What Are Surgical Options for Thoracic Aortic Disease?
The Northwestern Medicine Thoracic Aortic Disease Program performs both endovascular repair (minimally invasive) and standard open operations to correct thoracic aortic disease.
Endovascular or surgical repair is necessary when the thoracic aortic aneurysm reaches a significant size (5-6 cm or larger), which increases the risk of aortic dissection or rupture.
Surgeries performed include:
- Replacement of any part of the thoracic aorta
- Valve-sparing aortic root replacement using the "reimplantation" (David) technique and other root replacement techniques
- Aortic arch replacement using antegrade cerebral perfusion and hypothermia strategies for protection of the brain
- Thoracoabdominal aortic replacement using distal perfusion to protect the spinal cord
- Minimally invasive endovascular repair of aneurysms using thoracic aortic stent-grafts
Endovascular Repair for Thoracic Aortic Disease
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive surgical technique in which a catheter (hollow, flexible tube) is passed through a needle puncture in the skin (percutaneous approach) and used to insert miniature devices into the blood vessel for the treatment of disease.
Because these catheter-based procedures are considered minimally invasive, patients experience the following benefits:
- Less pain
- Faster return to normal daily activities
- Less blood loss
- Improved clinical outcomes
- Smaller incisions with less scarring
- Shorter recovery time
Endovascular repair is usually performed through the groin via the femoral artery; therefore it is important that the size (diameter) of a patient's femoral artery is large enough to accommodate a catheter. Women may have femoral arteries that are too small for this technique.
A small catheter that contains a stent-graft (usually a metal mesh tube covered with fabric) is inserted into the femoral artery via a tiny skin incision. Once inserted, the catheter is advanced into the diseased portion of the thoracic aorta where the graft is placed.
The purpose of the graft is to direct blood flow through the graft and away from the aneurysm so that the aneurysm does not increase in size.
Open Reconstruction for Thoracic Aortic Aneurysm
Whether due to the small diameter of the femoral artery or the location of the thoracic aortic disease, not everyone is a candidate for endovascular repair.
For those patients for whom endovascular repair is not an option, open reconstruction is the surgical technique used.
With open reconstruction, the standard incision for aortic repairs is a full sternotomy (incision made along the sternum, in the center of the chest), which is necessary to give the surgeon both direct access and a direct view of the heart, aortic root, ascending aorta, or aortic arch.
Some descending thoracic aorta repairs using the open reconstruction technique may require an incision on the left side of the chest.
Aortic Root Replacement
Repair of an aortic root aneurysm or dissection is done by replacing the portion of the aorta that is diseased with a tubular Dacron® graft of synthetic (man-made) material.
Aortic Root Replacement (Modified Bentall Procedure)
The traditional aortic root replacement surgery consists of replacing both the aortic valve and the aortic root with a composite (combined) valve-graft.
Typically, the composite valve-graft consists of either:
- A tissue valve (made from animal or human tissue)
- A mechanical valve (to replace the diseased aortic root)
If a mechanical valve is used, an anticoagulation medication like Warfarin will be necessary. If a tissue valve is used, anticoagulation medication is not necessary.
Valve-Sparing Aortic Root Replacement (David Procedure)
The aortic root replacement surgery that repairs the diseased aortic root with a Dacron graft but spares the non-diseased aortic valve, meaning the original aortic valve is left in place.
Aortic Arch Repair
Aneurysms or dissections may involve more than just the aortic root.
The aortic arch and the descending aorta may also be diseased. Repair of the aortic arch is made with a tubular Dacron graft made of synthetic material. These include:
Total Arch Repair
This is the aortic arch replacement surgery where the entire aortic arch is removed and replaced with a Dacron graft. Blood flow to the branches of the arch is restored typically with branches from the arch graft.
The aortic hemi-arch replacement is surgery where a smaller portion of the aortic arch is removed and replaced with a Dacron graft. More native aortic arch tissue is left in place surrounding the left innominate artery, left common carotid artery, and the left subclavian artery than in the total arch repair surgery.
In some cases, more than one section of the aorta is diseased and must be repaired.
For example, disease in the aortic root and a portion of the aortic arch may require an aortic root repair and a hemi-arch repair to be performed at the same time. In these cases, the different Dacron grafts are sewn together after each portion of the aorta is repaired.
Descending Aortic Repair
The descending aorta is divided into the descending aorta and the abdominal aorta. When aneurysms extend from the chest into the abdomen, the condition is termed a thoraco-abdominal aortic aneurysm.
Descending thoracic aortic aneurysms (DTAA) are repaired most often using thoracic endovascular aortic repair (TEVAR). Not all DTAAs are suitable for this approach, and careful review of multiple diagnostic imaging tests (dedicated imaging) is required to decide.
Thoraco-abdominal aortic aneurysms (TAAA) are typically repaired through an incision of the left chest and abdomen with reattachment of major branches of the aorta. Some patients may be suitable for an experimental procedure called branched or fenestrated stent-graft. Dedicated imaging is required to determine a patient's candidacy.
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