorders (vascular Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, or familial thoracic aortic aneurysm and dissection) should undergo elective operation at smaller diameters (4.0 to 5.0 cm depending on the condition; see Section 5) to avoid acute dissection or rupture. (Level of Evidence: C)"

"3. Patients with a growth rate of more than 0.5 cm/y in an aorta that is less than 5.5 cm in diameter should be considered for operation. (Level of Evidence: C)"

"4. Patients undergoing aortic valve repair or replacement and who have an ascending aorta or aortic root of greater than 4.5 cm should be considered for concomitant repair of the aortic root or replacement of the ascending aorta. (Level of Evidence: C)"

Class IIa

"1. Elective aortic replacement is reasonable for patients with Marfan syndrome, other genetic diseases, or bicuspid aortic valves, when the ratio of maximal ascending or aortic root area ( r2) in cm2 divided by the patient’s height in meters exceeds 10. (Level of Evidence: C)"

"2. It is reasonable for patients with Loeys-Dietz syndrome or a confirmed TGFBR1 or TGFBR2 mutation to undergo aortic repair when the aortic diameter reaches 4.2 cm or greater by transesophageal echocardiogram (internal diameter) or 4.4 to 4.6 cm or greater by computed tomographic imaging and/or magnetic resonance imaging (external diameter). (Level of Evidence: C)"

Recommendations for Aortic Arch Aneurysms

Class IIa

"1. For thoracic aortic aneurysms also involving the proximal aortic arch, partial arch replacement together with ascending aorta repair using right subclavian/axillary artery inflow and hypothermic circulatory arrest is reasonable. (Level of Evidence: B)"

"2. Replacement of the entire aortic arch is reasonable for acute dissection when the arch is aneurysmal or there is extensive aortic arch destruction and leakage. (Level of Evidence: B) "

"3. Replacement of the entire aortic arch is reasonable for aneurysms of the entire arch, for chronic dissection when the arch is enlarged, and for distal arch aneurysms that also involve the proximal descending thoracic aorta, usually with the elephant trunk procedure. (Level of Evidence: B) "

"4. For patients with low operative risk in whom an isolated degenerative or atherosclerotic aneurysm of the aortic arch is present, operative treatment is reasonable for asymptomatic patients when the diameter of the arch exceeds 5.5 cm. (Level of Evidence: B) "

"5. For patients with isolated aortic arch aneurysms less than 4.0 cm in diameter, it is reasonable to re-image using computed tomographic imaging or magnetic resonance imaging, at 12-month intervals, to detect enlargement of the aneurysm. (Level of Evidence: C) "

"6. For patients with isolated aortic arch aneurysms 4.0 cm or greater in diameter, it is reasonable to re-image using computed tomographic imaging or magnetic resonance imaging, at 6-month intervals,to detect enlargement of the aneurysm. (Level of Evidence: C) "

ACC/AHA Guidelines - Guidelines for perioperative care for open surgical and endovascular Thoracic aortic repairs (DO NOT EDIT)

Recommendations for Preoperative Evaluation

Class I

"1. In preparation for surgery, imaging studies adequate to establish the extent of disease and the potential limits of the planned procedure are recommended. (Level of Evidence: C) "

"2. Patients with thoracic aortic disease requiring a surgical or catheter-based intervention who have symptoms or other findings of myocardial ischemia should undergo additional studies to determine the presence of significant coronary artery disease. (Level of Evidence: C)"

"3. Patients with unstable coronary syndromes and significant coronary artery disease should undergo revascularization prior to or at the time of thoracic aortic surgery or endovascular intervention with percutaneous coronary intervention or concomitant coronary artery bypass graft surgery. (Level of Evidence: C)"

Class IIa

"1. Additional testing is reasonable to quantitate the patient’s comorbid states and develop a risk profile. These may include pulmonary function tests, cardiac catheterization, aortography, 24-hour Holter monitoring, noninvasive carotid artery screening, brain imaging, echocardiography, and neurocognitive testing. (Level of Evidence: C)"

"2. For patients who are to undergo surgery for ascending or arch aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, it is reasonable to perform concomitant coronary artery bypass graft surgery. (Level of Evidence: C)"

Class IIb

"1. For patients who are to undergo surgery or endovascular intervention for descending thoracic aortic disease, and who have clinically stable, but significant (flow limiting), coronary artery disease, the benefits of coronary revascularization are not well established. (Level of Evidence: B)"

Recommendations for choice of Anesthetic and Monitoring Techniques

Class I

"1. The choice of anesthetic techniques and agents and patient monitoring techniques should be tailored to individual patient needs to facilitate surgical and perfusion techniques and the monitoring of hemodynamics and organ function. (Level of Evidence: C) "

Class III (Harm)

"1. Regional anesthetic techniques are not recommended in patients at risk of neuraxial hematoma formation due to thienopyridine antiplatelet therapy, low-molecular-weight heparins, or clinically significant anticoagulation. (Level of Evidence: C)"

"2. Routinely changing double-lumen endotracheal (endobronchial) tubes to single-lumen tubes at the end of surgical procedures complicated by significant upper airway edema or hemorrhage is not recommended. (Level of Evidence: C) "

Class IIa

"1. Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta, unless there are specific contraindications to its use. Transesophageal echocardiography is reasonable in endovascular thoracic aortic procedures for monitoring, procedural guidance, and/or endovascular graft leak detection. (Level of Evidence: B)"

"2. Motor or somatosensory evoked potential monitoring can be useful when the data will help to guide therapy. It is reasonable to base the decision to use neurophysiologic monitoring on individual patient needs, institutional resources, the urgency of the procedure, and the surgical and perfusion techniques to be employed in the open or endovascular thoracic aortic repair. (Level of Evidence: B)"

Recommendation for Transfusion Management and Anticoagulation in Thoracic Aortic Surgery

Class IIa

"1. An algorithmic approach to transfusion, antifibrinolytic, and anticoagulation management is reasonable to use in both open and endovascular thoracic aortic repairs during the perioperative period. Institutional variations in coagulation testing capability and availability of transfusion products and other prothrombotic and antithrombotic agents are important considerations in defining such an approach. (Level of Evidence: C) "

Recommendations for Brain Protection during Ascending Aortic and Transverse Aortic Arch Surgery

Class I

"1. A brain protection strategy to prevent stroke and preserve cognitive function should be a key element of the surgical, anesthetic, and perfusion techniques used to accomplish repairs of the ascending aorta and transverse aortic arch. (Level of Evidence: B) "

Class III (Harm)

"1. Perioperative brain hyperthermia is not recommended in repairs of the ascending aortic and transverse aortic arch as it is probably injurious to the brain. (Level of Evidence: B)"

Class IIa

"1. Deep hypothermic circulatory arrest, selective antegrade brain perfusion, and retrograde brain perfusion are techniques that alone or in combination are reasonable to minimize brain injury during surgical repairs of the ascending aorta and transverse aortic arch. Institutional experience is an important factor in selecting these techniques. (Level of Evidence: B) "

Recommendations for Spinal Cord Protection during Descending Aortic open Surgical and Endovascular Repairs

Class I

"1. Cerebrospinal fluid drainage is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair for patients at high risk of spinal cord ischemic injury. (Level of Evidence: B) "

Class IIa

"1. Spinal cord perfusion pressure optimization using techniques, such as proximal aortic pressure maintenance and distal aortic perfusion, is reasonable as an integral part of the surgical, anesthetic, and perfusion strategy in open and endovascular thoracic aortic repair patients at high risk of spinal cord ischemic injury. Institutional experience is an important factor in selecting these techniques. (Level of Evidence: B) "

"2. Moderate systemic hypothermia is reasonable for protection of the spinal cord during open repairs of the descending thoracic aorta. (Level of Evidence: B) "

Class IIb

"1. Adjunctive techniques to increase the tolerance of the spinal cord to impaired perfusion may be considered during open and endovascular thoracic aortic repair for patients at high risk of spinal cord injury. These include distal perfusion, epidural irrigation with hypothermic solutions, high-dose systemic glucocorticoids, osmotic diuresis with mannitol, intrathecal papaverine, and cellular metabolic suppression with anesthetic agents. (Level of Evidence: B) "

"2. Neurophysiological monitoring of the spinal cord (somatosensory evoked potentials or motor evoked potentials) may be considered as a strategy to detect spinal cord ischemia and to guide reimplantation of intercostal arteries and/or hemodynamic optimization to prevent or treat spinal cord ischemia. (Level of Evidence: B) "

Recommendations for Renal Protection during Descending Aortic open Surgical and Endovascular Repairs

Class III (Harm)

"1. Furosemide, mannitol, or dopamine should not be given solely for the purpose of renal protection in descending aortic repairs. (Level of Evidence: B) "

Class IIb

"1. Preoperative hydration and intraoperative mannitol administration may be reasonable strategies for preservation of renal function in open repairs of the descending aorta. (Level of Evidence: C) "

"2. During thoracoabdominal or descending aortic repairs with exposure of the renal arteries, renal protection by either cold crystalloid or blood perfusion may be considered. (Level of Evidence: B) "