Circ Arrest and Frozen Elephant Trunk vs Two Stage Repair

[Silo004]

For aortic arch pathology, I have only been involved in dissections, congenital disease that extended into descending aorta, required both circ arrest and frozen elephant trunk. As such, I thought that was the standard of care for all these cases. Apparently this is not the case? Do any of you have recs for reading about anesthetics for which this is not the case? Can you point me to some evidence based decision tree???

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[vector2]

For aortic arch pathology, I have only been involved in dissections, congenital disease that extended into descending aorta, required both circ arrest and frozen elephant trunk. As such, I thought that was the standard of care for all these cases. Apparently this is not the case? Do any of you have recs for reading about anesthetics for which this is not the case? Can you point me to some evidence based decision tree???

A type A dissection that extends into the arch is not automatically an indication for arch repair / circ arrest / FET etc. The ascending (+- root) can be replaced and as long as the entry point of the dissection at the ascending graft -> arch anastomosis is tacked down and further blood flow to the false lumen is obliterated, you may be good. Arch repair is typically indicated when the arch is aneurysmal, acute dissections where the arch is aneurysmal, or if there's extensive destruction or leakage with a high risk for rupture and/or branch malperfusion.

 

[Silo004]

So arch disease with significant false lumen flow necessitates circ arrest, FET. Is this the right way to think about it?

A type A dissection that extends into the arch is not automatically an indication for arch repair / circ arrest / FET etc. The ascending (+- root) can be replaced and as long as the entry point of the dissection at the ascending graft -> arch anastomosis is tacked down and further blood flow to the false lumen is obliterated, you may be good. Arch repair is typically indicated when the arch is aneurysmal, acute dissections where the arch is aneurysmal, or if there's extensive destruction or leakage with a high risk for rupture and/or branch malperfusion.

 

[vector2]

So arch disease with significant false lumen flow necessitates circ arrest, FET. Is this the right way to think about it?

No, arch dissection in an aneurysmal arch necessitates repair.

Look at this picture

This is illustrating a Bentall for aneurysm, but say this person simply had a Type A dissection extending into the arch without aneurysm of any segments or severe malperfusion. You will fix the ascending aorta +- the root regardless, but if you isolate the dissection at the anastomosis where the green arrow is and there is no longer flow into the dissection flap at the arch, that may be all you need (since false lumens without flow will eventually obliterate).

 

[Silo004]

Ok. Got it. Understood.

No, arch dissection in an aneurysmal arch necessitates repair.

 

[dchz]

Circ arrest - necessary for anastamosis of the branches of the arch, because you can't flow from the aorta (where the normal cannulation site is) to the head if they need to fix that connection. You could still flow blood to the head through the right subclavian and clamp the brachialcephalic trunk (innominate artery), as antegrade flow, or through the jugular veins as retrograde flow (less common)

Frozen elephant trunk - repair technique for extensive dissections that goes from ascending to descending. After you repair the ascending, you leave a graft hanging in the true lumen of the dissected descending aorta for a later 2nd stage repair. Sometimes the 2nd stage can be done endovascularly without a second surgery, although only a few centers do this.

Two staged repair - when referring to aorta reconstruction, it's a more broad term. Usually the ascending dissection causes the most mortality and can involve very extensive pump runs. So the idea is let the pt recover from that and fix the less mortality inducing descending dissection later. The frozen elephant trunk is one type of two stage repair.

Evidence based anesthesia - the only evidence proven reduction in mortality is the temperature of blood while on circ arrest. Many people cool to 19c or colder. There are adjuncts such as high dose glucocorticoids, antegrade/retrograde cerebral perfusion, ice around the head, and others that are debated and very center dependent.

Hope this helps clarifying the confusion.

Ok. Got it. Understood.

I knew a resident who used to say understood in the place of "okay". I called him understood because I'm a huge troll.

 

[AdmiralChz]

It’s very interesting how each institution handles such pathology differently. The repair techniques widely varied (for mostly the same pathology) between residency, fellowship and my job.

Im not sure how it evolved, but my psuedoacademic center job does a lot of endovascular approaches with zone 0 TEVARs. If the arch is involved, de branching is done prior to TEVAR. Of course if the aortic annulus is involved, this isn’t really possible.

 

[anaesthetic]

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[vector2]

Evidence based anesthesia - the only evidence proven reduction in mortality is the temperature of blood while on circ arrest. Many people cool to 19c or colder. There are adjuncts such as high dose glucocorticoids, antegrade/retrograde cerebral perfusion, ice around the head, and others that are debated and very center dependent.

My favorite is that there are centers that still give 1000 of pentobarbital before turning off the pump. As if the BIS already reading 0 once 18c is hit wasn’t protective enough

 

[MirrorTodd]

Circ arrest - necessary for anastamosis of the branches of the arch, because you can't flow from the aorta (where the normal cannulation site is) to the head if they need to fix that connection. You could still flow blood to the head through the right subclavian and clamp the brachialcephalic trunk (innominate artery), as antegrade flow, or through the jugular veins as retrograde flow (less common)

Frozen elephant trunk - repair technique for extensive dissections that goes from ascending to descending. After you repair the ascending, you leave a graft hanging in the true lumen of the dissected descending aorta for a later 2nd stage repair. Sometimes the 2nd stage can be done endovascularly without a second surgery, although only a few centers do this.

Two staged repair - when referring to aorta reconstruction, it's a more broad term. Usually the ascending dissection causes the most mortality and can involve very extensive pump runs. So the idea is let the pt recover from that and fix the less mortality inducing descending dissection later. The frozen elephant trunk is one type of two stage repair.

Evidence based anesthesia - the only evidence proven reduction in mortality is the temperature of blood while on circ arrest. Many people cool to 19c or colder. There are adjuncts such as high dose glucocorticoids, antegrade/retrograde cerebral perfusion, ice around the head, and others that are debated and very center dependent.

Hope this helps clarifying the confusion.



I knew a resident who used to say understood in the place of "okay". I called him understood because I'm a huge troll.

Was he former military?