Thoracic Aortic Surgery Program
Cedars-Sinai's Thoracic Aortic Surgery Program specializes in the medical and surgical treatment of diseases affecting the thoracic aorta, which may cause dilation, aneurysm and dissection. The following links provide information about the program, along with the nature and treatment of thoracic aortic disease.
- Thoracic Aortic Surgery Program
- A Comprehensive Team Approach
- Coping with the Diagnosis
- Family Screening for Aortic Disease
- Aortic Disease Treatment Summary
- Introduction to Aortic Surgery
- Thoracic Endovascular Aneurysm Repair (TEVAR)
- Open Anastomosis with Hypothermic Circulatory Arrest
- Aortic Valve, Root, Ascending Aorta and Arch
- Surgical Procedures (Aortic Valve, Root, Ascending Aorta and Arch)
- Valve Repair Versus Replacement
- Descending and Thoracoabdominal Aorta
- Surgical Procedures (Descending and Thoracoabdominal Aorta)
- Timing of Elective Surgery
- Postsurgical Medical Treatment
- For More Information and Appointments
Additional Aorta-Related Resources from Cedars-Sinai
Thoracic Aortic Surgery Program
Current treatment options for the aorta, the largest artery in the body, are the result of many years of innovation. For 30 years Cedars-Sinai physicians have addressed the effects of injury and disease in this vital artery. Accelerated technical progress, particularly over the last 15 years, has resulted in today's state-of-the-art medical and surgical approaches to aortic disease. In the early history of aortic surgery, nationally the morbidity and mortality rates were high. Today even the most difficult aortic conditions in high-risk patients yield to world-class innovation and the expertise in aortic surgery at Cedars-Sinai's Thoracic Aortic Surgery Program. The program is under the direction of Dr. Alfredo Trento, who has led advances in thoracic aortic surgery at Cedars-Sinai since 1988.
Early detection, monitoring and treatment of aortic disease, including appropriately timed elective surgery, are key to successful outcomes. The goal whenever possible is to avoid life-threatening emergencies that too often prove fatal. Conditions affecting the aorta are serious, but through expert diagnosis and treatment, lifestyle modifications and ongoing medical care, patients under the care of aortic specialists may continue to enjoy normal, productive lives. If at any time you have questions about aortic disease in general or the treatment program at Cedars-Sinai, you are welcome to contact the program's liaison.
A Comprehensive Team Approach
Aortic disease is complex, degenerative, and typically progressive in nature. Other heart conditions may also be present, calling for a comprehensive approach to each patient. Under the leadership of Dr. Eduardo Marban, Director of the Cedars-Sinai Heart Institute, and Dr. Prediman Shah, Director of the Division of Cardiology, Cedars-Sinai Heart Institute is comprised of expertise spanning all aspects of the medical and surgical treatment of cardiac and aortic disease. The Thoracic Aortic Surgery Program, an area of specialization within Cardiothoracic Surgery, draws from expertise throughout the Heart Institute in providing world-class care for those with aortic disease. Please click on the Our Expert Team link in the side menu to become acquainted with the entire Cedars-Sinai Heart Institute team.
To comprehensively evaluate our patients, we work in partnership with other specialty areas at Cedars-Sinai Medical Center, including the Department of Neurosurgery. Because many of the risk factors for aortic and cerebral aneurysms are the same, patients with those risk factors undergo careful evaluations for the brain, as well as the entire aorta. Dr. Wouter Schievink, Director of Neurovascular Surgery, and the Department of Neurosurgery's neuroradiologists provide world-class diagnosis and treatment services for aneurysms and dissections in cerebral vessels.
Additional areas of expertise, including imaging and nuclear medicine, also perform some of the state-of-the-art diagnostic testing required for accurate measurement and assessment of each individual. A specific treatment strategy, designed to address all aspects of aortic, cardiac and vascular disease, is developed for each individual based on their diagnostic test results. Patients and their families are key members of this team approach to treatment, which includes medical therapy, lifestyle modifications, ongoing monitoring and potentially elective surgery.
Coping with the Diagnosis
The detection of aortic disease is often a complete surprise to many patients and their families. For others, with family members who have already been diagnosed, it confirms that the condition is present in them also. Regardless of your situation, it is normal to feel afraid and overwhelmed. Gaining knowledge and finding aortic disease expertise to help you are the first steps toward replacing fear with confidence and confusion with the treatment plan that is right for you.
Today more than ever before, there are advanced, life-saving medical and surgical treatment options for aortic disease. The information on these web pages, including Frequently Asked Questions based on real-life experiences, may be especially helpful in explaining those options to you. The Aortic Disease section has a simple diagram of the aorta, as well as descriptions of aortic aneurysm and dissection to help in understanding your diagnosis. You may also review the Marfan syndrome and Bicuspid Aortic Disease sections for additional information if you have been diagnosed with one of those conditions.
At first it may be difficult for you and your loved ones to read and absorb information. The diagnosis of aortic disease, like many other serious conditions, brings many questions about its effect on your life. While not fully understanding what it is, you wonder how dangerous this condition is and what the long-term effects are. It is also very typical, due to the absence of pain or other symptoms, to deny that anything could be wrong. At the same time that you are experiencing these emotions and asking these questions, you must make important decisions about finding the help you need.
The Thoracic Aortic Surgery Program at Cedars-Sinai is includes a liaison who works with our patients and families. Whether you are a patient or not, all questions are welcome. You may contact the liaison by e-mail or phone at: program coordinator.
There are a few basic questions that focus on the most important points about your condition, and the answers are important to both you and the aortic experts that will care for you, regardless of where you seek treatment. Typically, this information is given to you with your diagnosis. Your family medical history may also provide important clues regarding your own condition. If you choose to contact us by e-mail, including answers to the following questions is helpful. This is also the type of information that will be discussed in a phone conversation with you.
- Have you been told that you have an aneurysm or dilated aorta? Where is the aneurysm or aortic enlargement located?
- How big is the aneurysm or enlargement? (The size is given in centimeters. There are 2.54 cm in one inch.)
- Do you have any relatives who have or had an aneurysm?
- Do you know of any close relative that died suddenly? Was the cause of death considered to be heart related?
- Have you been told that you have a heart murmur or any problems with the valves of your heart? If so, do you know which valve or valves?
Family Screening for Aortic Disease
Those who are unaware of the presence of aortic disease are vulnerable to life-threatening emergency situations, including aortic dissection and rupture. In contrast, lives are saved when aortic illness is identified early and treatment (e.g., effective medical therapy, ongoing monitoring, lifestyle modifications and elective surgery) is begun.
Screening family members for aortic disease involves:
- Providing a detailed medical history of the individual and multiple generations of their family
- Undergoing diagnostic testing (including echocardiography and CT or MRI scans)
- Reviewing and understanding test results and medical history
- Planning appropriate ongoing monitoring, based on whether or not aortic enlargement is present
- Developing a treatment plan if heart valve conditions are detected (Bicuspid aortic valves are part of a broader-based connective tissue disorder.)
- Beginning appropriate systolic blood pressure control and planning for appropriately timed elective surgery (typically when the aneurysm reaches 4.5 cm) if signs of aortic dilation are found
If you have any questions about the screening process for aortic disease or would like to make an appointment for yourself or other family members, please contact the program coordinator.
Aortic Disease Treatment Summary
Lifelong medical treatment and lifestyle changes are necessary for those with aortic disease, both prior to and after aortic surgery. The following is a summary of some key points regarding the treatment of thoracic aortic disease. Please be sure to discuss the details of your individual situation with your doctor.
Blood Pressure Optimization
- Non-exercise systolic blood pressure (top number) generally should be maintained in a range of 105 to 110.
- Blood pressure medications should include long-acting beta blockers, long-acting ACE inhibitors, ARBs and a calcium channel blocker if needed. The addition of a low-dose diuretic may also be needed for those who retain water. These medicines can only be used if the patient is not allergic to them and there are no other contraindications.
- A home blood pressure machine will be needed to monitor your blood pressure on a daily basis. The digital type is simple and convenient to use. Please be sure the one you choose has an arm cuff. After purchasing it, check the accuracy of the machine by taking it to a doctor's office and having its readings compared with their equipment.
- Keep a daily record of your blood pressure, and fax or e-mail it to the Thoracic Aortic Surgery Program. An easy-to-use form will be provided for your convenience. Generally, monitoring blood pressure twice daily for a period of seven days will help fine tune the medication dosages and optimize blood pressure control. Once that goal is reached, you may follow up with your primary care physician for future medication adjustments.
Exercise and Diet
- Maintaining an active lifestyle, including cardiovascular exercise, is strongly recommended. Strenuous activities, including heavy weightlifting, should be avoided. Specific exercise recommendations should be discussed with the treating physician.
- Changing nutritional habits to a diet low in fat and carbohydrates and high in fiber and protein is recommended.
- Smoking is a risk factor for aortic disease and should be stopped immediately.
- Passive smoking is also harmful. It is important not to breathe any secondhand smoke.
- Systolic blood pressure can go as high as 300 from crack cocaine usage.
- Using crack cocaine, even once, puts you at risk of life-threatening aortic dissection (tearing) or rupture.
Blood Sugar Optimization
- Appropriate blood sugar levels are very important for the health of the cardiovascular system. Healing is quicker and the risk of infection is reduced after surgery when the blood sugar level is kept between 90 and 110.
- If you are a recently diagnosed diabetic (defined as having a blood sugar greater than 120 and an abnormal level of hemoglobin A1C), it is important to consult an endocrinologist. Purchasing a glucose monitoring device for home use will be necessary. By following an appropriate drug regimen along with balanced nutrition and daily exercise, the goal should be living a normal life span while maintaining an appropriate blood glucose level in the range of 90 to 110.
- The ratio of muscle to fat in the body is very important to overall health. The issue is not so much the weight of an individual as what makes up that weight. A heavy but muscular person is much healthier than a very thin individual who has lost their muscle as a result of unbalanced nutrition and inactivity.
- It is most desirable to have very little body fat. Both blood pressure and blood sugar levels are more easily controlled when the muscle-to-fat ratio is optimal. This will also strengthen the immune system and boost postsurgical healing, while at the same time decreasing the blood sugar level.
- A desirable muscle-to-fat ratio is best achieved by a balanced diet and a physically active lifestyle.
Dental and Oral Hygiene
- Aortic patients are at higher risk of endocarditis and graft infection if they develop a dental or gum infection.
- Conscientious daily dental and gum care is important to avoid infection.
- Regular dental checkups are very important, as is taking antibiotics prior to teeth cleaning and other dental work.
- Prior to surgery, echocardiography, MRI or CT with contrast are used to monitor the aorta. Generally, for enlargement less than 4 cm, testing will be done at 12-month intervals. Once the aorta reaches 4 cm, it is checked more frequently - every 6 months and in some cases every 3 months.
- Echocardiography is also used to evaluate the valves and chambers of the heart.
- A thallium test with adenosine may be used to evaluate the coronary arteries prior to surgery.
- Shortly after surgery, a baseline MRI or CT is taken. Followup tests are done on an annual basis and compared with this baseline.
Maintaining a Positive Outlook
- Expert, proactive treatment of aortic disease makes possible the continuation of happy, productive lives. Focusing on personal goals and enjoying hobbies and leisure activities with friends and family, as well as meeting the challenges of every day living, are all important aspects of normal life. When medical care, appropriate diet and exercise, and diagnostic monitoring are all in place, those with aortic disease may live active, fulfilling lives.
- Aortic disease in itself is no reason to become an invalid or "couch potato." Doing so is neither physically nor psychologically healthy. Assuming no other conditions are present that might restrict your activity, long periods of boredom, gloomy thoughts and inactivity should be avoided. Fully participating in your treatment plan, including the medical, dietary and exercise recommendations previously described, positively affirms that you, not the disease, are in control. You need not feel victimized by this condition. There is a great deal that you, in partnership with your healthcare professionals, can do to confidently live your life.
- When it is time for elective surgery, the most recent technical advances in aortic surgery are all available, aimed at achieving the best possible outcome. Following surgery, ongoing medical care, diet, lifestyle choices and a positive attitude are key factors in the pursuit of a normal, active life.
Screening Family Members
- All first-degree relatives (i.e., parents, siblings and children) of those with bicuspid aortic disease, Ehlers-Danlos syndrome, Marfan syndrome and other connective tissue disorders should have a complete aortic checkup. Since these conditions may skip generations, nephews and nieces, grandchildren, etc. should also be notified and have a complete aortic checkup.
- A family history of sudden heart-related death should be investigated. If autopsy reports are available, it will be possible to determine if the death occurred due to aortic disease (aortic rupture or aortic dissection). If no further information is available, all sudden heart deaths should be regarded with suspicion since aortic rupture or dissection may have occurred.
Introduction to Aortic Surgery
The surgical removal of some portion of diseased aorta is called aortic resection. A Dacron® graft is used to replace the diseased aortic tissue. Dacron grafts are an excellent example of successful substitution of a synthetic material within the human body. Dacron is so completely compatible with the body that rejection and calcification do not occur. With the passage of time the body deposits its own tissue into the Dacron graft. Today's modern Dacron grafts are strong, flexible and collagen impregnated, making them impervious to blood. The durability of these grafts exceeds that of the human life span.
Surgery on the thoracic aorta is in some respects similar to other types of open-heart surgery. Particular details regarding the size and location of the incision, the use of the heart-lung machine and specialized techniques used to provide neurologic protection vary depending on the type of aortic surgery being performed.
Thoracic Endovascular Aneurysm Repair (TEVAR)
Thoracic Endovascular Aneurysm Repair (TEVAR) is a recently developed treatment for patients with distal arch, descending or thoraco-abdominal aneurysms. Cedars-Sinai now offers this new approach and since late 2005, Cedars-Sinai surgeons have successfully repaired complex thoracic aortic aneurysms in high-risk patients using a minimally invasive catheter approach. X-ray and ultrasound are used by surgeons and radiologists to guide the delivery of a graft-covered stent within the aneurysm, through a small incision in the groin.
TEVAR is performed using a comprehensive team approach using the experienced thoracic aortic surgery and interventional radiology teams at Cedars-Sinai. Physicians and team members involved include cardiothoracic surgeons, interventional radiologists, anesthesiologists, thoracic aortic nurse practitioner, cardiothoracic physician assistants, liaison nurses, and interventional technicians.
For additional information about the TEVAR procedure, please contact the program coordinator.
Open Anastomosis with Hypothermic Circulatory Arrest
During typical open-heart surgery, blood continues to circulate throughout the body, although major blood vessels are clamped to prevent the flow of blood into the surgical area. However, in aortic surgery it is necessary to perform procedures without clamping the aorta, while at the same time keeping the surgical field free of blood. The dilemma facing aortic surgeons was how to temporarily stop blood circulation without causing neurological injury to the patient. An effective solution was found in hypothermic circulatory arrest (HCA), also called total circulatory arrest (TCA). HCA was first used in the late 1970s in conjunction with aortic arch surgery. In the mid-1980s it was applied to surgery of the ascending aorta, and since 1994 it has also been used in descending and thoracoabdominal aortic surgery at Cedars-Sinai.
Hypothermic circulatory arrest is the temporary suspension of blood flow under very cold body temperatures. At these cold temperatures cellular activity levels slow significantly, and blood circulation can be stopped for up to 40 minutes without harm to the patient. This allows surgery to safely be performed on the aorta when clamping to contain blood flow is either not possible or not desirable.
The open anastomosis technique for ascending aortic surgery, used in conjunction with HCA, clearly illustrates the significance of this approach. This technique has proven to be so important to the long-term results in surgery of the ascending aorta that it is now the standard of care for this surgery. With the open anastomosis technique the ascending aorta is not clamped while the aneurysm is resected and the Dacron graft sewn to the aortic arch, thus avoiding any damage a clamp might cause to the remaining aortic tissue. This same technique also applies when the surgery extends into the aortic arch. The ability to safely perform this procedure is due to the use of HCA during the time the aorta is open and unclamped.
Aortic Valve, Root, Ascending Aorta and Arch
Aortic disease often simultaneously affects some combination of the aortic valve, root, ascending aorta and arch. The arteries that branch from these aortic segments require special consideration during surgery. This includes the coronary arteries, which supply blood to the heart, as well as the arteries branching from the arch, which supply blood to the head and upper body. A combination of procedures may be used in one surgery. For example, a single surgery might address the aortic valve and root with either the Button Bentall or David procedure and use open anastomsis with hypothermic circulatory arrest (HCA) for the ascending aorta and arch.
Surgical Procedures (Aortic Valve, Root, Ascending Aorta and Arch)
- Button Bentall with Bioprosthesis or Prosthesis
- David Valve-Sparing Re-Implantation Procedure
- Modified Aortic Root Remodeling Technique
- Yacoub Remodeling Procedure
- Ross Procedure
- Porcine Root Replacement (Freestyle)
- Homograft Technique
The program's comfort level in performing a given procedure is always a consideration. In addition to that, the condition of the aortic valve, root, ascending aorta and arch taken together with the patient's overall health determine the surgical procedure that will be performed. Prior to surgery a strategy is developed based on what has been revealed by diagnostic testing. However, in some instances the final decision regarding the best approach is made during surgery itself.
The surgical procedures described here are the result of the continued pursuit of excellence in surgeries that may begin with the aortic valve and reach to the arch, or be limited to some subset of these structures. Generally, in order for a surgical procedure to be successful it must lend itself well to widespread usage across many surgeons and centers. Procedures that are too difficult to duplicate will not be widely adopted and will be replaced by a procedure that is easier to perform while maintaining good results. For example, if a brilliant valve-sparing operation cannot be duplicated easily, it will not be a viable procedure for use in a majority of patients.
Button Bentall with Bioprosthesis or Prosthesis
This procedure, a variation of the original Bentall procedure, is a simultaneous replacement of the aortic valve, root and the entire ascending aorta. A composite Dacron graft, which includes the new valve bioprosthesis or prosthesis, is put in place. Then the coronary arteries are implanted in the Dacron graft using aortic buttons. This procedure is typically required in severe connective tissue disorders such as the Marfan syndrome. It is also indicated whenever there is a combined dilation of the aortic root and annulus, as well as the ascending aorta.
David Valve-Sparing Re-Implantation Procedure
As its name indicates, this procedure is used for the replacement of the aortic root and ascending aorta only. The aortic valve is not replaced. However, it is re-implanted inside the Dacron tube graft, and both coronary arteries are re-attached to the Dacron. This procedure is primarily suitable for patients with trileaflet aortic valves with minimal aortic insufficiency. It may also be used in Marfan syndrome patients if their aortic annulus is not too dilated.
Modified Aortic Root Remodeling Technique
At Cedars-Sinai, this technique is used to remodel the aortic root while preserving some of the original root tissue. The entire non-coronary sinus of Valsalva is resected, and the segment of aorta between the left and right coronary arteries may also be removed depending on the coronary artery anatomy. A key difference from other procedures is that the coronary arteries are not disturbed and remain attached to native aortic tissue. The aortic valve is either intact, was previously replaced, or will be replaced during this procedure. It is potentially suitable for use in bicuspid aortic disease and some Marfan syndrome or Ehlers-Danlos patients.
Yacoub Remodeling Procedure
The Yacoub remodeling procedure uses a scalloped design to create a new aortic root out of Dacron. This scalloped shape was thought to experience less shear force and, therefore, might be expected to add more longevity and competence to valve-sparing operations. While the long-term outcomes of the original procedure have varied across centers, data regarding the latest modification to this technique is still emerging and requires careful analysis. This procedure is indicated for use in the same group of patients as the David valve-sparing re-implantation procedure.
The pulmonary valve is very similar to the aortic valve, and it has been found that a patient's own pulmonary valve may successfully be substituted for a diseased aortic valve. The surgical procedure to accomplish this is called the Ross procedure. Essentially a pulmonary valve autograft is placed in the aortic valve position, and a homograft (human donor) valve replaces the pulmonary valve. This could be an ideal operation for a young or middle-aged patient who requires aortic valve replacement. It has particular significance for children, meeting their need for a new aortic valve that will grow with them. An additional benefit of the Ross procedure is resistance to infection. However, the extensiveness of the surgery may be beyond the tolerance of those patients who are already septic and experiencing multi-organ failure secondary to infection.
The Ross procedure is more complex and technically challenging than a single valve surgery. Up to 20 percent of patients will require re-operation for degeneration of the homograft within 10 to 15 years. This procedure is appropriate in selected young patients who do not have Marfan's syndrome or a connective tissue disorder.
Porcine Root Replacement (Freestyle)
This is an easier procedure than the Ross. The porcine root is not long enough to address the ascending aorta. Therefore, added Dacron graft is required for replacement of the ascending aorta. This can be a reasonable replacement for the same indications as a homograft, as well as for a replacement of a short segment of aorta (aortic root). Possibly with the addition of a Dacron prosthesis, it can be used as an alternative Button Bentall procedure.
Homografts are the most resistant to infection, making this the preferred technique for the treatment of aortic root infection and endocarditis at Cedars-Sinai. The major disadvantages of a homograft include issues with the longevity, the size and the length. Since homografts depend on human donor availability, there is no assurance that there will be a sufficient quantity of the different sizes and lengths that may be needed. Regarding the longevity of this solution, chronic rejection causes severe calcification of the aortic wall, which becomes like a "lead pipe". To a lesser degree, the aortic valve leaflets also degenerate. Homografts may be considered for use in an elderly patient with a life expectancy less than 15 years for treatment of a heavily calcified (porcelain or egg shell) aorta in lieu of aortic valve replacement and endarterectomy of the aorta. The Synergraft, a de-cellularized homograft, theoretically has the advantage of less rejection and, therefore, less calcification and greater durability. Long-term studies are needed to confirm these theoretical benefits. A major draw back is the lack of overall availability.
Valve Repair Versus Replacement
The decision to repair versus replace the aortic valve is based on complex factors, as well as the experience and results of the particular treatment center. At Cedars-Sinai a repaired valve is expected to have a life of ten years or more (comparable to the minimum expectation for a bioprosthesis). If the repaired valve is not projected to last at least that long, the valve is replaced rather than repaired. A repaired valve could last a lifetime.
There are factors unique to each patient that must be evaluated regarding valve repair. The anatomy of the aortic valve, nature of the tissue and comfort level of the surgeon in performing the repair all are factors in the resulting durability of the repaired valve. Careful scrutiny is required for bicuspid aortic valves. In young patients where the bicuspid valve functions well with minimal calcification, or if there is localized prolapse of only one leaflet, a durable repair may be possible. However, generally for any given group of bicuspid aortic valves, approximately 75% of them cannot be repaired with acceptable durability and should be replaced. When a normal trileaflet aortic valve is present, there is greater potential for repair. Particularly during surgery for ascending aortic dissection involving a normal aortic valve, lifetime durable repairs are often possible.
Descending and Thoracoabdominal Aorta
Surgery for aneurysm of the descending and thoracoabdominal aorta typically involves older, higher risk patients who may have hypertension, atherosclerosis, pulmonary obstructive disease (COPD), a history of smoking and some degree of existing kidney disease.
Surgical Procedures (Descending and Thoracoabdominal Aorta)
There are several techniques for surgery on this segment of the aorta. The "clamp and sew" method is the simplest, fastest approach. It is used at Cedars-Sinai to treat trauma cases only. Currently for elective surgery of the descending and thoracoabdominal aorta, the Cedars-Sinai procedure involves total circulatory arrest. Regardless of the technique used, the main consideration in surgery of the descending and thoracoabdominal aorta is always spinal cord and kidney protection.
"Clamp and Sew" Method
This technique has the advantages of simplicity, and there is less chance of coagulation problems. It is the fastest technique, but also has the highest complication rate for: paraplegia, renal failure and embolization of sclerotic material to the visceral organs, lower extremities and kidneys. This is the preferred approach for trauma patients in which the aorta has been torn. The acceptable time limit for this procedure is 30 minutes. At Cedars-Sinai this technique, when performed on trauma cases, is typically completed within 25 minutes.
Partial Cardiopulmonary Support (Partial Heart-Lung Machine)
With this technique cannula are placed through the femoral vein and artery. A full dose of heparin is used, and the aorta is still clamped. This approach provides some protection to the spinal cord and kidneys. This technique is rarely used at Cedars-Sinai.
Left Heart Bypass
In this approach the patient's own lungs continue to function. Only the heart is bypassed. This technique can therefore be done with a low dose of heparin. Similar to the partial cardiopulmonary approach, there is risk of atherosclerotic embolization. At Cedars-Sinai this technique was used prior to 1994, but is not currently performed. It has been replaced by a TCA and no-clamp technique.
Total Circulatory Arrest Technique
At Cedars-Sinai Medical Center, the total circulatory arrest technique has been used since 1994. This technique has minimized the risk of embolization while also providing maximum spinal cord protection. Through the use of this technique, renal failure became extremely unlikely, and the risks of paraplegia and postsurgical mortality dramatically reduced. (Please see Outcomes for details.)
Timing of Elective Surgery
Elective aortic surgery is offered when the risk of rupture or dissection is greater than the risk of surgery. Declining surgical risk and the accompanying improved outcomes allow surgery to be performed earlier in the disease today than in the past, intervening before life-threatening rupture or dissection occurs. In determining the timing of surgery, the overall condition of the individual and their aortic tissue is evaluated, considering several factors including:
- Size of aneurysm
- Rate of aortic expansion (a growth rate of more than 5 mm in 6 months or 10 mm in a year is of serious concern)
- Shape of aneurysm
- Family history of early aortic rupture or dissection
- Type of aortic disease present (Marfan syndrome, bicuspid, other connective tissue disorder, etc.)
- General health and age of patient
- Symptomatic aorta - pressure or pain in the chest or back
General guidelines regarding aneurysm size and elective surgery, when performed at thoracic aortic surgery centers of excellence, are as follows:
- 5 cm in non-Marfan patient
- 4.5 cm in Marfan or other connective tissue disorder (Ehlers-Danlos or bicuspid aortic disease with severe aortic insufficiency)
- Same as ascending aorta within + or - 0.5 cm, depending on expertise of surgeon and associated patient risk factors
- For example, in a non-Marfan patient, the size range could be from 4.5 - 5.5 cm, depending on the mortality and morbidity results of the institution
Descending and Thoracoabdominal Aorta
- 5.0 to 5.5 cm is the accepted range presently, in an average risk patient with no connective tissue disorder
- 4.5 to 5.0 cm when severe connective tissue disorder is present
- 5.0 cm when chronic Type B dissection is present
- 6.0 cm in a high risk, morbid patient
Elective aortic surgery performed by an aortic specialist in a center of excellence focuses on providing state-of-the-art solutions for those who are appropriate surgical candidates. Following surgery, through lifestyle modifications and ongoing medical care, patients under the care of aortic specialists may continue to enjoy normal, productive lives.
Postsurgical Medical Treatment
Often during the postsurgical recovery period, patients experience back pain and discomfort. They avoid physical activity when it would be very beneficial for them. They often tend to walk less and gain weight, and their blood pressure becomes difficult to manage. These factors contribute to mental depression. The hallmark of postsurgical rehabilitation for aortic aneurysm patients is good pain management coupled with appropriate physical activity. Weight reduction and improved nutritional status are very important. A diet low in fat and carbohydrates and high in fiber and protein is recommended.
A rigorous, scientific approach to blood pressure management is important for these patients. Home monitoring with a blood pressure machine equipped with an arm cuff is recommended. This device should be calibrated to ensure accuracy. Daily blood pressure readings are used to adjust the regimen of blood pressure medications, which may include beta blockers, ACE inhibitors and calcium channel blockers, maintaining the systolic pressure within a range of 105 to 115 for normal activity.
Much of today's success in the surgical treatment of aortic disease is the direct result of innovation aimed at the continuous improvement of surgical technique, lowering mortality and morbidity rates, even in high-risk patients and procedures. The most recent thoracoabdominal surgery series clearly illustrates this success. From 1989 to 1994 at Cedars-Sinai, the left heart bypass technique was used for thoracoabdominal aneurysm surgery. Beginning in 1994, total circulatory arrest was introduced, producing significantly better results.
Cedars-Sinai today has one of the lowest reported incidences of paraplegia and renal failure for patients undergoing thoracoabdominal aortic surgery. These outcomes were achieved in a very high-risk group of older patients (with hypertension, heart problems and a history of smoking) undergoing complex surgery requiring an extensive surgical site. Given the highly specialized, complex nature of this surgery in a high-risk patient population, this represents a remarkable achievement.
In addition to providing current state-of-the-art medical and surgical treatment for aortic disease, Cedars-Sinai is also actively pursuing the solutions of the future. One area of leading-edge research in progress at Cedars-Sinai focuses on the underlying cause of aortic disease. The significant variation in the presentation of individual patients and families with aortic aneurysm and dissection, whether associated with bicuspid aortic disease, Marfan syndrome or other connective tissue disorders, has prompted investigation regarding the genetic abnormalities involved.
Gene expression studies in general have been in progress at Cedars-Sinai Medical Center for the past five years. Aortic tissue genetic expression studies, which began in 2002, are performed on aortic tissue samples taken during surgery. DNA and RNA are extracted from these samples through a multi-stage process. The genetic expression is then analyzed as a potential source of the abnormality contributing to the patient's pathology.
Also in the laboratory, the use of robotic techniques in the next generation of aortic surgery is being explored. The feasibility of using robots in the resection of the aorta through a small incision is being tested, and their use in suturing a Dacron graft within the critical time constraints required for aortic surgery is also being evaluated.
For More Information and Appointments
For additional information, please contact:
|Thoracic Aortic Surgery Program Coordinator|
|Cedars-Sinai Medical Center|
|8700 Beverly Blvd., Suite 6215|
|Los Angeles, CA 90048|
|Phone: (310) 423-6429|
|Fax: (310) 423-0127|
|Send Us a Message|
|Division of Cardiothoracic Surgery|
|Phone: 1-800-CEDARS-1 (233-2771)|
|Send Us a Message|
In the 2012-13 U.S. News & World Report Best Hospitals issue, Cedars-Sinai once again ranked among America's best in Cardiology and Heart Surgery.